El Jugo Me Hizo Daño

February 2010:

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.”

I do.

“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.”

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C.A. Rivera is a physician-writer born and raised in Los Angeles. His writing has appeared or is forthcoming in Ars Medica, Garfield Lake Review and Signs of Life, a literary anthology of experiences of illness and caregiving. He participated in the Bread Loaf Writers’ Conference with the writer Sigrid Nunez and is working on a collection of short stories. He lives with his family in L.A., where he is a practicing gastroenterologist. “I write because writing, like the practice of medicine, brings me closer to understanding the human soul.” You can find him at twitter.com/_CARivera.

Comments

11 thoughts on “El Jugo Me Hizo Daño”

  1. Patricia Shahamiri

    Dr. Rivera is the example of why we need to admit a diverse student body to our professional schools. In my lifetime, admission was once primarily focused on White Anglo Saxon men particularly of high social standing. The arrogance that went with the profession and can still be witnessed today, the attending in our story comes to mind, was brought into the profession from men who believed themselves to be superior by birth and training.

    As a patient whose primary language is English, I can say that it can be very difficult to communicate effectively with hospital staff. The stress of answering questions over and over again, feeling as though you aren’t giving them what they want and so they keep battering you with more questions. It feels like an interrogation. Often, I sense frustration from staff, as if I am not cooperating to give them what they want. Verifiable data is the penultimate driver of diagnosis and treatment and whatever I try to describe or contribute is treated as subjective and much less important.

    Dr. Rivera demonstrated an acknowledgment of Ms. Garcia’s value as a person, respect for her position in their community and a willingness to invite Ms. Garcia and her husband to participate in understanding the origin of her anti-coagulation problem. He offered the time to listen, discuss, and collaborate involving her as an important part of her own care. She became much more than a case. She was a person. Kindness is a language we all understand.

  2. Margie OConnor, LMSW

    Whenever I encounter someone who condescendingly asks… “ they are in America , why don’t they just learn English?”
    I wonder how they would fare, living in a new country and trying to navigate the new culture, let alone a new language.
    Try going to a foreign country as an adult, and see how difficult it is to learn a new
    language.
    We need compassion, not judgement . Every person deserves respect and dignity.
    I’m so glad Dr. Rivera was there that day. God bless him.

  3. Christine Jeffries

    This is a question, not a criticism. Why hasn’t Mrs Garcia, a patient for 25 years, learned to speak English? People from all around the globe move to the US, many from countries where the native language is very dissimilar to English, who learn to speak coversant English within the first year. Clearly it would be to her advantage to speak the predominant language.
    You say you have insight into her culture. Can you explain it?

    1. I can think of several hindrances to her not learning the language but first let me say that it is not uncommon for the first generation of an immigrant family to not learn English.
      English is a difficult language and some immigrants are not securely literate in their native language. Imagine trying to learn French is you could not read English well. Then a major path to learning a new language, the written word, is not at your disposal. I remember telling a patient in Spanish that they needed to go to area 7 and and that there was a sign down the hall. Her response was that she didn’t know her numbers.
      We often assume too much.

    2. As someone who lives and works as a physician in another country – and have been here for 5 years – and have learned the local language fairly well – I ALWAYS take a translator with me if I have to go to the hospital and see another doctor. Trying to discuss complicated medical care in a foreign language is DIFFICULT. Lots of nuances, new vocabulary (its not the vocabulary I use every day and I work at a hospital -but discussing the liver and delivering babies are 2 sets of vocab), and the stress of a system I’m not used to. Mrs. Garcia might speak decent English and STILL struggle in a hospital setting.

      1. Also, I didn’t really understand that until I moved here and needed to seek care. My appreciation and understanding for what immigrants deal with and why they might not seek care quickly or trust the system has increased exponentially.

  4. How true this interaction is and how sad it is for anyone dedicated to quality patient care
    This student served the patient and the care team remained ignorant Why did they go into medicine?

    1. When the attending gets vital information, he says:
      “Interesting. Please show to the attending and
      Pharmacist who will be rotating next week.”

      Next week? Will the patient be alive next week?

      Obviously, the current attending feels no obligation,
      no personal commitment to the patient.

      Meanwhile it’s hard to find people who speak Spanish to
      Care for folks in an large urban hospital ?

      Do the folks who admit people to med schools and
      pick the docs to work in their hospitals realize that in 20-25 years the majority of Americans will not be white?.

      This is is not because of illegal immigration, but because
      legal Hispanics who came here long ago continue to want larger families with 3 to 5 or even 6 children when they marry.

      Meanwhile, today, young married white couples choose to have zero,, one or two

      That is clearly their choice. But given changing demographics we need many more Spanish-speaking
      Docs in many of our hospitals.

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