Asombrado

Asombrado is a word in spanish that means amazed.   I often feel amazed, almost overwhelmed at the fullness of life energy in children .   Just today one of my patients came in, a girl of 9, spirited and comfortable in herself, direct with me, full of plans--truly something beautiful to see.  It reminded me of  a book I read years ago called The Girl Within, and the notion was this: that girls are especially free and full of ideals around 9-12 year old--and when women face difficulties in their adult years, they draw on the strengths of this period to carry on.   Ever since I read this book, I've have a special appreciation for girls of this age--girls who are free to feel their strengths, before they get hit with becoming sexualized and concerned with looks.

Oakland General Strike

   I went to Downtown Oakland before work on November 4th.  It was the day of the general strike, and the sight of all the people clamoring for the human rights brought tears to my eyes.  People have awakened and are connecting with their anger and feeling their strength.  The big media, despite themselves, seem to be giving a lot of attention, because deep down, they, too, know that something is deeply wrong.

   I'm going to quote the some stanzas of a poem written by Langston Hughes:

 Let America be America Again:

Let America be America again.

Let it be the dream it used to be.

Let it be the pioneer on the plain

Seeking a home where he is free.

(America was never free to me).

***

I am the poor white, fooled and pushed apart,

I am the negro bearing slavery's scars.

I am the red man driven from the land,

I am the immigrant clutching the hope I seek--And finding only the same old plan

Of dog eat dog, of might crush the weak.  

***

O, let America be America again--
The land that never has been yet--
And yet must be--
The land where every man is free.
The land that's mine--
The poor man's, Indian's, Negro's ME--
who made America,
Whose seet and blood, whose faith and pain,
Whose hand at the foundry, whose plow in the rain,
Must bring back our mighty dream again.
Sure, call me any ugly name you choose--
The steel of freedom does not stain.
From theose who live like leeches on the people's lives,
We must take back our land again, America!

O, yes, I say it plain,

America never was America to me,

and yet I swear this oath--

America will be!
An ever-living seed,
Its dream
Lies deep in the heart of me.

We the people, must redeem
Our land, the mines, the plants, the rivers,
the mountains and the endless plain--
All, all the stretch of these great green states--
And make America again.

I want her to have what I didn't have

     Back in February I spoke about walking into exam rooms and intuiting that some children had special family support, from both parents or weved siblings who had love to share.  Just last week I entered a room to see a 1 year old girl who was with her father that day.  Many young persons of this age are upset at being in a doctors office given all the shots they have had already, but this little girl was pretty relaxed and it made examining her a lot easier.   After a while it occurred to me that this father was giving his daughter a lot of special attention.  I told him so and added that fathers play such an especially important role in the lives of their daughters. Asked him how it was that was so involved.  Then his story came out.
     His childhood was rough.  His mother left when he was three, and he hung out with his father, and then had a stepmother who was abusive.  Then he said to me: "I want her to have what I didn't have."   I told him he was doing very well and wished him a good day.   It's true: every parent at heart wants their children to have it better than they did.

Credit cards and economic justice

      My girlfriend has an eye for economic justice.  She was buyng some some supplies at a green builder's store in Berkeley, and learned this about credit cards.  For VISA and Mastercard, the merchant pays around 0.5% of each transaction to the acquirer, the bank that forwards the transaction to the cardholder's bank and routes the money back to them from the cardholder's bank.  The cardholder's bank also charges a fee to the acquirer which is passed on the merchant.  Fees can be 2% or more.  If the card is a rewards card, the merchant fees are even higher.  BUT!   If you use a debit card and enter the PIN on a keypad, the charge is much less, because the card-issuing bank is out of the loop.
     So, if you're dealing with a local merchant, a small business for example, use your debit card.  Not only will you lower their expenses, less money will be headed to those nasty banks back east.  And consider where you buy things, too, although Big Box and on-line discounts are tempting: buy local and the taxes stay local.

