I toss and turn in bed, trying to fall back asleep; I have only a small cushion of time between getting up and heading to the hospital. I’m a third-year medical student doing my medicine subinternship. I have the choice of going to work or staying in bed a little longer.
On the other side of town, Ms. Garcia doesn’t have much choice about heading to the hospital: She’s bleeding from her nose and rectum. Standing in a puddle of blood, she calls 911.
The dispatcher doesn’t speak Spanish. Impatiently, Ms. Garcia hangs up the phone. She and her husband trudge several blocks through the blistering cold Chicago winter to the emergency room.
The ER triage nurse takes Ms. Garcia’s history. Ms. Garcia is so cold from her trek that the nurse can’t get a temperature reading. Ms. Garcia is moved to a back room to warm up.
The ER physician examines Ms. Garcia, draws labs and gives her a large quantity of IV electrolyte solution to rehydrate her. He finds that Ms. Garcia has dry blood in her nose and rectum and enormous bruises on her arms and legs. Her lab results show that her blood isn’t coagulating as it should.
Three months earlier, Ms. Garcia was prescribed the blood thinner warfarin following knee surgery. The ER doc can’t figure out whether she’s still taking it; he doesn’t speak much Spanish, and Ms. Garcia doesn’t speak much English. To help her blood to clot faster, he gives her vitamin K. Finally, she’s admitted to the medicine floor, where my medical team is preparing for morning rounds.
My co-intern stops me in the hallway. ‘”Hey, I couldn’t figure out whether Ms. Garcia is still taking warfarin,” she says. “Can you talk to her after we finish rounds?'”
‘”Sure, not a problem,'” I respond.
I’m one of the few medical students fluent in Spanish. We treat a large population of Spanish-speaking and medically underserved patients. Having grown up in the same type of community, I’m starting to realize how my understanding of the language and culture puts me in a unique position to improve these patients’ lives.
Rounds begin, and we enter the dimly lit room where Ms. Garcia lies in her hospital bed.
‘”Good morning, Ms. Garcia. ¿Cómo está?” asks the attending.
“No muy bien, el jugo me hizo daño.”
“What is she saying?” the attending asks me.
“She’s stating that juice made her sick,” I respond.
“Ask her if she’s taking warfarin, also known as coumadin.”
“Sí, I was taking the coumadin the way the surgeon prescribed,” she says in Spanish.
Seeing Ms. Garcia lying there, mumbling her answers, I reflect that she’s probably all too familiar with the medical system; after all, she’s seventy-one years old and has been a patient for over twenty-five years. From her perspective, it must seem like doctors always come in, speak to her, then leave without checking to see if she understands anything. I remember seeing my own mother try to navigate the medical system. Ms. Garcia’s defeated expression looks all too familiar.
When the attending pauses, Ms. Garcia stirs. “Ay, doctor, me duelen los huesos y las piernas. Ay, doctor, el jugo me hizo daño.” (“Doctor, my bones and my legs hurt. Doctor, the juice did me harm.”)
“Can you look into this juice, if you have time today?” the attending asks me, while Ms. Garcia’s husband speaks Spanish to the intern. I stand listening to the cacophony of Spanish and English.
“Since I drank the juice, I’ve had pain in my legs and my belly. Look, doctor,” Ms. Garcia says in Spanish, pointing to her bruises.
My team doesn’t pay much attention to her story. We’re medical professionals, concerned only with tangible medical explanations. We don’t care about juice. We assume she’s been taking too much warfarin; it’s the only possible explanation for her test results.
Still, this juice must have some significance, I think. So, when rounds are done, I go back to Ms. Garcia’s room. I close the door behind me and approach Ms. Garcia and her husband, who sits beside her bed.
“Buenos dias,” I say. “¿Cómo están?”
“Gracias, mijo,” Ms. Garcia says. (“Thank you, my son.”) This endearment signals that she knows I’m here to listen. She knows we’re both from the same kind of community. When an elder speaks, one listens.
Ms. Garcia tells me her story from the very beginning. How, as a child gymnast, she suffered a few big injuries. She wanders off into details–how she was born in Ecuador and moved to Tepic, Nayarit, in Mexico. Finally, she describes her chronic knee pain, and how it didn’t respond to different remedies. She trusted that surgery would improve things, but now it feels like she’s worse off.
“I drink juice because an herbalist in the community told me it’s good for my body,” she says, “and now I feel sick.”
I ask Mr. Garcia if he can bring in all her home medications–and the juice.
He returns shortly with a bagful of medicines and a goji berry drink. Reading its ingredients, I see Lycium barbarum. Looking this up in the literature, I find reports that Lycium barbarum interacts with warfarin.
I hurry to my medical team.
“I think I figured out why Ms. Garcia’s coagulation numbers were elevated.”
“What do you mean?” asks the attending.
‘”She was drinking goji juice, which contains an ingredient, Lycium barbarum, that interacts with warfarin.'”
“Aha! Interesting. Please present this to the new attending and the pharmacist who’ll round with you next week,” he says. (A new team is scheduled to start then.) “They’ll appreciate this case.”
Over the next two days, Ms. Garcia gets better. Her blood coagulation improves. The team decides that she can go home.
At discharge, I translate for the nurse who instructs Ms. Garcia how to take her warfarin correctly. Despite my having offered my team a plausible explanation for Ms. Garcia’s faulty coagulation, they still assume that she didn’t understand how to take her medicine. I find it ironic that, faced with their own ignorance of Mrs. Garcia’s language, they’ve concluded that she was the one somehow lacking in comprehension.
As a cultural nexus, I feel a dual responsibility–not only to educate Ms. Garcia about alternative supplements and their interaction with warfarin but also to educate my team about her case.
As Ms. Garcia is leaving the hospital, she grabs my arm, looks into my eyes and says, “Gracias, doctor.”
I smile, because up to now she’s called me mijo. Now, in her eyes, I’m a doctor. Before I can respond, she’s heading through the door, holding onto a cane with one hand and her husband with the other.
Thank you, Ms. Garcia, I think, for reminding me how important it is to listen to the details in a patient’s story.
And for making me a better “doctor.”