I have been a practicing Physician Assistant (PA) for over 20 years. People are still not always sure what I do, but this no longer bothers me. My focus is on delivering high quality and compassionate medical care to my patients, and I let the rest speak for itself. I am so proud to say that my PA colleagues are some of the most interesting people I have ever met. PAs often arrive at medicine through the side door. We were paramedics, EMTs, operating room technicians, midwives, chiropractors, acupuncturists, nurses, teachers, and artists.
I was a fine arts major in my former life, which gives me a unique perspective and, perhaps, a more holistic view of medicine. When asked during my admissions interview for Stanford’s PA program what my background in art had to do with medicine, I replied, “Art has taught me to pay attention to detail. In medicine, paying attention to details is so crucial, and some of them are so subtle you can completely miss the point.” In my spare time I am involved with a volunteer program at Roberto Clemente Clinic, a small rural clinic in southwestern Nicaragua. During one of my trips a couple of years ago I ran an OB/GYN clinic; a service that is not often provided in the area. Typically about two or three days after I arrive in town, word gets out that the female “doctora” is back, and before I know it there is a line out the door of women seeking care.
One particular trip, the pediatrician came to me at the end of a long day concerned about one of the mothers of a baby that he had just seen for a newborn check up. The baby was not gaining weight and the mother, only 14 years old, was paralyzed with fear for her child. The pediatrician had spent some time counseling the young mother on how to breastfeed and how to watch for signs of dehydration in the infant. He was not convinced that she had an adequate supply of breast milk. The nursing student brought the mother into the consultation room and weighed her. She weighed about 82 pounds. Her eyes were wide and fearful, like a deer in the headlights. We handed the baby to the grandmother, so that I could focus on the mother. We went into the exam room for some privacy and I began asking her questions.
What kind of delivery did she have? Was the father involved? Was she in any pain from the delivery? How was breastfeeding going? What was her support network at home?
She had been able to have a normal delivery, but had required a large episiotomy. The baby had been born one month early with a birth weight of 5 pounds 2 ounces. That day the baby weighed in at 4 pounds 6 ounces, not more than 10% of birth weight lost. The mother was so tiny I had a hard time even picturing her carrying a child. Her exam revealed lactating breasts that were so engorged I could barely touch them. She was running a low-grade fever of 100.4 F, was flushed, and looked dehydrated with very dry lips and tongue. Her blood pressure was 98/58. Her hair was dry, brittle, unwashed and pulled back. I was fairly certain her low-grade fever was due to breast engorgement and dehydration.
I was wondering how she was even able to sit down long enough to breast-feed her baby without excruciating pain. We went back into the consultation room and the baby was fussing and rooting, clearly hungry. I asked the nursing student to go and fill a plastic bag full of ice and to try to find some pillows so that we could create a comfortable seat for the mother to settle in with her baby. We encouraged her to take off her blouse for more comfort, and gave her lots of filtered water, which she gulped down with enthusiasm, glass after glass. And then we just sat; the four of us, and the baby. I don’t know how long we were there, but it was dark outside when we finally left the clinic. The baby would latch on for a few seconds and then either fall off of the breast or fall asleep. We talked about the weather, her home on the outskirts of town where she lived with eight other family members in a small house with a dirt floor.
We talked about the baby and her eye color and beautiful thick black curly hair, and we waited some more. There were long periods of silence punctuated by little squeaks and grunts and the cries of a newborn. The grandmother would occasionally fuss with her daughter and grandchild, wiping her daughter’s sweaty forehead and neck with a red bandana and telling them both in a scolding but affectionate tone that they needed to eat more. We continued to sit and wait. At one point when none of us were really watching the baby latched on and began to nurse. We all held our breath for a second and let out a collective sigh of relief. The baby fell into a deep sleep with the look of a drunkard on her tiny face. The mother started crying and said this was the first time her baby girl had been able to latch on since birth. She had wanted more than anything to breast-feed her baby, especially since a clean water supply was difficult to obtain and formula was too costly.
So, we discussed how she could boil water at home for sterilization, and how to obtain a water filter from a nearby village to make sure she did not become dehydrated again. I walked them outside into the night air, hot and humid, and hugged them goodbye, and told the girl that she would be a great mother and that her baby would thrive. The ending of this story involves no real heroics and no adrenaline filled trauma-save. It ends one year later when I was back in Nicaragua at the clinic. We were running a health fair for the surrounding villages, and had about 1,000 people come through our clinic in one day.
At the end of the day, I was sitting in one of the exam rooms covered in sweat, exhausted, and seeing my last patient, when a local nurse came and got me saying that I had a visitor in the waiting room that had been there for the past 3 hours. I walked out and there she was—the young mother that I had helped one-year prior. I barely recognized her. She had put on weight and her face was radiating a huge smile. She was impeccably dressed in skinny jeans, a flowing blouse and strappy sandals. Her hair looked thick and healthy. She was holding up her baby girl for me to see, now a year old, chubby, and just as beautiful as her mother. She had dark sparkling eyes, even more thick black hair, and a toothless, dimpled smile.
As I walked up to them, she practically threw the baby in my arms, laughing. “Look!” she said to me in Spanish, as we hugged, “Isn’t she precious?” I was absolutely stunned, speechless. We both started crying.
“Thank you so much for what you did and how you helped me,” she continued, “Without you, I would have never been able to do it, you know, to have the confidence that I could be a good mother. I will never forget you. I wanted you to see how healthy she was.”
“It was all that strong milk you have,” I joked. I tried to remember our exact encounter one year before. What had I done that had been so profound? The answer is not much, and sometimes that’s just the right amount of medicine. Sometimes just sitting and being present with someone, paying attention to detail without judgment, and supporting the patient is all that is called for. I try to remember this as I rush through my busy days from one patient to the next. Sometimes we just need to rule out the life-threatening concerns and then just stop, talk, and listen, realizing that every now and then the patient just needs practical solutions, like clean water and a comfortable place to sit.
