14 Dec 2012
An old man was making his way towards me, pushing his walker in front of him. There was a scale in his path that I quickly moved aside. He came into the room, sat down, and handed me his chart.
Silvano. 76 years old. With high-blood pressure controlled with three medications, diabetes not-quite controlled with two, venous insufficiency, and a history of a below-the-knee amputation on his right.
According to the chart during the patient’s last visit Hugo, one of our clinic doctors, referred him to a “vein clinic”. Silvano said that it went fine.
“Se puso una máquina de sonido en mi pie.” They put a sound machine on my foot. “Then they gave me a pair of long socks, told me that I should walk around when I can and elevate my leg at night, and were very emphatic that I come here regularly for control of my blood pressure and diabetes.”
“So the test that they did on your leg, that went fine?”
“Yes, they said everything was okay.”
They probably did an ankle-brachial index, I thought.
ABI is the ratio of blood pressure in the legs to pressure in the arms. Lower pressure in the legs is an indication of atherosclerotic disease in the arteries, buildup of cholesterol deposits and plaque causing blockage of vessels.
Listening carefully, the patient’s heart and lungs sounded fine. His left lower leg was discoloured with mild swelling. But there were no lesions, his pulses there were strong, and he had good sensation.
Because I was a student, he wanted to show me his amputated leg. He took off his prosthetic and began unwrapping the ace bandage around the stump.
“Por qué necesitó la amputación?” Why did you need an amputation.
“I had an infection. It began in my little toe and kept growing. To stop it they took off my leg.”
When it seems like a patient’s everyday might be difficult, I’m curious about what support they have. And I ask.
“Who do you live with? One of your children?”
“I don’t have any children.”
“Do you live alone?”
“Yes. I do everything for myself. Cook. Clean. Everything.”
“Do you have any family?”
“Yes but it’s as if I have none.”
At this point my Spanish slightly faltered, but it sounded like he was estranged from his family because of a religious disagreement.
Silvano began re-wrapping his knee.
I wondered, how do people here do it? How could Silvano manage on his own?
In the developing world there are few constants, little support that you can depend on, outside of family. The education system is likely to fail you. There is no health insurance. The government or an NGO may or may not have a helpful presence in your area. But there are, usually, big extended families that live together, work together, often fight with each other, yet help each other.
And most of our patients have family. Grown children come with parents and translate from their Mayan language into Spanish. Parents bring all their young children and the doctor sees the whole family at once. But occasionally a patient wanders in who has no family, lives alone, and endures a scary illness.
When Silvano was ready I told him that I would be increasing the dose of his metformin as his glucose was still too high. I also emphasized the walking and leg elevation, and discussed the time for his next appointment.
As Silvano left to wait for his meds, I went to find Hugo. I thought he would want to know how his patient was doing.
Hugo was pleased to hear about how things went with the vein clinic, agreeing that they would have done an ABI. The only thing he wanted to add to the plan was re-counseling about diet.
“Where is Silvano?” he asked.
“In the waiting room.”
We looked around the waiting room. He wasn’t there.
Worried, I asked the receptionist if he had left.
“No, he’s outside by the food vendors. Drinking a glass of atol.”
Atol is a corn drink laced with sugar.
My and Hugo’s heads turned in unison to look out the front door. Sitting in a chair with his walker folded next to him, Silvano was holding a glass of atol and eating a chuchito covered in thousand island sauce.
“Ay, no.” Hugo shook his head and sigh-smiled at once. “He should not be doing that.”
Hugo strode forward to talk to Silvano. I listened carefully to learn the vocabulary. So I could discuss diet with the next patient who probably wouldn’t listen.