After a medical mission in Honduras, complaints of more privileged patients seem a little harder to bear

I’m back in the office after volunteering again for a two-week medical brigade in Honduras, but I just can’t seem to get back into the routine.

My patient is well-known to me. Middle-aged, she visits often, always with a list—a frustrating collection of symptoms and questions, usually arranged in order from least significant to most. Today is no exception: She tells me her migraines are worse, asks me if I know the reason why, describes in great detail a single episode of chest pain she had while grocery shopping, wonders what I think about Q-10 “to build up my immunity,” wants to know why she is sweating so much when she exercises. . . . The list goes on.

We are playing the medical equivalent of “Where’s Waldo,” trying to find the significant symptom in this constellation of complaints. I feel the room get hot, and resist the urge to grab the list out of her hands. I try to calm myself, and then my mind wanders.

She was also middle-aged, but with only one request: Could I help her sleep? There was no list—she couldn’t write. No Kleenex—she wiped away tears with her hand. Dressed in a faded blue dress, eyes downcast, she sat on the child’s desk in the school room we used as an examining area.

She told the story simply: Her 14-year-old son had died 12 days ago, from pneumonia. She had taken him to the hospital, a painful hour and a half journey by bus. He had been given antibiotics but, two days later, back at their home in the mountains, he had worsened. She had been unable to borrow money for another bus trip back to the hospital. That night he awoke, gasping for breath on the bed he shared with his two brothers. He sat up, shouted her name, then fell back. That was all. She shook him, cried out for help, but no one came. He was dead, and she couldn’t function, spending her days rocking back and forth, calling his name. She was grateful for the sleeping pills we had brought with us—samples from a drug rep. Her family helped her out of the school, back into the sunlight and the heat.

Differences in pain
Back home, another patient, who works as a machine operator, comes in with his Workers’ Compensation form to be completed once again. The injury—slipping on water on the shop floor—was months ago, a twisting only. He didn’t even fall down, but he’s been on light work since, with persisting pain in his back and neck despite trips to the chiropractor and physio. He takes muscle relaxants and pain killers regularly, and MRIs, CT scans and nerve conduction testing all show only minimal changes. Handing me the WSIB form, he shakes his head—“You know how they are. They need their forms.” He can’t bend his back and jerks his muscles as I press, describing his pain as “excruciating—11 out of 10,” as I sit down to complete the form the same way I have for months. I am my patient’s advocate, he has a right to be treated  for his injury. But I wonder how I fit into this picture. How I am helping by documenting the disability, perpetuating the problem, giving it validity?

She was nine years old and brought to our clinic by her father. She was crying loudly. It was hot and dusty, and she held an old towel over head for protection from the sun. But it couldn’t hide her disfigured face, a hideous mass of thickened black scars. I tried to settle her as we got the history through the interpreter.

Her father told us the child’s skin was normal when she was born, but a few months later she began to develop dark open sores on her face. Soon, most of her body was covered. As a toddler, she couldn’t stand the pain of the sun hitting the ulcerated skin, so she spent most of her time inside their adobe house. As her disfigurement progressed, the family became more ashamed of her, keeping her inside day after day, away from school. Painful skin infections went untreated, as her father could not afford antibiotics.

We lifted away the towel and loosened her light green dress. My stomach tightened as I saw that her skin was unbelievably mutilated, every inch covered with the irregular black plaques, some oozing yellow fluid. Her face looked as though she had been tortured—keloids pulling her eyelids down and away, cheeks raw and swollen with infection, tears flowing down, dripping on her faded dress. I thought I was going to cry.

Making a difference?
My patient is diabetic, overweight, frustrated. “I just can’t seem to lose weight,” she says. “I’m exercising, but it’s too cold to go outside these days,” she continues, waiting for me to agree. We review the lab work. I threaten insulin once again. “Anything but that,” she says. Her abdomen is huge, her face puffy. Her arm is so thick I can barely get the blood pressure cuff around it. I renew her medicines, not certain if I have helped at all in her care.

Because she was very old, 62 years, she was given respect by being sent to the head of the line. Her problem was a rash—a thickened brown ring around her neck, on her ears, the back of her hands and forearms. Desperately poor, she was dressed in a tattered rag. I noticed her sandals—pieces of rubber cut from a car tire and tied on her feet with string. Through the translator we learned she could not afford food and only ate corn tortillas. She was lean and thin to examine, with chronic impetigo on her legs and feet, and on her neck the rough brown ring of pellagra—Casal’s necklace. We gave her a year’s supply of vitamins and plastic bags filled with rice, beans and small packets of coffee. We took up a collection for her among our volunteers. She folded the bills carefully, stuffing them into the waist of her skirt.

Back in my office, the diabetic is leaving. “Oh, doctor, tell me, how was your trip to Honduras this year?” I stumble. She wants a few words, not a paragraph. How could I possibly say anything that would give her even the slightest hint?

“I bet you saw a lot of things there, eh?”

“Yes,” I say, “it was quite an experience.”

Somehow, this time, I just can’t seem to get back into the routine.

Paul Caldwell is a family physician in Cobourg, Ontario.