Friday, April 2, 2010
The malingerer. The bane of our existence as practitioners of emergency medicine. The patient who walks into the ER faking an illness for secondary gain -- sometimes for attention, sometimes for narcotics, sometimes for an excuse to be absent from work.
Malingers think they are so clever. Yet their behavior is transparent and predictable. The patient who limps in on one foot and limps out on the other. The one who chats happily in the waiting room, but then moans as the doctor walks in. The physical exam that makes no logical sense, consistent with no known disease process and no pattern of human anatomy. The frustrating, time consuming, irritating, abusers of the medical system. The malingerers.
So, wasn't I surprised when the malinger walked through our gate in the form of a eleven year old boy Ramon. He had been a resident of our hospital for nearly two months, healing from a severe foot wound sustained when he fell from the second story of his house during the earthquake of 12 January. Two weeks ago, declared healed, he was finally discharged home to his neighborhood -- the slums of Pele, from which we had initially plucked him. Pele is a 30 minute drive through the city from our Field Hospital, so it is rather amazing to me that Ramon has magically appeared at our gate several times -- alone, without a guardian. Despite his mere 11 years of age, Ramon demonstrates keen urban street smarts necessary for survival in the slum he calls home. Each time he has appeared, he is welcomed in, greeted by fellow patients who have become his friends, fed dinner, and offered a cot to sleep on. We examine his foot. "Looking great, Ramon!" we say. Each time, we allow him to stay overnight, only to bring him home on our next truck visit to his slum. This might seem uncouth -- to keep a child in a hospital without his guardian's permission -- but in a city in which many families have no phone and no way to be contacted, and in a slum too dangerous to be entering after dark, it is the safest solution for all.
Much to my surprise, on Sunday afternoon, Ramon approached me holding his stomach. "Fe mal..." he moaned, looking ill. An exam revealed a generally tender abdomen, but no fever, no change in vital signs. His severe wincing made me concerned for an early appendicitis. "Poor Ramon," I cooed, as I touched his cheek. "I think you need to rest today and we'll watch you closely."
And as I watched closely throughout the day, I was surprised at what I saw. A boy who giggled and smiled and joked with his bed neighbors, rolling hither and yon on his cot, swinging legs carelessly... but who morphed into a giant, grimacing, writhing form when he saw me approach his bed. "Ohhhhh, fe mallllllll...." He would moan. "oooohhhhhhhh...."
I was on to him.
"Where's the pain, Ramon?" I asked. He gestured all around his abdomen. "Is it here?" I asked touching his belly button. "Oui!" he said..."Yes!" "How about here," I asked, pointing to his hip bone. "Oui!" he said, moaning dramatically. I pointed randomly...to his ribcage, his left shoulder, his right kneecap. "Ooohhhh, fe malllllllll," he moaned. "It hurrrrts..." "Would you like some dinner?" I asked. "Yes!" he responded quickly -- confirming my suspicions that this was not his appendix -- as with that malady, the appetite is the first thing to go. I performed my favorite malingerer exam -- rolling his hair between my fingers. "Does this hurt?" I asked, touching the insensate hairs of his scalp. "Ohhhh, fe malllllll....it hurrrrrtsss..." he moaned. Liar. Bad liar.
I smiled internally as I stood and spoke in my stern but quiet doctor's voice.
Through a translator, I advised, "I see your stomach hurts you, Ramon. Why don't you eat something and get a good night's sleep. I am very sure it will be better in the morning, in time for you to return with us to Pele. If it's not, I'm afraid we will have to bring you to another hospital, because you will be too sick for us to care for you." He nodded, eyes wide. I patted his head. Within minutes of my walking away, he rolled on his belly, swinging his feet happily, chatting with the 12 year old boy in the cot next to him.
Can you blame him? A young, impoverished,malnourished boy from the slums, seeking three square meals a day, a soft, warm bed, a quiet courtyard, a supportive social network, nighttime singing that rocks the house, and an occasional movie projected on a cotton sheet hanging by the metal gate. Paradise? This has become his safe haven, from his slum, his poverty, and the painful and horrifying memories that are the earthquake. The earthquake that killed one out of every 10 people in his neighborhood. The earthquake that shattered his foot.
The next morning, Ramon walked up to me. "Do we need to take you to the other hospital?" I asked, pushing on his stomach.
"No," he responded. His belly was fine.
So, we loaded Ramon into the truck, and drove the thirty minutes back to his neighborhood. We hopped out and walked down the street and into a back alley. Before us stood a looming, teetering structure that was once a two story building, now leaning treacherously to the left, the front wall missing revealing the small rooms withing.
"That's my house," Ramon declared. My heart sank. Ramon's house. The house that he fell from when the wall to his bedroom shook off and crumpled to the street below. The house that still looms threateningly, like a nightmare; a house that blocks fall from with every minor aftershock.
I remember the command given by the Haitian president last month. "Haitian people, return to your homes. Leave your tent cities. Your houses are safe."
Does anyone come in to these slums? Certainly no engineer. No building inspector. I am sure not the President, who commanded the people to return to their homes. Ten weeks after the earthquake, this treacherous building looms, awaiting the next rumble that will rip down the next wall. A nightmare.
I turn to the malingerer. Now I understand. "You're not living in this building?" I ask, with deep concern.
"No," he replied. He walked past the building, between two narrow walls, into an open area behind the structures. Ramon's mother stood there, outside of a shelter made of a cotton sheet held up with four wooden spears. She greeted us and showed us her home. She was not surprised that we brought her son to her...not surprised nor questioning where he had been the last few days. The floor under the sheet was a makeshift mosaic of crumbled cinderblocks. There was no waterproof tarp to keep out the rains. No pad or blanket to sleep on. Just a cinderblock floor and a cotton roof. She was surrounded by five small children -- hers? Neighbors? Children taken in out of necessity, now orphans? No evidence of food...or cooking supplies.
"Okay, bye Ramon," Alicia our nurse and I said as we patted his head and turned to leave. We met each others' eyes with a knowing look. How do we leave this child here? How is this family surviving? Did we invest two months in his life, his recovery, to dump him here on the streets? With inadequate shelter? With the shell of his former house teetering just meters away? Does he have food? What happens when the rains come? How many other children are squatting this way? Statistics say perhaps one million Haitians are now living in flimsy tent shelters. How do we leave this boy here? How do we leave these people here?
I stare at his cotton house. I recall the rains that pour down every other night now, dumping 2-3 inches of rain an hour. And the rainy season is upon us. I feel helpless.
The motivation of an 11 year old street-wise malingerer, revealed.
We walk slowly back to our truck, Alicia and I. Speechless. Yet, unfortunately not surprised. As one stares out at the hillsides, the story is repeated, tens of thousands of times over.
Today we returned to Ramon's alley...and found him playing with his siblings. We presented him with a three person tent and a sleeping pad -- a donation from a nurse who spent a few days volunteering in our clinic. He stared in awe as we handed him the tent. He touched it hesitantly.
"This is for you and your family," we said. "It's not much...but maybe it will help."
He hugged us tightly. We hugged him back.
We walked away.
One life. One small bandaid. One gigantic hemorrhaging wound that is Haiti.
Mother Theresa said: "If you cannot help everyone, help one."