Home visit and [floor]side manner

Fond greetings from the land of warmth and war, from the land of schizophrenic civility and criminality, from the land where beauty and bestiality walk comfortably together.

I am including this picture (with the patient’s permission) because I wanted you to be able to join me in a home visit.  I wish you could have seen all my eye observed as I entered the house: The grandson sitting in a low chair with his knees spread apart to form a human recliner against which the patient could lean to relax his back; the daughters wrapping their arms in tenderness as they helped him lie down for the examination; the free-range dogs joining the medical consultation, listening silently, and leaving when they became bored with the conversation.

But why isn’t a guy like this in the hospital?  He had been.  The hospital did some diagnostic tests, told the family that he had a kidney stone, and that the family should care for him at home since the hospital had no further help to offer.  The patient was dismissed without medications or any discharge summary.

I cajoled the family to borrow money so I could send him for a single abdominal x-ray and an abdominal ultrasound to help form my own diagnosis.  He does indeed have a kidney stone (which is causing him no trouble at all) and the cause of his excruciating pain and wasting is still unknown.  The family is grateful for a presumptive diagnosis (cancer, of unknown origin) and for medications which help his pain.  We work together to find simple measures to bring more distance between the dirt floor and his emaciated body and try to find some sort of food or drink that he can tolerate.

Not only does the photo give you a limited view of the immediate surroundings, but you also don’t see the matting for the photo:  In my mind’s eye I see those of you who have donated meds so I have a few opioids to help this man sleep occasionally, you who have prayed recently for specific clinical or personal needs, you who have helped fund our ministry—thank you so much for being in the picture of Pedro’s health care.

Having tried to explain the first snapshot, let me add 2 others to this note.  The first is a local snapshot of our clinic work, and the second a wide-angle snapshot of current national events that impact us.

Our local medical work tends to make me grimace in the morning and grin (or groan, depending on the day) at night.  We have tried for years to close the practice to new patients and have been entirely unsuccessful.  We decide to “severely limit” new patients, and still the calls  stream in:  “I have had this terrible itch for years” or, “I’m suffering from shortness of breath and chest pain” or, “I used to get diabetes meds at the hospital, but they ran out of meds” or, “our sister is mentally ill and for the last 3 weeks she hasn’t been sleeping at night and instead gets lost wandering among the hills until we find her again and no clinic has been able to help her”.  And once again, “severely limit” becomes a relative term and we’re relieved that we’ve never been so foolish as to entirely close the practice to new patients.

Yesterday’s phone flurry was an example of the kind of grimace that becomes almost normal.  We received a call from the family of a 65 year old woman who had been suffering from wheezing for the past 3 days; her shortness of breath was so severe that she could walk only a few steps at a time.   Despite having been hospitalized 3 times in the last years, she had been prescribed no ongoing medications and the family wondered if we couldn’t just send several inhalers to the house, since she had gotten treatment for her asthma at our clinic some years before.

The clinic was already swarming with people and requests for help.  Sending the medications to the house would have been the logical solution if I hadn’t been so concerned that she might die without medical supervision.  The emergency room in the public hospital would have been another logical solution, but these hospitals are closed due to strikes.  Besides, the family can’t afford the needed transportation to take her anywhere.   We ignored the obvious, that the clinic was already overloaded and that the family had no way to bring the patient to us and started negotiating over the phone about how the patient could be evaluated and treated by a clinician.  No, there was no way she could walk the 40 minute trek from her home.  No, no one in the family owned a vehicle.  No, the family’s horse was in use in a corn field.  No, there were not enough concerned family members to be able to bring her in a hammock.

OK.  No help from the family; try our medical staff.   No, nobody could think of anyone from the village who owned a vehicle who would be willing to donate a ride so the patient could be seen.  But, couldn’t we…? …and we chose the only obvious option,  using our own funds to hire someone to go bring her and take her back home (yes, of course, decisions like this complicate the finances of the clinic, but….).

I was so grateful when she finally got to the clinic.  Tough country woman that she was, she still managed grins around the few words she could squeeze out. Several nebulizer treatments later I found her dozing with the nebulizer still in her hand:  a sign of improvement for someone who had been unable to sleep for 3 nights in a row.

And now, for a bit of a country-wide snapshot.  Perhaps the widest setting of the lens would focus on lawlessness and ever-inadequate resources.

Lawlessness: in the late spring, we were horrified to hear that gangs had attacked a public bus, doused it with gasoline, and set it afire.  Some of the passengers–intended merely to do an errand that day—ended up being buried and many more ended up in burn units.

In the past year over 100 of these bus drivers have been killed while driving their routes, because the owners of the buses refuse to pay “rent” to gangs. (Buses make a handy target for terror due to their general use and predictable schedules).  When the national legislature passed a law last month making gang involvement illegal, the gangs retaliated by threatening to kill any conductor of public transportation who dared to drive during the days the law was being debated.  No one doubted the gangs’ ability or will to carry out their threats and the entire country was paralyzed for three days.  Businesses closed because employees couldn’t get to work and because clients were stranded.  Our busy road was eerily quiet except for an occasional private vehicle which dared to venture out.  This complete paralysis of the country served to remind us where much of the power of the country lies, and it isn’t in the hands of the lawful.  In ugly irony, clinics like ours were at the same time wrestling with greater enforcement of importation laws, making it extremely challenging to access donated medications meant for the country’s neediest people.

Even medicine gets mixed up in lawlessness at times.  Don Guadalupe, distinguished gentleman who would never stoop to stupidity, shot off a firecracker last week to warn prowlers outside the house that he knew they were around.  At age 75, he failed to release the explosive from his fingers soon enough and ended up with significant burns.  But but he was not robbed that night.

So many thanks for your faithful friendship and prayers!
Jana Nisly

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