A little bit of medicine, a lot of hope

After nearly a week of treating patients in Nicaragua, this physician realized that curing isn't everything. Her story was runner-up for the Young Doctor Award in the Medical Economics Doctors' Writing Contest for 2000.

By Christine M. Pluta, DO
Family Medicine Resident/Stratford, NJ

Rain. Torrential rain. Depressing rain. It rained from the moment I stepped off the plane in Managua, Nicaragua, last September until I left five days later.

A petite nun, who was also a physician, met me and a few other volunteers at the airport on a humid evening and loaded us into a white minivan of ancient vintage. We wove in and out of city traffic, avoiding eye contact with the beggars roaming between the cars at every stoplight. Too soon, we went from city streets to an unlit, two-lane road, with only the taillights of another car to guide us. A dense fog had descended, and the car windows were opaque from our breath, but I could see that there were no guardrails to protect us from the cliff on the left or the ditch on the right.

Our habited driver kept a heavy foot on the accelerator so she wouldn't lose the glow of the lights that sped along in front of us. While the nun's friend joked about her nine lives and infamous driving record, I silently prayed a rudimentary form of the rosary, losing track of the Hail Marys because my fingers were gripping the seat. The lights in front of us disappeared into the fog, daring us to go faster. Maybe this whole trip was a bad idea, I thought.

My medical mission to Diriamba, Nicaragua, began with a request by friends at Cabrini Mission Corps, run by the Sisters of the Sacred Heart, to help test a volunteer medical clinic. The trip was actually a Volunteer Optometric Services to Humanity mission, but the sisters thought it would be an ideal opportunity to offer medical care as well as eye exams. Although I would be joined by a gynecologist, I was a second-year family medicine resident and had no experience in Third World medicine. I could think of many reasons to say No, but with a little reassurance that my services would be a big help and that I'd have support, I began to seek donated medical supplies.

My "office" was a tiny classroom on the third floor of the school in a dismal village with dirt roads, and my "pharmacy" was in another classroom. I had a desk and two chairs; a bed covered with brown paper served as my exam table. As surely as the rain fell every day, people humbly lined up outside my door as if they were going to receive some sacramental healing. Many waited for hours to see the American doctor, whom they viewed as a godsend.

The first day was an exhausting blur, the second day a challenge, and the remainder of the time a lesson in love. Most people came with common complaints and illnesses. But what could have easily been treated at home with a scratch of the pen or a referral to a specialist was a nightmare for a novice doctor like me in an impoverished country with limited medical supplies.

The vitamins were gone in a day. The analgesics and anti-inflammatories lasted two days. The liquid antibiotics barely lasted the week. We had antifungal cream to spare; had I removed everyone's shoes, I'm sure we would have easily exhausted that, too. The children, who ate the dirt from the floors of their huts, were anemic from parasites. Young women looked twice my age and complained of arthritic pains and headaches. Everyone had symptoms of reflux and gastritis; I gave away my supply of antacids on the first day. Men came with chronic pain and deformities from war injuries.

The first day, Maria brought her daughter, who had an infected rash. The girl's dirty clothes were sticky from lollipops the nurses had given her. On the second day, Juanita, whose husband thought her ringworm was an STD, breathed a sigh of relief when I reassured her and handed her some cream. Miguel showed up on the third day with an uncontrollable twitch of his neck and obvious neurological problems. Yet he never stopped smiling as his aunt told me of the near-fatal meningitis he had survived as an infant. My signature and an official stamp from the nuns would give him a chance of being seen by a specialist in Managua. I also saw Juan with his X-rays from 1996, Teresa with uncontrolled hypertension, José with chronic epigastric pain, Carmen with probable angina, Tomás and his brother with their big brown eyes and draining ears, and beautiful 9-month-old Ana, propped up by her father because she couldn't raise her own head.

On the fourth day I met a man I called Señor, since I never learned his name. He couldn't walk up the three flights of stairs to my office, so I waded through the sea of people waiting for their new glasses to where he sat on a bench near the courtyard. His crutches were two thick tree branches with the bark carved off and a little branch at the top where he could place his hands.

Señor rolled up one pant leg to reveal what looked like another tree branch. His leg was simply bone covered with skin that was oozing something foul from a small hole near the proximal tibia. I couldn't believe he'd been able to walk on it, and I hoped he didn't see my disgust as the flies that hovered around him flew from his leg to me and back to him. I cursed myself for leaving a new set of crutches at home because they didn't fit into my luggage.

Nothing I had in the "pharmacy" would begin to help him. "Just do what you can," said one of the nurses.

All the frustrations of the past few days came to the surface and a voice inside me screamed, "But I can't do anything! Doesn't anyone see that I'm not really helping with my lack of experience and paltry supplies? The optometry patients are walking away with new glasses, but my patients are leaving with rotting legs, ear infections, rashes, ulcers, and arthritic pains that are going to return when the medicine is finished. And 100 patients in less than a week are just a microcosm of the suffering here!"

Fortunately, no one heard that voice. So I began to clean Señor's wound, dress it, and chase away the flies while he told me how he had been caring for himself in the damp shack he called home. I gave him some extra gauze and tape and Tylenol for his fevers. Over and over, he thanked me. As he grabbed his crutches and pushed himself up, he said, "Doctora, cuando peudo volver a verle?" ("Doctor, when can I return to see you?") A lump filled my throat as I replied, "Lo siento, señor. Es que me voy mañana." ("I'm sorry, sir. You see, I leave tomorrow.") I was embarrassed to look him in the eye as he graciously thanked me and hobbled away. Here I was, a privileged American, turning my back on this misery to return to my own comfortable world.

Slowly I walked up the three flights of stairs. Perhaps my tears, like the rains, would water some little seeds of hope and love and faith that were planted among all of us that week. As I reached my office and saw the patients waiting with their numbers in hand, I realized that it's not always about what we do but, rather, how we do it. So I dried my eyes, smiled, and invited the next patient in.

It was early morning and raining as we drove through the hills back to the airport. I pictured the mothers and fathers and their children. I saw Señor again as he limped away. I thought of the wonderful nuns, nurses, and volunteers. As the clouds slowly lifted, I knew that someone besides me could feel that ray of hope shining through the mist on to the road. And the road really wasn't all that dark or frightening anymore.

 

Christine Pluta. A little bit of medicine, a lot of hope. Medical Economics 2001;11:64.