Muñeca

I had been following a little girl, “Muñeca,” in the PICU. She was only 3 years old, but after a horrendous procedure gone wrong in Mexico, she was brought over for any sort of saving efforts.

During a weekend visit with her dad in Tijuana, family noticed their Muñeca was acting unlike her usual self: she was vomiting excessively, stumbling around, and her eyes were deviated inward. They took her to a clinic and received news they were not able to understand. Their little girl had a “brain tumor” and needed to be taken for surgery “immediately.”

The parents did not even have time to react, it’s as if they stood still as everything around them sped by. By the time they came to their senses, they were in the recovery room, only to find that their once normal, cheeky, talkative daughter still had not woken up. Something obviously was not right, but the doctors were not providing any clear answers.

So mom picked up her still intubated little girl and drove straight to the border, where Muñeca was then ambulanced over to our hospital. From our assessment and findings, Muñeca indeed had evidence of brain resection, but there was also significant brainstem injury and damage to her midbrain. Her neurological sequelae was unfortunate and she would require mechanical ventilation indefinitely for her poor airway tone: while she is alive, her quality of life would remain poor.

Mom could not understand this, let alone accept it. Every morning I would come see Muñeca, and every time mom was at bedside talking, singing, or praying to her little girl. There were never any changes, and what kept mom hopeful was not the lack of progress, but the absence of deterioration.  I was moved by the mother’s faith even though I felt it to be displaced. I can’t even imagine the pain she must be experiencing, seeing a child that is not like the one she brought in or once knew. It is truly a loss and process she is still working through.

So every day I continued to see Muñeca, but I found I was taking away more from seeing mom. I realized how much people can move us — with their hopes and dreams, sorrows and grief. I never want to forget that feeling as I continue through medicine. It’s the only thread that keeps us together, reminding me just how human life makes us to be.

Te cuidas.

Anonymous

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Dealing with the question of “Could I have done more?”

Submitted Anonymously

During my underserved medicine rotation, I had a patient encounter that left me with the question of could I have done more or done something different. This patient has history of pulmonary nodules and possible mass at sphincter of oddi. Two weeks prior to my encounter with the patient, she had presented to free clinic with unintentional weight loss of 50-60 lbs in the past 6 months, chills, night sweats, shortness of breathe, chest pain and fatigue. She was recommend to go to the ER to rule out possible pulmonary embolism and with the hope they would do a CT of her chest and abdomen to further explore the possibility of malignancy. The patient went to the ER the following week with chest pain. However, when the patient arrived at the ER, a new medical record number was created for the patient. Because of this, the ER department never read the free clinic note and never received the history about the weight loss, unknown nodules and possible abdominal mass. The patient was worked up for chest pain, diagnosed with musculoskeletal pain and was recommended ibuprofen and physical therapy.

I saw the patient at free clinic for an ER follow up. The only symptom that had resolved was the shortness of breath. The conclusion during her visit was that malignancy was still high up in the differential and that she needed a CT of the abdomen and chest. The visiting attending and I pondered over the possibility of sending the patient to the ER again, but the patient was in no acute distress. We decided to begin a project access application for a CT of the abdomen and chest. This decision left me feeling very disturbed and dissatisfied. I wanted this patient to get the CT now, not in months. I feared that this patient had a malignancy that could be treated, and that the delay in treatment was affecting her outcome. 

I went home that night and asked my mother about emergency medical. My mother works for the Health and Human Service department. She said this type of insurance is given when the person’s medical condition is life or death. This answer just left me more unsatisfied and frustrated with the fact that the lack of access to resources is what’s keeping me from determining if it is a life or death situation.

For this experience, I learn that the current health system still allows human beings to suffer for lack of insurance. It is a great reminder that the affordable care law is about providing insurance to the majority of the United States, but it doesn’t fix access issues for the most vulnerable populations in America. This learning point was reinforced when I went to the First Baptist Church of Ocean Beach, where I saw an intoxicated homeless woman for lower extremity edema. This woman’s health did not improve with new eligibility for medi-cal. She suffered from alcoholism and likely cirrhosis, lived on the streets, was alienated from her children and other means of social support. She couldn’t provide her social security number so that we could follow up on her medi-cal application. In the end, we could not provide her with the resources and support she would need to change her life in that visit, which made me feel helpess and useless. Fortunately, we did wash her feet and provided her with supplies to care for her feet. We began a follow-up plan with the hope that she would return to receive the clinic’s support to start on a path to healing.