Bipolar is more than a label

23-year old Jennifer was in today with husband Todd and step-daughter. Despondent, she had just just dropped all of her college courses and has not slept for 2 weeks. I thought we were making progress only 3 weeks ago when we found the proper combination of medications to clear her migraine headaches...even figuring out that her perfume was a trigger. But now she has not slept, her weight is slipping away and her anorexic patterns are returning. She finally admits to her depressed feelings, though it goes completely against her religious faith and her attempts to generate the gratitude and joyfulness that her cognitive brain understands to be true. Because of her lack of sleep I am suspicious of bipolar depression, and if I put her on a typical SSRI antidepressant such as Prozac or Zoloft, I could trigger a manic episode. I downloaded the Goldberg Screen for Bipolar Depression from the internet and administered the screening questions. She is positive for 11 out of 12 questions. I think she is bipolar, presently depressed, and in danger of serious anorexia. I will get her in to a psychiatrist as soon as possible. Unfortunately, the health care system is broken in that I can not refer her directly to someone. The psychiatrist will only accept an appointment made by the patient, so tomorrow I will need to call to make sure she has an appointment.

Life across the generations

The Montoya family was in today. This is why what I do is called "family" practice. Two-year-old Nadelis was in for her well child check, and to follow up on pneumonia. She is bright-eyed, tall, smiling and talking constantly. She answers questions in English or in Spanish, seamlessly changing languages though she is not aware of it. She is at that magical age where language is exploding. Every day new words appear and she delights in the attention she gets for her accomplishments. Her parents are attentive and delighted with her. It is an easy visit for me.

I was thankful that my nurse put her great grandmother, Adeleine, age 85 in a separate room, with her daughter. There I could inquire more deliberately about her blood pressure, still out of control after adding a medication last time. Immaculately groomed, elegant, and proper, Mrs. Montoya exuded the pride of being honored as the matriarch of her family, surrounded by her children and attended by them. I made an adjustment in her medication and will see her back in a couple of weeks to be sure that her blood pressure is coming under control.

Four generations from this family spead over 80+ years of age. It's not possible to be their physician without being a member of their family too.

What will become of Madeleine?

Madeleine was sleeping poorly. The 8-year-old girl who had always been a joy to have in my office stopped sleeping about 3 months ago. She won't fall asleep until 2 am, and she is afraid to go to sleep, afraid of monsters and sounds in the night. Of branches scratching the house and the wind. When she does get to sleep she gets up screaming uncontrollably, or she is up walking around the house in the middle of the night but not really aware of what she is doing. She is sleepwalking. And because she gets so little sleep, she can't get up in the morning for school. She's tired at school and beginning to be irritable and to lash out at her younger brother. Laura, her mother, is at her wit's end. She is getting no sleep either. First I tried standard pediatric sleep interventions, then a little hypnotic, but it was getting worse, not better. Finally, 3 weeks ago, Laura was pleading for me to find a way to help her daughter. I decided she may have an anxiety and depressive disorder, and started her on a low dose of an antidepressant, Zoloft. I explained, a few children may become more agitated, we need to watch closely and stop the medication with the earliest sign that it may be making her worse. I hoped for the best, and sent her off to a child psychiatrist.

Yesterday, Madeleine returned. I opened the door and Madeleine shot me a huge smile. Laura said Madeleine is back to her old self. She is sleeping through the night, her sleep cycle is restored, and she is back to her old self during the day. The psychiatrist concurred with the medication. And now Madeleine has the most infectious, beautiful laugh I can ever remember hearing. She will stay on that little, miraculous dose of antidepressant for now. Drugs may be overused in children, but I hope they will never be completely taken away from us. Children like Madeleine need them.

