11 May 2007

"Tres En Una"

Cuban Threesome

The previous post and comments on the dedicated Cuban health care professionals that make due with hardly any resources and a lot of dedication, made me think of an extremely moving and funny story that I came across a few months ago that illustrates the dismal reality of Cuba’s health care and the incredible ingenuity of the Cuban healthcare professionals.

This is my own crude translation and if you are fluent in Spanish, I strongly urge you to read the original in Spanish, as stories told in Cuban are much more entertaining then when they are butchered by someone who is a functioning illiterate in two languages.

“Three in One”
by Jose Luís Amiéiro Rodriguez

What I am about to tell you can be collaborated by just about any Cuban doctor, and it contains no exaggerations.

Doctors “on call” in Cuba do not get paid, not even a red cent.

In a month you may be on call, five or six times, depending; One weekly “on call”, plus one on a weekend.

In addition, once you go off call, there is no rest. On the following day, you continue working until completing your eight hour shift. Not an hour more or an hour less. There are hospitals and policlínicos that by an internal policy adjustment from management, allow the staff to leave one or two hours before the usual quitting time, but these sites are rare. Normally, you would have to work a full shift.

Some doctors, me included, would scheme to go home and leave our time card with a trusted coworker so that he would punch us out. It was a risk for both the coworker and the beneficiary, but we did it anyway.

Another disadvantage encountered by the medical professionals was that the material shortages and poor infrastructure made it difficult to provide the good service, that it was assumed we had to provide the population.

When the “On Call” shift began, we would be assigned a given amount of x-rays. They almost always gave us five or six, not more. They also counted the vials of each medication: salbutamol, aminofiline, two rolls of medical tape, five or six packets
with the sutures, three scalpels, a bottle with hydrogen-peroxide and half a liter of red aseptil, etc. Ah, also a liter of rubbing alcohol dyed with timerosal so that they wouldn’t drink it.

They took inventory at the beginning and at the end of each on call shift. If something whose use couldn't be justified was missing, you could find yourself in trouble. "The Holy Inquisition" was waiting for the slightest mistake to pounce and gut you. Heaven help you if you were considered a dangerous element to the nation: indifferent, apathetic, that you had asked to be allowed to leave the country or that somebody, an informer, had heard, by pure chance, that you liked the North American films or that you had a relative abroad who worked in stone quarries and who was doing better than to you, a doctor in socialist Cuba, land of Fidel.

Well, after this introduction, let me tell you an amusing anecdote. And just because
it happens to be amusing, it doesn’t mean it’s not true.

It was Sunday and I was on call for 24 hours in the” policlínico.” (neighborhood clinic)

The building was not that old, but it was falling apart in some areas: broken blinds, chipped walls, broken light bulbs and screeching stretchers.

The examining room was suffocating. A narrow room of four by five meters, ventilated by a very old "Orbit" fan, bolted to the wall, that only worked in the first speed, emitting a tenuous breeze that did not refresh my face, already contorted, sweaty and greasy by the effort I had made, just minutes before arriving at the center, because I had climbed, with bici (bicycle) in tow, the lofty hill of Jesus del Monte. Legendary slope in the neighborhood that shares its name.

In an “on call” shift, you could take care of up to 200 patients, in 24 hours. Virtually, without hardly eating anything.

Sometimes I brought something from my house, a bread with something and plastic bottle with instant beverage of an undefined color or flavor, on the yellowish side, that mitigated, subjectively, my thirst. Or at least that’s how it seemed to me. But, it was better than drinking the chlorine flavored tap water.

That Sunday, I began to diagnose rapidly: colds, tumors, syphilis, influenzas, infected boils, madness, paranoia and depression. There wasn’t much to prescribe, except for home remedies and infusions; as a guide I had my “vademécum of green medicine” handy. We were and are the vanguard of naturist medicine. Surely the abundance of flora and the shortage of fauna and of grey matter in the brains of our leaders has something to do with it.

That day they had assigned me only two (X-Ray) plates for my on-call shift. An exception, because the rest had gone to the “Dependiente” (Surgical Clinical Hospital Ten of October). Normally they left me five or six. “Shortage of supplies in the municipality”. That was the excuse that the doctor that had been on call at the policlinico from Saturday to Sunday had given me. Only two x-rays Only two! And the number resonated in my mind.

