The weight of money – Balochistan memories

2012
Jones, Lanice

It was the upright posture that caught my eye. He was sitting cross-legged in the wheelbarrow, hands gripping his knees, chest rigidly erect, mouth open as he gasped for breath. Incidentally I noted the child pushing him, a boy perhaps twelve years old, but with the stunting of malnutrition he could have been fifteen. Behind trailed a woman shrouded in a black burka.

I adjusted my dupatta over my head, grabbed my stethescope and headed out the door to meet the wheelbarrow procession at the treatment room, noting as I hurried around the corner that two other wheelbarrows were lined up outside the door. A busy day in OPD, when wheelbarrows lined up like ambulances, I thought, grinning even though I knew that each individual story would house some horror; a burned child, a shrunken and handicapped elder, or in this case, a thin man gasping for breath.

“This one is next!” I called in, as the nurses unlocked the door to allow another burka clad woman to leave with her freshly bandaged toddler in her arms, a victim of open flame heaters in cramped mud and canvas huts. “He’s having trouble breathing.”

Gul Mohammed the male nurse helped the man off the wheelbarrow and onto the one treatment bed. “No, don’t lie him down,” I urged. “He can’t breathe - he needs to sit up. And get him oxygen!”

The burka woman had peeled off the head covering, her face broad and heavily lined. She handed me a rolled-up x-ray. As the two nurses settled the patient and fiddled with the wrench to open the portable oxygen, I held the x-ray up to the window. One of the other docs had been attending another patient and stopped by to look at the x-ray.

“Look at this!” I beckoned the doctor over. “This is from ten days ago!” The translucent black clarity of the right side of his lung field indicated a large pneumothorax.

Meanwhile the patient’s shirt had been removed, he was on oxygen but still gasping for air. His trachea was visible in his scrawny neck, clearly deviated to the left, as he worked his accessory muscles.

Gul Mohammed and the patient’s mother were conversing in Pashto to gather some history as I percussed and auscultated his chest, amazed even after all of the years of practicing medicine to find that the chest was hyper-resonant with absent breath sounds. “Has he been going around like this for ten days?”

The story slowly unfolded. The man was from Afghanistan, and he’d been coughing for some time. He suddenly developed severe shortness of breath and was taken to the hospital in Chaman, the Pakistani border town. They had taken the x-ray and removed some air with a syringe, but been unable to do more for him. He’d been slowly getting worse.
Wow! Here I was with a real, live pneumothorax, needing stabilization before transfer to the nearest government hospital. This wasn’t an intubated and anesthetized dog, this wasn’t an intubated pig, it was a real live person and I was going to have to do something quickly to sort things out.

I took a moment to point out the findings of the deviated trachea and the hyper-resonant percussion note, pleased with this excellent teaching case, as I thought about what to do next. Was I going to tape a latex glove tip to the needle and stick it in? Or put a 60 cc syringe on the end and try to extract air while the patient held his breath? Then what? Our facility was a Mother-Child Unit and we only treated men as an emergency step and then transferred. I’d have to get permission from our medical team leader to transfer the man with our ambulance, but there would be an extra cost in the government hospital for a chest tube, medications and we wouldn’t be able to pay for that.

I pulled out my mobile phone and called the MTL, quickly explaining the situation. I was given permission to use our ambulance, but then what? Theoretically I should needle the chest so he didn’t crump on the twenty-five minute ambulance ride. But he’d lasted ten days. What if I made things worse and he dropped dead in front of me? How would that look, the great white lady-doctor killing a patient she shouldn’t have touched?

Gul Mohammed explained to the mother that we could relieve his immediate shortness of breath but he’d need to go to the government hospital. We could drive the young man and his mother in our ambulance, but wouldn’t be able to pay for any necessary care.

Tears left dust-streaked tracks on her burnished cheeks as she spoke haltingly in Pashto.

“Her husband is in jail in Afghanistan. This son is a heroin addict. The younger son is mad. She has no money. She can’t afford even the simple treatment at the government hospital,” Mohammed translated.

What to do? I felt the weight of my cell-phone pouch tugging against my neck, aware of the sixty Euros of security money tucked inside, along with the three thousand rupees we had to carry in case we were abducted. It was forbidden to give gifts or money, and would create endless stream of desperate people were I to break the rules.

“Just give him some pills. They will leave with hope,” Mohammed suggested.

“I can’t do that. There are no pills that will help the air go away,” I replied, studying the man’s body. There were no track marks on his arms. How did he ingest the heroin? If he injected, did he have HIV? How old was he? He looked about twenty-five, my oldest son’s age. How would I cope if my oldest son was a heroin addict gasping for breath, and my youngest son was mad, the local expression for any kind of mental illness?

Beneath it all, there was this hidden desire, this itchiness of the fingers as I imagined pushing the needle in through the chest wall, fourth interspace mid-axillary line, straight out of ATLS. I’d never done it, and this guy was a goner if I didn’t do something. But what if I hit a vessel, if I caused a tension pneumo, if...if...if...

“Explain that I will remove as much air as I can, like they did in Chaman, and give him some antibiotics. It may re-accumulate and then he’d have to go to hospital. There would be nothing else anyone could do but do a proper chest tube.”

I was washing my hands as I spoke. ‘I need sterile gloves, a 16 guage needle and 60 cc syringe. Gul Mohammed, you will have to make sure he holds his breath until I tell him he can breathe.” I pointed to his left chest. “And you have to stand here, to give him support as this will hurt.”

I cleansed the chest wall, mentally reviewed the anatomy, reminding myself: “vascular bundle runs under the ribs.”

I pushed, expecting more resistance but the needle slipped through the tissue as if through butter. Gul Mohammed worked with the man to have him hold his breath, but it seemed so inefficient and ineffective. I wondered if there was a better way. Should I have tried the glove-finger technique? Should I have used an IV catheter? When would I know it was time to stop? Check the trachea to see it was midline?

By now the man was sweating and groaning, his face blanched, lips pale. I slid an occlusive dressing in place as I pulled out the needle. We sat him back against an upright pillow. His trachea was nicely midline, and he nodded his head when asked if his breathing was easier. Gradually his color returned and his respirations eased.

I wrote out a prescription for antibiotics and paracetamol as my own breathing slowed. A hammering on the door of the little treatment room interrupted us as Gul Mohammed was reviewing the instructions to go to the government hospital if things got worse.

“Doctor, they need you in the birthing unit. Twins.”

I gathered up my dupatta and flung it over my head to look culturally appropriate as I dashed twenty-five meters to the birthing unit, glad to have someplace urgent to escape to, the weight of my sixty euros weighing as much as a lead apron as my feet kicked up the dry dust of the baked Pakistani soil.

Theme: Family | Famille
Theme: Health Care Delivery | Prestation des soins de santé
Theme: Patients | Patients
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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