Quiquil's daughter

Like most natives of the remote province of Huehuetenango in Guatemala, Eufemia is surprised that I am familiar with her home territory. I spent a short period of time working in a clinic in Barillas, where the road stops as it winds through the mountains north of the capital, Huehuetenango. There, you are as likely to hear K'hanjobal on the street, an ancient Mayan language, as Spanish. Now, for whatever reason, there are many Guatemalans from this region in our town. They work the lowest of the low jobs. Eufemia is a seamstress. She had 5 children at home with the help of a midwife in her home town of Quiquil, the site of a 1981 massacre of 32 people. Humble and reserved, she labors to give her children a chance of doing better than she. Today I see Eufemia for a routine physical and advise her on exercise...which must seem strangely foreign to a person who grew up with physical labor from daybreak until dusk.

Zuleyma's painting

I've been trying to slow down Zuleyma's weight gain, almost from the day I delivered her, 15 years ago. Now, at 15, she weighs 258 pounds, and both of her parents weigh close to 300 pounds. Even at her first newborn visit at 2 weeks of age, she was already off the charts for weight. At first I thought it was overfeeding, then lack of appropriate exercise, or fattening school lunches, and more recently I've come to believe it's a genetic force I can't beat. At least, I do not want to be so frustrated with her weight and my own personal feeling of powerlessness that I stop seeing Zuleyma as a girl, a unique person who is trying to find her way in this world. I am not willing to give up the unique relationship I have with her, caring for her from conception until adulthood. It's too easy to dehumanize people with obesity or with any other problem and look at them only as their problem. When I walk by Zuleyma's 2nd grade painting in the hallway, I see the river winding through the complex topography of our city and I smile.

Judy's cat is dying

Judy's cat is dying of cancer. At age 76 she doesn't think she can survive the loss of Precious. After all, she almost died of heartache after her husband, Ted, died 9 years ago. Somehow she survived then, on a diet of donuts, coffee, and a steady chain of Kool cigarettes. But after 9 years her self abuse finally caught up to her. On November 3rd she began to feel unwell. She called her next door neighbor, who happened to be a cardiologist, who came right over and was immediately suspicious of a heart attack. Soon after the EMT's arrived her heart went into a series of arrhythmias (electrical short circuits) that reduced her blood pressure to dangerously low levels. She received shocks 3 times in the ambulance and another 9 time in the ER and intensive care. Somehow she survived, though she lost a large chunk of heart muscle in the process --- a massive heart attack. But today it is not her own survival that concerns her, it is her cat, the only being in her life that gives her companionship and someone to share an otherwise lonely place in this world. Could she have an antidepressant to help her get through this? That's not problem. I know she will not go to a counselor, but she will take an antidepressant, and perhaps stay in a little closer touch with me. Pets are so important to the emotional and even physical health of widows who live an otherwise isolated life.

Get up and walk, Ignacio

Ignacio appeared to be in pain as he was pushed by wheelchair into Room 16. Pulling his pantleg up it was clear why. His right knee was about twice the normal size, and tender to touch. Apparently he had been in the urgent care center over the weekend and had fluid aspirated from the knee to look for bacteria and crystals. Because he had had an episode of gout before, gout was the number one likelihood as the cause. But two things bothered me, first that he had no crystals in the fluid, and second, Ignacio is not a completely straight shooter. By that I mean he has a long history of drug addiction, and that means he could have a septic joint, infected by bacteria that happen to get in the body by dirty needles and then take up residence on the heart valves. Also, I have to think about gonorrhea, which can also migrate from the genital area to the knee if not treated. Fortunately, fluid had been sent for the proper analysis on Saturday and there was no sign of infection. I prepared his knee with iodine and then stuck a long needle into the center of his knee, aiming just under the kneecap. Within 5 minutes the local anesthetic was beginning to take effect and his complaints had settled down. He was able to get up and walk out of the room. There's not much more dramatically effective than an injection of steroid and lidocaine for someone suffering from an attack of gout. Next week we'll try to address the alcohol abuse and heavy seafood that probably triggered the attack.

