Our patient had a broken back. After falling from a tree three weeks earlier, he was unable to move his legs. Now he was in our clinic with his family, asking for advice, showing us an X-ray he’d had taken days ago by the nearest machine, two hours’ drive away. Things had improved, he told us, since a traditional healer had manipulated his spine. Now he could twitch his quadriceps, and he’d regained some feeling in his calves. But he still couldn’t walk. Could anything else be done?
Pak Hasan (not his real name) was among many patients at Alam Sehat Lestari (ASRI), the rural Borneo clinic founded by Kinari Webb, M.D. ’02, who forced me to think outside my emergency medicine training. [For more on Webb, see “A Life’s Work in Indonesia,” Yale Medicine, Autumn 2008; and “Health and Ecology in Borneo,” Yale Medicine, Online Extra, November 2009.] Such an injury would never appear in my ER untreated and three weeks out, nor was I accustomed to relying on a lone X-ray. Moreover, I wasn’t trained to advise our young Indonesian doctors on a neurosurgical decision like this one. But the nearest CT scanners and neurosurgeons were a jouncing eight-hour speedboat ride away—hardly ideal for someone with an unstable spinal fracture. Moreover, the costs of trip, scan, and neurosurgeon would devastate the family’s finances. They might be tempted to illegally log the rain forest to cover the expense, a type of destruction that Webb’s work is dedicated to preventing. And to what end? Would fixing the broken fragments in place, standard of care in the West, do Pak Hasan any real good?
Questions like these arise every day in low-resource medical settings. “We try to save lives and livelihoods,” Webb told me, shortly after I arrived in March for a month’s stay as a clinic volunteer. I soon saw what she meant. When testing means an expensive trip out of town, it isn’t appropriate to order chest X-rays on all patients who present with months of coughing, nor chem 7s on sick diabetics. In a country with few safety nets—where a family’s $20 shortfall can keep a child out of school, where some people can’t make it to clinic because they can’t afford to rent a motorbike—costs must be borne in mind. Should we ask the family of a child who needs risky heart surgery to liquidate their meager assets in order to fly him to Jakarta? Should my fellow volunteer, an American internal medicine physician, recommend a costly CT for a patient with a persistent post-traumatic headache if it meant the family would have to sell two cows? (“If your clinical acumen’s not worth two cows,” her physician father told her over the phone, only half-jokingly, “I shouldn’t have paid for medical school.”) She decided against the CT. Her patient did well.
~ ~ ~ ~ ~ ~ ~ ~ ~ ~
Webb has a warm and inclusive leadership style, and the sunny clinic is collegial. My responsibility was to help newly-minted Indonesian doctors think through their cases; we discussed the vivid pathophysiology we saw and consulted textbooks. The staff and volunteers frequently broke into laughter, and that camaraderie continued after hours in the “boys’ house” and “girls’ house” where unmarried staff lived apart. (As did I and my boyfriend Roberto Cipriano, an architect who had come to advise Webb on a planned new hospital.) Many of the staff come from faraway parts of Indonesia; they believe as Webb does that poor health, poverty, and environmental degradation are linked, and that these problems must be addressed simultaneously. The clinic’s organic garden, for example, which supplied vegetables alongside the rice and local fish in our daily lunches, is often staffed by patients’ families, who work there to defray medical bills they might otherwise pay through illegal logging. (Some later earn money by starting their own organic gardens.)
Cats, ants, and cicadas, wending their way through the clinic on their own business, were part of its casual and lively atmosphere. Indeed, Borneo seethes with life, both outdoors and in. Spiders and scorpions occasionally surprised us from dark corners—in the girls’ house a green lizard lived in the ceiling lamp. From my bed in the mornings, I often heard my housemates shooing out the rooster and hens that would herky-jerky their way into the house through an open door. I would gaze at my mosquito net, listening to muffled cries and the birds’ affronted clucks on the other side of the bedroom door, and laugh till I cried.
~ ~ ~ ~ ~ ~ ~ ~ ~ ~
Laughter is a necessary prophylactic in the face of the tragic cases, the ones you suspect you can’t do much about. There was an emaciated woman in her 30s who had months of belly pain and wore a haunted look. An examination revealed a hard mass sitting in her upper abdomen, but God only knew what it was. We crossed our fingers, admitted her, and started her on antibiotics, hoping it was an abscess instead of the cancer we feared.
More often, though, what struck me was how far clinical acumen and basic medications can take you—and how a clinical response can be as intellectually satisfying as a lab result. A thin, listless child with fevers, cough, bellyaches, and a failure to gain weight is likely to have intestinal parasites, malaria, and/or tuberculosis; empirically treating the first two often results in a heavier, newly ebullient child at follow-up. If not, there is still time to pursue TB. Patients with characteristic belly pain often get better after a course of therapy to eradicate the commonplace ulcer bacterium Helicobacter pylori. And when the nearest cardiac cath lab is in Malaysia, a hypertensive, middle-aged man with angina-like chest pain will wind up on aspirin and antihypertensives, whether or not our EKG machine is working.
Sometimes you improvise. No one could find a vein for an IV on one feverish newborn, nor did the clinic have central or intraosseous equipment to place the other types of lines we would have resorted to in the states. So we visited the newborn’s house three times a day to give antibiotics by the intramuscular route—that is, until persistent fevers and a second blood smear tipped us off to malaria. For Pak Hasan, we sought expert advice from the United States via telemedicine. I held the X-ray against the sky, took a digital photo, then e-mailed it to a friendly Kansas neurosurgeon I’d met on a relief mission in Haiti. He recommended surgery, and Pak Hasan managed to travel to the city. But we do not know how it turned out; he hasn’t yet returned to the village. We have a wheelchair waiting for him.
As with the work of a country doctor anywhere, the rewards range from satisfying to breathtaking. One night, an Indonesian doctor, Webb, and I attended a childbirth on the floor of the mother’s house. Though we sat for hours on the hard boards and had to carefully set aside and reuse our sterile gloves for vaginal examinations, we didn’t have to worry about dropping the infant, nor was neonatal hypothermia a concern in the warm air. The baby’s family was thrilled to welcome a healthy son, and it was lovely to have seen the birth go right. When we emerged from the house at 4 a.m., toting our equipment, we looked up at the night sky. There was the Milky Way, bright and magnificent. “Welcome to being a doc in Borneo,” Webb said, and we embraced.