Immigrant Life Number 19

     It was 5 AM when a group of  heavily armed,  uniformed men broke down the front door to raid a house.  A ten year old boy who was sleeping on the couch awoke to see 15 men with guns drawn.  The men searched and ransacked the house and then handcuffed  the boy's father and 15 year old brother.   The paramilitaries did not speak the language spanish, so they made the boy and his sister translate.  The girl began to have an asthma attack but they wouldn't let her use her medicine.    
     This wasn't Iraq or Afghanistan and these weren't US soldiers.  They were a SWAT team in Oakland, California,  looking for a drug dealer, but unfortunately for this family, they broke in to the wrong apartment.   The suspect was actually in a neighboring apartment.  There was no apology by the SWAT team, nor was any compensation for the damage, nor any offer of emotional counseling.   There were given a form to ask for restitution of their broken door, but 4 months later they have not received anything. 

     I learned about this when the family came to my medical office 3 days later because the younger children of 10 and 12 years old were having anxiety attacks and insomnia.  Worst of all, the children had been afraid that their father would be deported.  A year ago a five year old boy was brought in for aggressive behavior.  His mother, a Salvadoran immigrant, said that the SWAT team that burst into their apartment were looking for her younger brother, perhaps a low level drug dealer, and in that raid the little boy's grandmother was pushed down.   I asked that mother a while later how things where, and her brother was back at home--I guess he was not such a dangerous figure after all.

     That morning in my office I felt  both sad and angry.  As a doctor and as a human being I care deeply for my families.   I've worked in East Oakland as a doctor for 35 years; the working class, immigrant families I know endure great hardships: poverty, violent crime, work accidents, deportation.  It's an outrage that these raids are added to their quota of suffering. 

     I've done some research about SWAT and what I learned is alarming.  Since the 1980s, when Congress mandated that the military make equipment available to civilian police as part of the War on Drugs,  as many of 70% of the police departments in cities of over 50,000 have formed  heavily armed SWAT units--and really, they are paramilitaries. 

     According to a report  by the Conservative CATO Institute, paramilitary units are essentially soldiers, and soldiers are supposed to use lethal force and initiate violence on command.  This contrasts with the police,  whose role is to apprehend suspected law breakers, with minimum force, and adhere to constitutional procedures.       

     Albuquerque  had to dismantle its SWAT unit after losing  several wrongful death lawsuits.  An outside evaluator said that, "They had an organizational culture that led them to escalate rather than de-escalate violence."   In 1997 a SWAT team in Dinuba California--population 15,000--killed an innocent man during a raid.  A jury awarded the family $12.5 million, and Dinuba, too, disbanded its SWAT unit.  Dallas and Seattle no longer send  SWAT teams on suicide calls or drug raids.  

     I made some calls to to the police review commission, the local city councilman's office, and a community organization dealing with police brutality.   The family, although they are un documented and risk deportation, decided to press their case with the police.  Maybe at least they'll get compensation for the damages to the apartment.   Meanwhile the children are anxious and have trouble sleeping.

  

It's not fair

     Today I saw an eight-year-old girl for her first visit to our clinic.  She was a bright, healthy girl, and her mother seemed very nicely attuned attuned to her.  The girl was a good student.  I asked her mother if the family ever got to eat together--amongst Pediatricians, this is felt to be a good thing for families: drugs and other risky behaviors occur a lot less when families are able to have dinner and other kinds of quality time together.  I assumed that this must be the case because the girl seemed so together.
      I learned that in fact, dad spends a lot of time in Mexico helping his family, and this mother cares for her three children AND works two jobs--one from 8:30 to 4:00 and the 5:00 to 10:30PM.  She kind of joked that her chldren are raising themselves--but clearly she is doing a great job because this girl just shined--and wanted to be a teacher when she grew up--but there has to be some cost.  
      Mom had four siblings, and felt she was so short because they had been malnourished.  Like many immigrant parents, she had left school and gone to work at an early age, eleven, in her case, taking care of other children.  I can only picture her own mother being a skilled manager of scarce resources, and who taught this mother well.  
     I would give anything for her to have a chance to finish high school someday and have a chance to go back to school and  enjoy learning, run a day care or become a teacher--to have a chance to do something for herself.   It's unfair that it is so hard for working people, that immigrants are scapegoated.  And I know a many more immigrant parents as worthy as she is.   We need a better world for that to happen.

