From a Week in Practice
Am Fam Physician. 2005 Apr 1;71(7):1294-1296.
This week, I returned to Palenque in the state of Chiapas, Mexico, for a mission with the Franciscan Sisters of Stella Niagra. The team consisted of two family physicians, one internal medicine/pediatric resident, a pediatric nurse practitioner, an interpreter/physical therapist, and an assistant. The first order of business was to sort the abundant supply of antimicrobials, H2 blockers, antiparasitics, antihypertensives, analgesics, hypoglycemics, and creams for every type of rash, which were donated to the mission by the good Sisters from the hospital at San Cristobal. Even with such an armamentarium, the first patient of the day caught me off guard. Manuel came to the clinic (set up in the Sisters’ convent) with a note from a doctor and laboratory results attesting that he had Chagas’ disease. At his present stage, he was free from the debilitating cardiomyopathy that signifies invasion of the parasite into the heart muscle or the swallowing difficulties that result from esophageal involvement. Manuel was highly cognizant of the disease progression and was willing to do anything to prevent its potentially fatal course. Unfortunately, the Mexican doctor who ordered the test was unable to acquire the medicines recommended for treating the disease: benznidazole or nifurtimox. He thought the patient’s only chance was to ask the American doctors for help. I copied the reports and told Manuel I would do what I could. The first step was to learn more about this scourge and determine the efficacy of treatment. If the proper medication could be obtained and it was effective, I would send it down with the next mission team in three months.
The ability of people to tolerate illness when they lack access to care or the ability to pay for it has never ceased to amaze me. While many people seem to seek relief at the first hint of a problem, for those eking out an existence and lacking what many consider the bare necessities of life (i.e., running water, sanitation, a solid floor under their feet, and an intact roof overhead), medical care is far down on the list of priorities. Years of stomach pain, headache, vision and dental problems, back pain, and skin rashes go untreated until the opportunity arises for free care. When that time comes, even a trip of four hours seems worth it. Today, patients came from the ejidos (villages) in the hills surrounding Palenque at great personal sacrifice. The heavy rains in the past month had brought disease to the animals and a sparse harvest, and the one or two chickens it cost to make the trip to town were much harder to spare. Come they did, speaking their native tongues of Chol or Tseltal, which the good Sisters translated into Spanish for the “docs.” “Kush-kush” (pain) was universal—the hard part was sorting out the specific origins of their maladies. It was not always possible, and many of the patients could be treated only symptomatically. Diagnostic studies were a luxury few of them could afford. This was the practice of medicine that for the most part relied on history and physical examination. Our teachers in medical school always stressed that those two skills revealed 90 percent of diagnoses. We would have made them proud.
Doña Lucy, a native of Palenque, arrives early each day to enroll the patients as they queue up at the convent clinic iron gate. Today, as she called the next patient, I introduced myself to Jesenia, a middle-aged woman, two years post hysterectomy, still suffering from surgical menopausal symptoms. Sister Consuelo, the mother superior, told me that “they don’t give hormones after hysterectomy in Mexico.” There was a medicine given immediately after surgery, but Jesenia had forgotten the name, and it did not relieve the subsequent hot flashes. Several other complaints were elicited, including urinary frequency, headaches, and a lump in her neck that had been there for five months. Her blood pressure was 172/90 mm Hg, the urine dipstick showed leukocytes, and there was a 2-cm nodule on the right lobe of her thyroid that moved with deglutition. The nodule had a firm consistency, not rock hard, and was most likely cystic. Jesenia’s husband was invited into the examination room and I explained the options. If it was a cyst, aspiration could resolve it. If it was solid, the nodule probably would require more extensive study and possibly excisional biopsy. Not having access to an ultrasound, I explained that aspiration could help with the diagnosis and treatment. The patient and her husband were agreeable to the procedure and aspiration was performed. No fluid was obtained and a diagnosis of adenoma became more likely. I gave Jesenia a diuretic for her blood pressure, an antibiotic for her urinary tract infection, an analgesic for her headache, and the recommendation to follow-up with a surgeon. Without Sister Consuelo’s help, there is little likelihood that the latter will ever be accomplished, but she seems to be able to accomplish the difficult tasks, and at times, even the impossible ones.
The ‘colonias’ are small communities that spring up in Mexico on land no one seems to own. The plywood or cement-block walls hold up corrugated tin roofs that keep most of the elements out and serve as conduits for the rain water, channeling it into cisterns to be used for bathing and washing. Today, I was asked by one of the patients to make a house call on her mother in a home close to the convent. She had fallen and injured her shoulder and the daughter was concerned about a fracture. I followed the daughter to her home, which had a low wire fence around the front to keep in the chickens. The mother was lying in a hammock resting on the opposite shoulder from the injured one. The vital signs were normal, but as I was removing the patient’s blouse to examine her shoulder, I felt a cold, liquid substance that I at first thought was blood. When her shoulder was revealed, it was covered in Vaseline and ice. The shoulder was fully mobile, there was no point tenderness, swelling, or bruising, and the arm was neurologically intact. I reassured the family that nothing was broken, gave her some acetaminophen for the pain, and gathered my equipment to leave. “Por favor, esto es para ti.” (Please, this is for you.) The sack of oranges they gave me was the family’s way of saying thank you. I had not expected anything, but graciously acknowledged their generosity and returned to the convent with much more than I had when I left.
Today, the clinic moved from the old convent to the new one located on the outskirts of Palenque. This new “orange house,” named for its bright color, is where the medical team had been sleeping for the past week. The roosters that inhabit the convent grounds have no sense of time and crow throughout the night which, along with the barking of the plentiful canine population, punctuates the night air making it difficult to have a complete night’s rest. Mosquitoes are another ubiquitous neighbor, especially during the evening hours, but are kept at bay by the slow burning of an insect repellant coil and the liberal use of DEET. One of my first patients was a teenage girl, Micaela, who spoke so rapidly it was difficult to follow. “Tengo bronchitis,” (I have bronchitis) was easy to understand, but how long she had had it was a different story. “Todo el tiempo,” (all the time) was her answer. The wheezes in both lung fields were sufficient to diagnose asthma, but an even more pressing problem was the tension that was occurring at home between her and her mother. They were constantly battling over school, her clothes, and her friends, and the conflict was taking its toll on Micaela. She had made suicidal gestures and now was seeking help for a situation that was deteriorating. The clinic’s asthma medicine would improve her breathing problems, but she needed a person to talk with to help her handle the adolescent angst that was causing her so much pain. Sister Consuelo knew of a counselor in Palenque who would help, and she talked at length with Micaela, reassuring her that she would be there for her. There was no easy solution to all her problems, and with limited resources, the path would be difficult.
This was the day of goodbyes. Our interpreter/physical therapist chose to remain an extra half day to help the Sisters restore the convent to its pre-mission state. Her generous nature and fluency in Spanish made her a vital member of the team. At 8 a.m., the bus left Palenque for the two-and-a-half-hour ride to Villahermosa, where the team would catch a flight home. While waiting at the airport, the team made suggestions for what might have been done better, what other medicines were needed, and what other resources could be tapped to help those who have so little. One immediate need that could be met was the lack of an automatic washer in the Sisters’ convent. All clothing was washed by hand and hung out to dry on the third-floor roof. Our assistant came up with the idea and got the team to chip in for the “luxury.” It wasn’t anything extravagant, but would certainly give the Sisters a bit more time to minister to the physical and spiritual needs of their poor neighbors. Sometimes it is the simple, mundane things that can mean so much.
To preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2005 by the American Academy of Family Physicians.
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