Winning some trust

Those of you have ever seen or used a bronchodilator know how quickly and strongly it can take effect. Sometimes in clinic I like to use albuterol in nebulized form as some sort of instant gratification--as much for me as for the patients. It's nice to know within a couple of minutes that a medicine is going to work, especially when it reassures the families that the cost will be worth it. For someone whose trust is wavering, this can be the key to a successful treatment and relationship.

Working with the families at the clinic brings up some unique obstacles. Many of the families cannot read, though the often deny this. I try to ask the question a couple of times to make sure they don't need any extra help with things. But when they admit they can't read, I try to use symbols, explanations, and help them match things up. I'm still trying to figure out the best ways to do things. I'm tempted in the future to try a color-coded diagram of pills for a complex therapeutic regimen. It might sound crazy, but we have to do what we can to help. If they leave the clinic and don't know what to do with the 50 pills we've given them, they're just going to end up worse off.

Aside from the serious financial limitations in this population, the hardest barrier to address is the distrust of the medical system. Often people don't bring in their children until they are gravely ill, probably a combination of both of these problems. Earning a family's trust not only for yourself, but for the entire medical system is a huge task. I have heard horror stories, most of which I cannot confirm. I've heard that one of the barriers to birth control in this area is the major distrust that arose after the government gave Depo-Provera shots without telling people that they were a contraceptive. Needless to say, by the time our patients come to see us in the clinic, most of the families have already tried several herbal or natural remedies (including honey for infants).

On Thursday I had a very interesting experience. We were working with a 12-year old girl and her mother. The girl was having serious abdominal pain due to an ulcer. But she also had wheezing and a productive cough. The girl's expression was like that of any other adolescent who had been dragged to the doctor against her will, but with twice the disdain. Her mom looked desperate, seeing her daughter in so much pain, and was worried we wouldn't be able to help her. While considering using an antibiotic for the girl's respiratory situation, I wanted to see if she would respond to albuterol. When I explained the process to her, she gave me a blank stare and nodded, showing a certain amount of distrust. We gave her a nebulizer treatment in the clinic, and within minutes she felt better. She actually admitted to being able to breathe so much better.

For any patient it is helpful to be able to see immediate results, but for her, it was even better. Her ambivalence for treatment of her stomach pains, and her frustration with being at the clinic made her a difficult patient to treat. She left the clinic with 6 medicines, requiring her to take some sort of medication 4 times a day! In a patient like this, trust and compliance are vital to the success of the treatment.

I was lucky to have another foreigner working with me and this family, because the perspective was interesting. Cody was treating this patient with me, and he pointed out the drastic change in her expression after finally being able to breathe. It was incredible. She didn't look happy, but she finally looked like she was going to trust us to take care of her. I really believe that by demonstrating the effectiveness of the albuterol, we were able to gain some of this family's trust. I never would have thought of using a nebulizer in clinic like this, but it turns out to have been way more effective than I would have ever imagined.