Diagnosis

     Diagnosis is an essential and challenging part of medicine.  I feel satisfied when I get it right--unless I've confirmed a new case of leukemia or something else with a possibly bad outcome. 
     When I fail to make a diagnosis, I feel bad.  Twenty five years ago I was working a Saturday drop in clinic and a boy of around 18 months was brought in.  He was in and out of being alert and the rest of the time moaning and falling asleep.   I immediately thought that he ingested some one's medicine or something toxic--that he was poisoned.  He reminded me of a boy with an ingestion from my internship--that boy was in and out of consciousness like this one and who got an invasive test for possible brain tumour.  It turned out he had taken a relative's medicine.  I barely examined this boy I was so convinced and asked a lot of questions and had the family search their house for an empty container.  Nothing was found.   I knew something was up, maybe that I hadn't thought of,  and asked a colleague to look at him.  He did something I hadn't--felt the boy's abdomen--and determined that he had an intussception, when the small bowel gets telescoped into the colon, a kind of surgical emergency.   Some babies have cyclical vomiting and obvious pain, and others get lethargic with their pain, like this one.   I had begun to narrow my thinking too soon.  Learning to keep one's mind open is essential
    Sometimes a missed diagnosis occurs because an illness just had not revealed itself yet.  A lot depends on when a disease is ready to 'declare itself':  to have developed to the point that a specific diagnosis can be made.   Once I saw a 3 year old boy with vomiting who otherwise seemed well, I figured he had mild gastroenteritis.   The next day I found out that he had gone to the ER with seizures, and when they scanned his brain, he had a tumor.   I felt terrible, but several colleagues with similar experiences said that this is typical of brain tumors,  that they are are often well advanced by the time they cause enough symptoms to be diagnosed.    Another time I saw an infant as a well baby check and his mother mentioned something about decreased appetite.  There was nothing at all obvious, but something didn't seem right, so I had her come back earlier rather than later.  Two or three days later the baby was diagnosed in the ER with leukemia. 
    Years ago I saw a girl  of six with fever and purple spots on her skin.  She had been seen by several colleagues for other visits during the previous month for fever and vague complaints.  By the time I saw her,  her leukemia had 'declared itself.'   What I'll always remember is her mother's reaction to hearing the diagnosis.  I told her that there was bad and good news:  the bad that she had leukemia and the good that nowadays we had excellent treatment with very high hope for her survival.   Rather than being shattered like almost all parents, she expressed some relief:  She had already figured out that her daughter had leukemia and expected the worst, so the possibility of cure gave her hope.
    Appendicitis in small children is notoriously difficult to diagnosis, and most children less than 4 or 5 progress to rupture before diagnosis.   This week I saw a 4 year old with vomiting and abdominal pain for 6 hours.   She looked like many children I had seen in the previous week with viral gastroenteritis.  I did ask some questions relative to appendicitis, but in the end sent her home on pedialyte, always with the instruction to come back if she didn't improve.  Two days later I learned that she had been admitted for appendicitis.  For days after,  I went over and over in my mind how she she had looked and what I should have done differently--even though I know most people would have done the same thing.   
     Just as one can miss a diagnosis by going down the wrong track, the opposite can happen.  Quite a few years ago I was seeing patients at work when four siblings with vomiting and diarrhea came in.  I was about ready to send all of them out with the same instructions for clear liquids when I began to notice something different about the oldest girl of 14.  As they started to walk out, I saw that she walked a bit stooped over. A doubt began to form and I tried to put my finger on it. I asked them not to leave and reconsidered.  She looked a little more in distress than the others, and she had more pain.  I examined her again and she had pain in her lower right abdomen.  When I put it all together, I thought it was quite likely that she had appendicitis, and I sent her off to the ER, where this was confirmed.  It would have been so easy to miss this one girl out of four who had something different.
     A few years ago I saw a 6 year old girl a few times and noticed that her abdomen seemed to be full of air all the time, and that her torso seemed elongated.  It nagged at me and I spoke to one of the radiologists who said maybe she had a connection between her esophagus and trachea which allowed air to leak into her GI tract.  Sure enough, that is what she had.  She had had one or two episodes of pneumonia as children with this problem do.  Her mother recalled that her abdomen had filled up with air just after birth.   Sometimes subtle problems can slip by for a long time until someone gets curious.