Marina's back

I came in late to work on a letter for Marina tonight. She can't work because of a back injury, and like so many immigrants, an injury at work is often ignored by employers. It seems to be the attitude that if you don't speak English well, don't expect any rights as a worker. If you get hurt working you will not have the rights that Americans have for workman's compensation or disability insurance. We can find someone to replace you tomorrow. And yet, immigrants work in the most dangerous jobs, and the injuries can be ordinary -- or horrendous. That's a story for another day....

Jazlyn's long fingers

Last week I was surprised to see Magali again. I hadn't seen her in a couple of years, since she almost bled to death trying to carry a pregnancy that she should never have attempted. She was so angry at me for telling her the truth, that a pregnancy could kill her, so she went ahead with her boyfriend and conceived anyway. As a Mexican woman, the thought of not being able to offer a child means being cut off and thrown away by most men. So she went ahead, got pregnant, and as her aorta began to rip apart she was forced to have an emergency C-section and dangerous replacement of a large section of her aorta. Somehow, I don't know how, it's a miracle, she and her baby survived.

She hadn't talked to me for a long time, but a couple weeks before she told me she was concerned about her daughter Jazlyn, now age 5. Could Jazlyn have the same Marfan's Syndrome as her mother? We agreed that she would bring her in.

Mexican children are taught to be polite to their elders, and so any child, age 18 months and above will offer a formal handshake. The day Jazlyn came in, I walked into the room, she held out her hand, and when I took her hand in mine, I recognized the same long spindly and flexible fingers as her mother, the same fingers that indicated she probably has Marfan's syndrome too. Medical books call this "arachnodactyly", or spider-like fingers. Of course I needed to go over her exam more formally. Yes, she was way above normal height for her age. Yes her fingers and wrists had almost rubber-like flexibility. We talked about the genetics of Marfan's syndrome that her daughter had a50% chance of having the disease, and that we needed to start monitoring Jazlyn's heart and blood vessels. I hope Jazlyn will not have to make the same choice as her mother, between remaining childless and loveless or risk of death from attempting pregnancy.

Where to go with weakness?

Greg is a handsome man in his early 30's who looks worried. The note on the chart says he is in for recheck of urinary tract infection/fever. But as often is the case, the supposed reason for visiting falls far from the mark of what is on Greg's mind this morning. It starts fairly simply-- he had a urinary tract infection a couple of weeks ago, was treated with an antibiotic, but now has some mild diarrhea and fever again. As I go over the history, the first thing that is puzzling is that he had a urinary tract infection. Men are not supposed to have them. It could indicate an underlying condition of some type. Greg hesitates, and then says, he has actually been having changes in his urination since last summer, when he started having to get up at night numerous times to urinate, and since then his urination has never completely normalized. Asked about his fever, he states that he actually feels weak. Weakness is often interpreted differently by different persons, so I ask him about the weakness in different ways, finally concluding that he has had generalized weakness of his muscles, that worsened with the onset of his infection two weeks ago, and now is worsening again. Weakness is a worrisome symptom if true in a strict sense, and not just merely fatigue or feverishness. Prompted by this detail, I ask him more about his recent history. He's actually had an episode of double vision last November that lasted for a couple of months and required the use of special lenses. Together these symptoms raise a troubing possibility: that he has been struck by atleast 2 epsiodes of loss at different times and locations in his nervous system. One in the part of his brain controlling the coordination of his eye muscles, the other in his spinal cord, controlling the function of his bladder and leading to the current urinary tract infection. Multiple sclerosis causes this sort of pattern, and Greg's cousin has been diagnosed with MS as well. Greg seems relieved that someone is starting to put together his variety of symptoms, and was actually very worried about what was happening to him. He will have an MRI of his brain next week. It is never easy to broach the possibility of a disabling, chronic illness, but never as bad as the fear and loneliness of falling through the cracks and knowing that something is terribly wrong.

