Internal Medicine rotation in Rural health clinics in Chiapas, Mexico Part 1

David A. Cardona Estrada, M.D.

Internal Medicine Resident, North Shore Medical Center

PGY- 3

March 05, 2019

“To cure sometimes, to relieve often, to comfort always”

I have known this expression since I started medical school, but it has never been so present in my mind until I arrived to the Sierra Madre region of Chiapas, Mexico a couple of weeks ago.

I was trained in Mexico and I knew before coming to this rotation what it was like to practice medicine in a low-resource setting. I remembered that you had to do as much as you could with whatever you had, even if it was not the gold standard for treatment. What I forgot during my last 2 years of training as an internal medicine resident in the United States, were the feelings of powerlessness, frustration and sadness that arise whenever you know that you could cure someone, but because the resources, environment and social determinants of health you are not able to do so.

They were several days that I asked myself: what am I doing here?, Am I really helping?, What does being a doctor really mean?. I was having an internal crisis, until I was asked by the palliative care team to evaluate one of their patients.

She was a 30-year-old women with liver cancer with lung metastasis.  She was initially treated with palliative chemotherapy, but due to the lack of response, adverse effects and economic burden, she decided to stop her treatment a year ago. Unfortunately, during the last month, her hepatomegaly has been increasing and causing more pain, so she had to be started on morphine for pain control. She has been losing weight and developing lower extremity edema. She started wondering, if it would l be worth traveling l to the closest city (4 hours away) to be re-evaluated by oncology.

Image of Laguna del Cofre, one of the 10 communities where
Partners in Health has community health clinics 

We went to evaluate her on a Friday night. When I entered her small house, I found a very frail and emaciated woman sitting down in bed, surrounded by several family members. After my 2 colleagues introduced me to her, I asked how she was feeling. She said her pain was better controlled with the morphine, but her appetite was gone and she started having fevers 3 days ago. On physical exam, she was so emaciated  that she could not close her eyes anymore due to the lack of peri-orbital fat and I could see her heart beating through her chest. Her liver occupied the right half of her abdomen and right hemithorax. She had lower extremity edema up to her thighs, more in the left leg than in the right. A DVT as the cause of her fever, was my highest differential on the list. We asked her if we could come back the next morning to evaluate her legs with our ultrasound and to have a family meeting.

The next morning as we arrived, she told us that she had an episode of bloody emesis. Instantly, I felt my heart racing as I thought she may have esophageal varices and she would decompensate in any moment. Her vital signs and physical exam were stable. She told us that she has been using NSAIDs for more than a month, which gave me a sensation of false reassurance as I thought she may have a gastritis or a peptic ulcer. We performed the lower extremity doppler ultrasound and found a left femoral DVT. Oh my God, can this poor woman catch a break?

My colleagues and I stepped outside. We all knew her prognosis was grim and traveling 4 hours to the city was not feasible. We also could not anticoagulate her because her hematemesis. We agreed that to continue the palliative care route was the most appropriate plan. Now we just had to talk to her and her family.

We sat down with the patient and her family to tell them the bad news. She said, “I do not want to go to the city, it will be too much for me”. We told her that unfortunately she was going to die from her cancer. After the bad news, I sat down by her side and grabbed her hand in silence. While grabbing her hand, I looked up and saw her husband and family crying, and near the doorway I noticed her 3-year old beautiful daughter hiding from us. My heart broke as I thought: she is my age and is going to leave 4 children. I have never felt so useless. I apologized to her for not being able to offer her better news. We all promised her to do as much as we could to alleviate her symptoms and to help her enjoy her family during the time to come. She looked at me with her eyes covered in tears and smiled with one of the most beautiful smiles I have ever seen.

Do you have any questions?, I asked at the end of our conversation. “No doctor”, she said. “I just want to thank you all for taking care of me”. There are not enough words to explain how grateful I am, because you have come to my house to see me, because you worry so much about me and my family.” At that moment, everything became clear. That’s what being a doctor its all about: the purest human connection with our patients. We were not able to offer a treatment for her disease – in fact, we only had bad news for her that morning. What we were able to do was to sit down in her house surrounded by her loved ones, grab her hand, look her in the eyes and promise her to do as much as we could to alleviate her symptoms and comfort her at the end of her days.

Because that’s what being a doctor is really about: “To cure sometimes, to relieve often, to comfort always”