Healing Patients One Family at a Time
For four weeks, I worked as a medical student at Zamboanga City Medical Center in the southern Philippines. I wanted to learn more about a country that my mother and I call home. In medical school, we learn that our patients are our best teachers; I came away changed by my experiences with Filipino families. In the Philippines, the family is an indivisible unit, treated as a whole.
“Sa labas. Sa labas.” (“Outside. Outside.”) I speak in my best Tagalog, but it makes no difference since he speaks Tausug, one of the three common dialects spoken here (none of which are Tagalog). More important, my frantic hand gestures point concerned and grieving Tatay (Father) in the correct direction. This is the first of many trips to the small independent pharmacy during his six year-old daughters’ stay in the hospital. She is suffering from profuse rice-water diarrhea that began three days ago. Her parents waited until today, after seeing that this was different than any previous bout of illness, to take the ninety-minute ferry ride from a nearby island. They left their five other children under the care of a neighbor.
Tatay’s task is simple: to cross the street to purchase an intravenous cannula, tubing, one liter of fluid and antibiotics. Fluid is needed to restore her sunken eyes. While he is away procuring supplies, Nanay (Mother) lovingly tries to wipe away the fever with a damp cloth. The young patient is thankful that she is escorted by both of her parents. She cannot tell you because of her profound weakness brought on by low potassium.
With sweat pouring down his face, Tatay returns. While I quickly re-hydrate his daughter, he is off to his next task. Tests on stool and urine are ordered and he must first pay the cashier before obtaining specimen vials. Family members collect and submit samples, and they are also responsible for obtaining the results and bringing them to the doctor. The same holds true for radiographs. The first set is of poor quality and must be repeated. Tatay returns shaking his head with a puzzled look. He is speaking, but I understand only after he hands me a bill. He has been asked to pay again.
We walk together through the empty, dimly lit corridors to the other end of the hospital. No words are exchanged, but we know that we are on the same team. I clarify the issue with the on-call radiologist and the second bill is torn up. Tatay turns to me with a gaze of gratitude and says in his best English, “You are good doctor.” “Salamat.” (“Thank you.”) “Thank you,” I reply.
Another prescription for antibiotics is written. Nanay looks at it and then looks at me with desperate eyes. “More?” I read behind the film that has gathered after a long night of worry. Agitated and pacing back and forth, her speech mixed with sobs and tears is too rapid for me to understand. Then, I hear the words walang pera (no money) as she presents her empty palms to me to demonstrate her poverty. Her hands rise toward the heavens asking for divine intervention and all I can do is think to fill them with tears of my own. She takes off her ring and shows it to me. This valuable investment in her daughter’s life could cover the expenses. It was once her mother’s and she had planned on giving it to her daughter eventually.
I could not think of ways to cut costs. We already had been prescribing cheaper generic medications. Also, there are no doctor’s fees at this hospital; had there been, we would have waived them. A resident gives me a slip of paper from behind signed by the senior house officer. It is a coupon to reduce medication costs given in the most dire of circumstances. The mother of the child in the neighboring bed hands a few pesos to Nanay. The gesture saves not just the patient, but also the family heirloom, both beyond value.
A bata (baby) is brought to us by her lola (grandmother). She has just been born at her home, where her mother is recovering from delivery. She has been breathing rapidly and eating poorly, and a clinical diagnosis of neonatal pneumonia is made. Appropriate antibiotics are started. However, the child has more and more difficulty breathing as night falls. The nurse on duty (one of the two watching over sixty ward patients) writes a note and instructs Lola to find the physician on duty. Lola is also the pager service.
Lola finds us in the emergency room busily triaging new patients. She hands us the note with a look of calm aloofness. Expecting to see a minor request, our expressions change drastically upon reading the note. We run through the mud to the pediatric ward behind the hospital.
We find Bata in a small crib just outside of the neonatal unit since all the beds are full. She is breathing about twice per second and her lips are becoming dark. The resident places a breathing tube to assist Bata’s respiration. A bag is used to fill the small lungs with oxygen. Ventilators are available, but renting one for a single day takes food out of the mouths of a family of four for an entire week. Unable to afford this technology, Lola has to ventilate by hand. She is responsible for the life of her granddaughter to a degree that is almost unimaginable. A small squeeze of the ambo bag every second is the assignment charged to Lola. With this baby’s life literally in her hands, she performs this task dutifully.
Without the direct touch of her grandmother, Bata is bathed in the warmth of the only incubator in the hospital. Its 100-watt light bulb’s golden hue offsets the blue tint of the baby’s lips. I place a feeding tube through Bata’s mouth into her stomach to provide nourishment in these critical early hours of life. Feeding her granddaughter five milliliters of formula every hour using a syringe is added to Lola’s list of duties.
Lola begins to tire and asks to take her granddaughter home. Lola does not fully understand the severity of Bata’s condition. I explain that Bata is not currently able to breathe or eat independently; assistance from those who love her is essential for Bata’s survival. The family is compelled to stay and I help Lola call some friends and family for help. Four people, ranging from young to old, arrive and a rotation develops to ensure consistent respirations over the next thirty-six hours until the baby can be extubated. After a few more days of antibiotics, Bata leaves the hospital in the arms of her loving mother.
Chest pain is the symptom that brings a thin forty-six year-old man to our immediate attention. Given the high prevalence of heart disease in a nation raised on salted meats and coconut milk, heart attack is our first consideration. A simple electrocardiogram would be able to tell us if he needed immediate life-saving medication, but the ECG machine in the emergency room (on loan from Spain, as is most of the other equipment here) no longer works.
The patient begins coughing violently and produces a cup of fresh red blood. His long history of cough with night sweats suggests to us that he has tuberculosis. His destination will be the isolated “infectious” ward while his sputum is analyzed for bacteria. With his continued coughing overnight and the paleness of his skin in the morning, he needs a blood transfusion.
The blood bank is always in very short supply, and the fastest, most reliable way to get blood is to ask a generous family member or friendly student to give their own. Moments after a call is made, five nieces and nephews arrive requesting to donate blood for their tito (uncle). Many of them stay in case he needs more blood or to run to the pharmacy when more medication is requested. More important, they bring life and laughter.
At night, the ward is as full as a can of sardines. Tito’s bed has two people, with three others on the floor beneath him and in the aisle. The other ten patients in the ward attract similar support groups of their own. All are crowded into a room the size of a small classroom. There is no complaint about space as everyone finds a comfortable niche. The windows are always open and electric fans constantly hum. A humid breeze is able to pass through to bring relief from the heat of the bodies and the tropics. I step gingerly to avoid the many supporters and follow the IV tubing to find my patient. In a week, after transfusions and medications, Tito is able to go home to finish his course of government-supplied anti-TB treatment.
In the Philippines, your family is your life line, the ultimate patient advocate. Family and patient cannot be separated. Young and old offer warmth, nourishment and companionship, no matter how seemingly grave or innocuous a situation might be. Their breath is your breath. Their life-giving blood flows through your veins.