Josue and Jessica

Josue came to the office today because of a "rash" today. At 19, I didn't expect it would be much; after all, Josue and his family members all seem to be a bit nervous about their bodily ailments. I asked him to remove his shirt, and I was surprised to see the telltale clustered blisters on his left shoulder, a sure and unmistakable fingerprint of herpes zoster, or "shingles". Shingles is the late form of chickenpox. After being infected with chickenpox as a child, the immune system may wane later, allowing the dormant infection to emerge, but only at one level of the spinal cord, thus causing a rash that forms on one side of the body, in a band-like distribution. Fortunately, Josue's outbreak is not particularly painful, and with his youthful immune system he will probably recover quickly without a prolonged period of pain that I often see in older people.

Surprisingly, Josue's twin sister, Jessica, had been in the office just 24 hours prior. She is married and expecting her first baby. Now, at 34 weeks, she presented with a sudden paralysis of the left side of her face. I received a call from her obstetrician and had her come right over. The weakness had accelerated since the day before, but was still not severe. I was glad she had come in fairly early in the course of her illness. Strangely, it is felt that Bell's Palsy is caused by herpes simplex in the facial nerve(herpes simplex is a close relative of herpes zoster). As the nerve courses through the temporal bone, it has little room to spare. A mild swelling associated with the inflammation of this nerve can cut off it's circulation temporarily causing the entire side of the face to become paralyzed.

What I am left unable to answer, to the best of my knowledge, is why do brother and sister each develop a problem on the left side of the body caused by a member of the herpes viruses only one day apart? I can only wonder if the virus of one sibling could somehow activate a virus in the other.

Julia's lovely Valentine

In the last 3 days I've had 3 older couples in, all trying to navigate their end with grace and love. All in their 80's, each have one of the couple who is deteriorating more rapidly, yet it's not clear who will go first. Julia was in today. At 83, she has always been the least "doctoring" of the two. While her husband, Jack, 85, checked his blood pressure daily and followed doctor's recommendations to a "T", she stayed away, allowing her blood pressure to be uncontrolled, not taking medication, and being a feisty woman who refused to age. But now her husband is fading. He is losing weight, tests are disclosing no diagnosis, and the only label that fits is "the dwindles". It is the genetic card, the strength of being a woman that is in her favor. She is vigorous and of good humor. Now she is taking her medication, but I suspect that it is so that she can keep her health together enough to take care of Jack in his final days. Today, dressed in a classic suit and not a hair out of place, she shared the beautiful Valentine that she received from Jack, and the deep meaning it had for her. 54 years of marriage has not dimmed the love between this couple. And now she is ready to return his Valentine, by being there through whatever it takes in Jack's final days, weeks, or years.

Susana's tears

Susana's family is from Guatemala, and she is in for her 9 year old well child visit. Susana is a pretty girl, with her long silky black hair. She is quiet, and it takes a while for me to get her to open up. But what works for her is what works for so many children. I start at the beginning. Well, Susana, the first time you were here, in 1997, you weighed 4#9 oz, you were premature, and your mother had just given birth to you. Now you are a big girl, 59#, and growing up. What is the thing that makes you the happiest? Susana begins to tell me about some things, and she begins to smile. It's clear that she is having some troubles with her mother. Immigrant children have an especially hard task -- how to survive and fit in with peers in an inner city school with kids of all races and cultures, and at the same time make sense of the culture at home, which does not accept the norms of the child's peers. I am going to have to give Susana an update of her chickenpox vaccine. She is very fearful and begins to drop big tears all over the exam table. I try to reassure her, you are big now, it will not hurt very much...and I will give you a sticker when you are done. In another 5 minutes, the tears are already drying, and Susana is busy choosing the best sticker in the drawer. Hasta luego, Susana.

Real men get breast cancer

Roberto is a muscular, middle-aged Cuban guy who has worked hard to make a life in this country since immigrating from Cuba some 20 years ago. His father's death last month reminded him that he is mortal, so he decided to come in for a physical. Aside from being overweight and having high cholesterol from the heavy Cuban food, he says he's noticing a painful lump in his right breast. Indeed, there is a lump about an inch in diameter, but more suspiciously, the skin of the nipple is crusty and thickened. Sometimes this nipple change is called peau d'orange, a sign of inflammatory breast cancer. Roberto is getting a mammogram, an ultrasound, and a consult with a surgeon next week. The death of a man's father is an effective counter to denial that so often keeps them from seeking care.

