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Reverberations.

I still considered myself a new attending, only 5 months into my first practice as a family physician at a community health center. I was on call one weekend and I received a call from the emergency department physician. He was seeing one of our patients, a young woman who was a migrant farm worker. "Well, she was in yesterday with nausea and vomiting. I gave her some IV fluid, she felt better, so I discharged her with presumed gastroenteritis. Today she's back with the same symptoms, except now she's significantly jaundiced. I'm not sure what's going on, but I think she needs admission."

I thought about hepatitis as I headed down to see her. I found the patient lying on a gurney, looking only mildly ill, but quite yellow. After introducing myself to Carmen and her husband I asked her all the usual questions; there were no apparent risks for hepatitis except that she had just arrived from Mexico several days before to work in the spring planting. It seemed relatively late in life for her to have acute hepatitis A, but in the absence of other serious symptoms, it was my leading diagnosis.

Her husband stood close by. "Doctora, do you think she will die?" His words stunned me. I tensed up involuntarily and quickly answered No, I didn't think so. She would be admitted for testing and more intravenous fluids, and we would do our best. I did not know then how his words would roverberate over the next weeks.

That night I received a call from the floor nurse reporting a fever to 105 [degrees] F. I went back to see the patient. She was tired and mildly disoriented but had no abdominal findings or other changes in status. Her picture confused me, so I consulted a colleague and decided to start broad antibiotic coverage for ascending cholangitis. I returned home for a worried night's sleep with her husband's question echoing in my dreams.

My partner took over the case on Monday morning, and as the days progressed he told me her coagulation studies, initially normal, were starting to rise. Several days later, on my call night, my partner and the infectious disease consultant decided to transfer her to the university hospital. I again visited Carmen in the hospital to arrange for her transfer. She looked much worse; her husband's question returned.

Not long afterward, she died. "Doctora, do you think she will die, think she will die, think she will die ... ?" She was 28 years old, with a young husband and a not-quite-2-year-old daughter. Her final diagnosis at the university: fulminant hepatic failure. It simultaneously reassured and disturbed me that the university specialists had no better answers than my colleagues or myself. What were we missing? Could we have prevented this untimely death? I ran the case over in my head for quite a while afterward, while the words "Doctora, will she die?" continued to haunt me. I missed the funeral because of a vacation.

I thought the case was over, as I'm sure it was for the university specialists and house staff who had cared for the patient. I guessed from my own inpatient residency rotations that this woman on whom they had endlessly presented, rounded, discussed, and researched, now would be gone. The medical team would doubtlessly be caring for other critically ill patients. What I didn't realize until much later was that the reverberations in my practice were just beginning. Carmen had died, but she would return to visit me again and again over the next few months, teaching me about continuity of care even in death.

Agriculture is the main economic activity in the rural county where I practice, and spring is the time of year when the migrant farm workers return to the area. Many farmers and landowners rely on the cheap labor force of these workers to plant, cultivate, and harvest the crops. Many workers come from Mexico and Central America, speaking Spanish or Mixteco and little English. Since I speak Spanish I see many of them, and their stories, travels, and experiences fascinate me. Because they live in a rural area, they are often quite isolated from the larger community geographically, linguistically, and culturally. Over time my migrant worker patients would teach me about the hidden threads that bound them, even thousands of miles and a language or two away, to their native places.

More than 2 months after Carmen's death I saw a young woman with muscular chest pain. I noted from the chart that she had a no-show appointment 2 months earlier, and I gently inquired. She began to apologize profusely and told me that a friend had died. "Who?" I remember asking. She described the illness, and I immediately recognized Carmen's story.

She continued, "She was my best friend. We knew each other for 4 years. When I first came here I got to know her. We worked in the fields together, picking tomatoes, chiles. She was my best friend. We took English classes together. She got very sick, and they put her in the hospital. Then she got worse, and they put her into the university. I visited her there, and then she died. I was from Tlaxcala [Mexico], and she was from Michoacan. But she was my best friend." Her eyes shone with the trace of a tear.

Inquiring about the missed appointment had led me into this woman's world of friendship, loyalty, and loss. Carmen had made her first revisit to me, as a best friend. As I evaluated my patient's chest discomfort, explained treatment to her, and filled out the encounter form ("Right pectoralis major strain and right wrist tendonitis") it occurred to me that these were the least of the visit.

A month later a 20-year-old woman who was a migrant farm worker came in with multiple vague concerns. Her husband, who appeared to be at least twice her age, seemed to be the more concerned of the two and hovered extensively. I was concerned about the possibility of abuse, so I interviewed the woman in private. She denied any abuse and reiterated her husband's concern about "cancer in her blood" and gave other vague symptoms like intermittent nausea and decreased appetite. Her physical examination was completely normal. I sent her for a complete blood count and asked her to follow up in several weeks to see if I could discover what was really troubling her.

They returned 5 weeks later, and her husband requested hepatitis testing. I felt a little dense when they finally explained that a friend of theirs had died in the spring from ."some liver problem." Another echo of Carmen, this time she had returned as a diagnosis to be feared. I felt conflicted, because no amount of explaining the risk factors for hepatitis B, the uncertainty in the diagnosis of their friend, or the normal and reassuring physical examination and complete blood count helped him. My note read "He says if I do not order the blood work he will get it done somewhere else. He is very respectful about this but does not seem to trust my clinical impression that she does not need this test now." I agonized about the cost-effectiveness of getting a hepatitis B surface antigen test when the probability of her having the disease was low. In the end I capitulated. The test came back normal.

Two months after this encounter I visited with another woman who was a migrant worker in her ninth month of pregnancy with a known anencephalic baby. I had asked her to bring her husband, so they could decide how to handle the delivery. I carefully explained a do-not-resuscitate order. When reflecting to me her understanding of a DNR, the mother said, "I don't want the baby to suffer. A breathing machine would only keep the baby's heart and breathing going. A friend of mine was on a breathing machine, you know. I visited her, and they told us she was brain dead. All that machine was doing was keeping her breathing. So it would be the same with my baby, since it won't even have a brain."

Here was Carmen again, this time as a vivid image of the intersection of technology with life and death. My patient, this young woman who spoke only Spanish and hadn't completed eighth grade, had perfectly explained to me the concept of brain death based on her own visit to her dear dying friend.

It has been more than a year now since Carmen's death. It is time again for the farm workers to return to the area to plant the crops, trim the apple trees, tend the fields, then harvest the land's produce. I will see many of them in the office for back pain, muscle strain, well-child visits, prenatal care, and other routine family medicine visits. Most will not have a serious illness or disease. A few, like Carmen, may have compelling stories that push me to look beyond the individual and the family. Though I barely knew Carmen during her life, her friends and community have brought her back to me, teaching me about connection, community, and continuity in practice and in life.

All correspondence should be addressed to Colleen T. Fogarty, MD, 4079-A Lake Road, Brockport, NY 14420.
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Author:FOGARTY, COLLEEN T.
Publication:Journal of Family Practice
Date:Mar 1, 2001
Words:1554
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