The morning passed without incident. By twelve noon we had taken care of 80 patients. A few minutes after one, a bicycle accident victim arrived. A taxi brought in a stunning blonde with what appeared to be a fracture of the escafoides bone on the right hand. Typical: pain in an injury where you fall with the palm of the hand extended.

Should I waste an X-Ray already? I thought. One? No, it could not afford that luxury. And I began to lucubrate. It was a state of emergency, I had to bet it all on one card. Patience, much patience. It could not waste X Ray plates, but neither could I misdiagnose the patient and let her leave without putting her hand in a cast, or vice versa, put a cast on her for no reason.

Then I decided what I should have never decided. I gave the to the woman an analgesic and laid her down it in the only stretcher that we had, with the excuse that it was to alleviate the pain before we performed the necessary radiografic examinations. The husband who accompanied her was thankful for the kind gesture.

In fact wanted to use one radiographic X-Ray plate for three patients (my specialty, a creation mine from the “special period”), I would wait for another victim to arrive, or two, depending on the injuries that they had, which was not uncommon on a summer Sunday in that part of the city. In a shift, you would see up to five or more seriously injured.

In effect, a half hour later they brought an enormous black man with a machete blow in the left shoulder. We canalized a route, we cured him, we sutured him, we vaccinated him and we stabilized him clinically. We only needed to take an x-ray to verify if his clavicle was injured and to assure us that the vascular-nervous package of the zone had not suffered damage, or he did not suffer a pneumotorax (air intake the pleura by breakage of the same), although the auscultation of the lung worked well. Good entrance and exit of air. But I had to make sure. In medicine it is better to sin by excess and not by defect. That Maxim has never failed to me, until the moment.

Happily, I rubbed my hands. Things were moving along quite nicely, with another injured patient we could put to play what I used to call "three in one". Thus it saved radiographic material for an urgency at dawn, where things, sometimes, got ugly. But it was getting complicated.

At four in the afternoon we got what we were missing. An old guy with a shot in the left buttock. A quarrel in Santa Catalina and Milagros. There little lost blood, but it had entrance hole, and no exit, where was the projectile lodged? Soon I would know it. For that it was the whole X-Ray plate.

I took to the three victims to the room of Rx. a euphemism. It was a dark tomb in the cellar of the building. The blonde walked down the stairs, the old guy limped down and black guy was lowered it by three of us, the nurse, the CVP and I.

We laid the black guy down it on the hard cold bed of the Rx – face up -, the hand of the blonde, opened, was placed under the right armpit of the black guy, since he could raise this arm leaving me a usable space, and to the old man I laid down on his side, next to the black guy, with is back towards the black guy and with his feet in the opposite direction and in a fetal position, that is, with his buttocks very near the face of the black man, not his armpit since he could not move that arm because of his injury, In this way I would have all three injuries: the one of the blonde, the one of the black man and the one of the old one.

While the nurse calibrated the equipment, I struggled to keep the old man on the stretcher, he would slip and fall to the ground if I wasn’t careful. The stunning blonde was obnoxious, all the while complaining the body odor coming from the armpit next to her delicate white little hand.

To honor the truth, the stench that emanated of the armpit of the brother was terrible, but he was calmest. He was sedated and the machete blow that he had was not funny. We had given 25 stitches.

When we had everything ready: BUM, the door to that cavern suddenly burst open. It was the director of the policlínico in one of his surprises rounds that he made once in a while to see how the things were going. The scene was like something out Max brothers film.

Thank heavens that we were all dressed and the husband of the blond one was a witness to our good intentions. He sat next to her calming her down: "Easy My Love, stay still, hold on just a little bit longer, the doctor is doing all this because he does not have a choice…... Easy…Stay Still...just a little more until he’s finished.. "

From that one ill-fated day on, they only left me two radiographic plates.

The director of the policlínico praised my good work, my boldness, using me as an example before an incredulous mass of fellow workers. Nobody gave credit to my resources, to my imagination to get out of the pothole.

I gained a few enemies, why? I only wanted to do good, don’t you think?

* For the curious: the blonde did not have a fracture, but just to make sure I had her take another X-Ray in fifteen days, not without before immobilizing her hand. The old man was sent to the “Dependiente” with the exact diagnosis of where the bullet was lodged and the black had a fractured clavicle, thus also I referred him to see the orthopedics. They both left with another five patients in one ambulance that carried the injured in groups to save gas. The driver, you see was as imaginative as me to convoy his load.

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