Skin and joint mystery solved

Jude is a handsome personable college kid who came in today to follow up on recent tests to try to figure out his mysterious joint pains. It was just a month ago that he presented with a fiery, scaly rash on his buttocks, now confirmed to be psoriasis by the dermatologist. The other piece of the puzzle-- pain in his neck, back, low back knees and feet is starting to come together. Tests for rheumatoid arthritis and ankylosing spondylitis were negative today. As he took off his pants and shoes to show me the joints more closely, there appeared the telltale clue -- sausage digit, a diffuse swelling of a single toe that resembles a sausage. There is only one thing that I know that can cause this finding -- psoriatic arthritis. It's not easy to tell a young man that he has a chronic illness, but hopefully with modern disease modifying drugs he can be relatively free of symptoms. He'll be off to the arthritis specialist next week.

The power of denial

Bill came in today with an earache, and left in an ambulance. Two weeks ago he suffered a heart attack. While checking him for his ear pain today, he admitted that he was having chest pains across the upper chest and into the left underarm, and that he had had the same symptoms yesterday. He has nitroglycerin to take for chest pain but hasn't taken it. "It's not my heart," he stated emphatically and we rolled in the EKG machine and started an IV and oxygen. The EKG readout told a different story, flipped T-waves in the lateral leads suggested that the left side of the heart was not getting enough oxygen and he was at risk for another heart attack. He started to become agitated and threaten to leave. He wanted his breakfast and he was sure the breakfast would not be good at the hospital. At this point I called his wife who was able to calm him down and convince him to go to the emergency room for further evaluation. While he was leaving on the stretcher, I ducked back in the room with the African-American girl with fevers for 3 weeks for which there is no answer so far. No time to think about why this man could put breakfast ahead of saving his heart. Denial can be an incredibly powerful defense against reality.

Flat-iron tendonitis

C. was in to day with pain in her right elbow. She's tried everything for it already -- anti-inflammatory medications, ice, and even a forearm band. She has researched the treatment well. As I examine her elbow, noting the particularly tender "lateral epicondyle", that bump on the outside of the elbow, I ask her what she's been doing with her arm lately. Nothing unusual at work, no lifting, no repetitive grasping. Finally she reveals she has been using a flatiron for straightening her hair. I'm reminded that very straight hair is back in style, and thus the return of the flatiron, but now in a portable electric form rather than the old-fashioned ironing of the hair on an ironing board. The repetitive motion of ironing her hair everyday using the newer portable versions has stressed the tendon coming into the elbow. After an injection of cortisone she has complete resolution of her pain. She's decided to try a different hairstyle, one that won't cause tendinitis of her elbow.

Ethiopian interlude

Kifle was back from her native Ethiopia to recheck on some GI upset. It turned out she didn't have any exotic African parasites causing her intestinal upset. It was just plain coffee. She stopped the coffee and the problem has disappeared and she no longer needs medicine. The epitome of self-assured, tall east Africans, Kifle was resolute. She had left her boyfriend. She did not want to live with the heavy smoking that was giving her chronic laryngitis and the abusive drinking that was keepng her in constant tumult. I know the man, but his demons from that war-torn country are not going to go away easily. I wish them both well as they find their own truth and healing.

Ramiro drops his saxophone

Ramiro is 12, and two years ago he was messing around on his bike without a helmet, fell hitting the pavement and smashed his skull. He bled around his brain and required a hole to be drilled in his skull to relieve the pressure. He came out of the accident intact. But last Monday he lost consciousness and fell on the ground; and the same thing happened a few days earlier at school. No one witnessed the spells. Ramiro remembers something, though. He remembers coming home, opening the door, and then without wanting to, his saxophone dropped out of his right hand. A couple of seconds later, Ramiro loss consciousness and fell on the floor. That 2 second delay tells us something very important. He probably had a seizure, and the seizure probably started in his left parietal lobe, or perhaps the switching stations on the left side of the brain that coordinate movement of the right hand. Then, like power surge causing a blackout through the eastern United States on a hot summer day, the seizure activity spread across his brain causing him to lose consciousness. We will order tests and get him to a pediatric neurologist. A good history can be as good as all the technology. It's worth listening closely, even to children.

