6-21-08 – Esmeraldas, Ecuador
She is sixty-two years old with mismanaged diabetes and does not speak much. Perhaps this is just her personality, or perhaps she fears I might take her foot. I don’t know yet that I might take her foot because someone tied a ratty yellow tablecloth around the ulcer, and it still hides the wound. The doctor has not yet taken a look either – just a sniff. That’s why I’m alone with the woman up on the second floor in an isolated room where cleaning won’t contaminate the ER’s resources – but the ER’s resources are already unclean, so I don’t know why I’m up here.
“Como se llama, señora?” I ask, using the usted form to show respect. She tells me her name and I try to start a conversation that doesn’t go anywhere, mostly because my Spanish is only functional, not fluent, and therefore debilitating at 2 o’clock in the morning. When we unravel the rag, I see that it was just a placeholder for a quarter of the underside of her foot that was missing, eaten away by disease. The edges are black, and the inside a moist rotting gray that squishes when I press it with my finger. Fanned out at the crater’s base lies plantar aponeurosis, a covering of tendons - the strings that pull on toes. She walks on it without pain, but when she tells me this there is an upward inflection at the end of the sentence, a subconscious effort to convince me it is not as bad as it looks. But really this is worse; it means her nerves have festered away too, along with the padding of skin and fat. She walks, then, only on tendons and muscles, both of which naturally lack sensation.
I want to be a surgeon because I like working with my hands; the OR is challenging and fascinating, and I don’t mind the blood. But if I want to help this woman, I have to cut off all the dead tissue – and this is harder for me because I’m in a drab room and I’m holding her leg and I can see her face. And I can see when I reach for the scissors that she doesn’t want me to cut, so I tell her not to look, that it won’t hurt, and I cut until it bleeds – a sign that what’s left is alive.
This is the first I’ve written about chronic disease in the northwest corner of Ecuador, but not because it is rare. It exists, and it is everywhere. Diabetes is out of control. Apart from trauma, it is arguably the most common disease seen in the ER, and second on the street only to HIV/AIDS, which has already infected one out of every five persons in the city. I’ll admit my ignorance that before arriving at this hospital I thought of diabetes as being an illness that primarily affected the United States – and primarily the Midwest, where one finds some of the highest obesity rates in the world. But I’m much more aware of diabetes here than I am back home because the disease is more difficult to manage in the developing world. People cannot afford glucose monitors to check their blood sugar levels. Because of this, the disease progresses, and because it progresses, it finds itself in the ER in patients who are missing feet – or at least, last night, a quarter of a foot.
She is sixty-two years old with mismanaged diabetes and does not speak much. Perhaps this is just her personality, or perhaps she fears I might take her foot. I don’t know yet that I might take her foot because someone tied a ratty yellow tablecloth around the ulcer, and it still hides the wound. The doctor has not yet taken a look either – just a sniff. That’s why I’m alone with the woman up on the second floor in an isolated room where cleaning won’t contaminate the ER’s resources – but the ER’s resources are already unclean, so I don’t know why I’m up here.
“Como se llama, señora?” I ask, using the usted form to show respect. She tells me her name and I try to start a conversation that doesn’t go anywhere, mostly because my Spanish is only functional, not fluent, and therefore debilitating at 2 o’clock in the morning. When we unravel the rag, I see that it was just a placeholder for a quarter of the underside of her foot that was missing, eaten away by disease. The edges are black, and the inside a moist rotting gray that squishes when I press it with my finger. Fanned out at the crater’s base lies plantar aponeurosis, a covering of tendons - the strings that pull on toes. She walks on it without pain, but when she tells me this there is an upward inflection at the end of the sentence, a subconscious effort to convince me it is not as bad as it looks. But really this is worse; it means her nerves have festered away too, along with the padding of skin and fat. She walks, then, only on tendons and muscles, both of which naturally lack sensation.I want to be a surgeon because I like working with my hands; the OR is challenging and fascinating, and I don’t mind the blood. But if I want to help this woman, I have to cut off all the dead tissue – and this is harder for me because I’m in a drab room and I’m holding her leg and I can see her face. And I can see when I reach for the scissors that she doesn’t want me to cut, so I tell her not to look, that it won’t hurt, and I cut until it bleeds – a sign that what’s left is alive.
This is the first I’ve written about chronic disease in the northwest corner of Ecuador, but not because it is rare. It exists, and it is everywhere. Diabetes is out of control. Apart from trauma, it is arguably the most common disease seen in the ER, and second on the street only to HIV/AIDS, which has already infected one out of every five persons in the city. I’ll admit my ignorance that before arriving at this hospital I thought of diabetes as being an illness that primarily affected the United States – and primarily the Midwest, where one finds some of the highest obesity rates in the world. But I’m much more aware of diabetes here than I am back home because the disease is more difficult to manage in the developing world. People cannot afford glucose monitors to check their blood sugar levels. Because of this, the disease progresses, and because it progresses, it finds itself in the ER in patients who are missing feet – or at least, last night, a quarter of a foot.*First picture comes from "Color Atlas"
No comments:
Post a Comment