Daniel's purple spots

The practice of family medicine can be compared to that of a commercial aviation pilot-- long periods of normalcy and routine interrupted by brief moments of extreme danger.

Daniel, age 3, is the son of Salvadoran parents, and was brought in today with a history of fever for two days, headache not relieved by Motrin, and a purplish rash on the face. Initially, his exam was fairly typical of any child with an upper respiratory infection, but I pulled out a magnifying glass to examine the rash more closely. It was purplish and the outlines were irregular, of different sizes and shapes. This was not a rash that I am accustomed to see..strep, Fifth disease, chickenpox. Somewhere from deep in the mists of medical training I began to wonder.... could he have dreaded meningococcemia, a life-threatening illness that can rapidly progress to sepsis and death. Though it didn't seem overly likely, this was worth a trip to DeVos children's ER to consult with the emergency specialists and, if necessary, with infectious disease specialists.

Later I was called by the emergency room physician...Daniel would have tests drawn and be treated with antibiotics while observing closely for any signs of worsening disease. This is a case where it is better to send in several false alarms than to miss one child who perishes.

A seductive, sad girl

I just scratch my head when Cirulia comes in. She has come in numerous times in the past year, for headaches, depression, menstrual pain, pelvic pain and stomachaches. On the exterior, she is overly seductively dressed, with skin tight jeans, piercings, and stiletto heels. But face-to-face, she is a shy, sad girl with very little to say, and constantly hovered over by her mother despite her 19 years of age. When she had severe pelvic pain, her mother refused letting her have a pelvic exam because it would destroy her virginity, no matter if she had a severe, fertility threatening disease, even if exam was performed by a female physician.

But today everything became clear. She came in for a followup of unexplained stomach pain. We reviewed her upper endoscopy which was absolutely normal. I spoke probingly, "sometimes this pain could be caused by a problem in the gallbladder or the liver, though I see nothing in your history to suggest these problems, and sometimes it can be caused by stress or depresssion", trying carefully not to induce a defensive posture. Then the floodgates opened. Cirulia began to cry uncontrollably. I knew I had hit pay dirt, I had finally gotten through her defenses. She came up for air long enough to sob, "My father....he is with that girl, and they have a baby, and he doesn't pay any attention to me". Her father continues to live at home while maintaining an affair with a young lover somewhere, and now there is a baby. He pays no attention to Cirulia, his beautiful daughter, who now tries to compete with the charms of his young girlfriend by dressing as provocatively as possible. As I dialed the bilingual therapy center, I was surprised and amazed to find out that the bilingual therapist on duty was my friend K. from church. I am so thankful she will be there for Cirulia. Maybe there is a chance that Cirulia can find her own value as a woman and a daughter before she falls in with some loser boyfriend on drugs.

A nervous girl

L. is the daughter of immigrant parents, the kind of girl who is always there for her parents, interpreting for them with words way beyond her emotional maturity. But today it is L. who has an appointment, because she, at age 14, has not slept for a week and is crying and has headaches. "I worry all the time" she explains. She is the worrier, the overachiever who gets a perfect 4.0 average, who spends all of her time doing homework, as if she is going to save her parents from the stifling factory work that is the only work they can get as non English-speaking parents. But now it is going beyond perfectionism. Now she is crying and having panic attacks. She is having mixed anxiety and depression. Fortunately, her parents are both understanding of the situation -- in fact her father is under my care for generalized anxiety and her mother is being treated for depression. She will get a low dose antidepressant and start seeing a children's therapist. She is very intelligent and she will do well. She smiles and says good-bye to me in Spanish. She has a sparkle of hope in her eye.

Alcohol abuse wins today

Mrs. J. was in today after her recent hospitalization for bleeding from her stomach. After a half dozen tranfusions and almost as many hospitalizations for GI bleeding, the truth finally came out. At age 86, Mrs. J has cirrhosis of the liver and she is bleeding from large distended veins in her esophagus. In cirrhosis the liver becomes so hardened and scarred from the alchohol, that all the blood that must go through the liver to get to the general circulation must find an alternative tributary, tiny vessels that connect the liver to the esophagus. But after years of trying to get through these vessels they are large distended blood vessels, and in one day, Mrs. J bled out half of her blood to reduce her total hemoglobin level from 12 to 6. In typical alcoholic family fashion, I got a call from one daughter before Mrs. J's appointment : don't tell her brother about it. Alcoholic family members often weave an intricate web of delusion and deception to keep the truth from coming out.

Later, A., a Mexican immigrant, came in for his annual physical. Previously I had made a breakthrough with A., he had recognized his alcohol abuse and begun attending AA. It was clear that his anxiety disorder was being self-treated with alcohol, but in reality the alcohol was making it worse. Now, he's back to drinking again. But now he doesn't try to hide it. He tells me, "Yeah, I did drink last weekend, and I don't know how much." Did he mean he couldn't count how much and he was stone drunk? Yes. Did he feel rotten for 3 o 4 days after getting drunk? Yes. Today was his first day of feeling well again. A., you need to go to AA tomorrow, do you want me to take you? They won't let me in because I am not an alcoholic. Don't be ashamed. AA is a place where people with that same shame are brothers. Ok he says, he will try to go.

Whose child is this?

Magda was waiting in Room #2 with twin girls who seemed too young to be her own, only 18 months old, and she is 47, here to be seen for diabetes. It turned out to be about much more than her diabetes of course, it was also about the strange pains that went up and down her spine which made her worry about her kidneys. After all, she knew that diabetes could cause renal failure...and she had already had one kidney removed 10 years ago. And it was about the pain in her neck, and the swelling in the left side of her neck and the weakness left over from the strange viral illness that left her paralyzed for a time, known as Guillan Barre syndrome. Soon her husband arrived and I showed him how to massage the aching muscles in her back, since with no transportation, she would surely not get to a physical therapist. As the visit came to an end, I asked Magda, are these your children? No they are his, as she pointed with her eyes to her husband. The pleasant, smiling man, with an accent from central Mexico seemed proud of the two children born from an outside relationship, now taken in by his wife, who looked at him with resignation and acceptance.

Taken in the night

Celia has been barely making it in the last few years. With her severe diabetes, hypertension and mental illness, it is amazing that she continues on, and that she was able to marry a Guatemalan man 5 years ago. As a poor Dominican immigrant, she can't afford much in the way of therapy or psychiatric care, so she has relied on me, on my encouragement and management of her medications, trying to keep at bay her psychotic features, while at the same time trying to keep newer antipsychotic medications from worsening her diabetes.

Last week her husband was taken. Eduardo went out in the evening to return a pickup truck to a friend. Somehow, the "Migra", as the Immigration Service is referred to, staked out his neighborhood, and grabbed him. He was put into detention and will be deported. Of course, like almost all Guatemalans, he has no papers.

Now I have Celia in my office crying inconsolably, and I can find few words of encouragement to give her. "It will be OK" is probably not true. "You will survive this also" may be true, but she might not. All I can do is say I will be there, and I will do what I can.

Beginning

It seems that everyone is blogging these days, so I am not sure that this needed, except as a form of self-reflection, and to share my thoughts with a few friends. I'd like to try this as a forum for sharing experiences from my practice as a family physician in a diverse medical practice in a blue collar suburb of a midwestern city. Due to the need to preserve confidentiality, I have taken the liberty of changing names, combining identities and any other liberty I feel necessary to protect the identity of the people I am writing about.