Katherine Guzman, MS3, SUNY Upstate Medical School
It's a regular Tuesday morning, I've dropped the kids off at school. My wife worked overnight and I'm weary. David was throwing up the entire night, Elia was fussing, and my mother-in-law is out of town. The last time I was nearly this exhausted was my first year of residency, and I can't wait for the day to be over. I can sleep in the car for about 40 minutes if I finish all my visits by lunchtime and then I'll just complete the notes at home; if I get the chance.
I get to the office and patients are already in the waiting room, signed in, and my first patient is ready in room 5. This place is like a well-oiled machine but sometimes I just wish things would slow down.
I drop off my bookbag at my desk and look at Luciana. Her under eyes are a dusky purple, her frown lines are more pronounced, and her lips are chapped. I ask her if she's remembered to eat between everything that's going on at home. She smiles tightly and says she did this morning, but her chiseled cheekbones and sharp jawline say otherwise. I'll remember to order her lunch today before my nap. She chews on her lips while she looks over the patient chart, her face tightens like leather under the sun and finally, she exhales. Luciana then puts her hair into a bun and walks out. I hear her knock on the door and brightly exclaim "¡Buenos Días! Señora Maribel!".
I sit down and let out the longest sigh known to man. I do love my work and I enjoy helping my patients, but I'm exhausted and today I just don't have the energy to be who my patients need me to be. The next patient scheduled is a constant no-show and this couldn't have come at a better time. After 20 minutes I'm taking my early lunch and I'm going to sleep peacefully.
I'm ordering Luciana lunch when I see that the patient has checked in. Why today out of all days? Couldn't she just have no-showed like the last 5 times? What could be so urgent that she finally made it in? On top of that, she never pre-registered and I don't have any information to review except for her name, address, and insurance. Maybe she's here to establish care or maybe I'm about to walk into a tornado of diseases and comorbidities that will take me way past lunch time. I decide to bite the bullet and go to the exam room.
"Good morning, Sarai,"I say as I walk in. Even though it's almost 11 am, meaning it’s almost lunchtime, which means it is almost noon. Which ultimately means that I'm going to make this the quickest appointment ever. My patient doesn't answer and naturally, I'm relieved. The less chatting that happens the quicker this will go. I ask her what brings her in today and she responds "I've been wanting to get a primary care physician in the area," she shrugs.
We go through her history and physical exam without any issues. She doesn't have any chronic illness and no family history. She's in great condition and her physical exam was unremarkable. I give her my recommendations for baseline labs and a follow-up. She nods her head. We've managed to complete this visit in about 15 minutes. However, I feel uneasy. It could be that I'm nauseous from lack of sleep or maybe there's something else that I'm missing. I don't know Sarai personally but I don't want her to leave my office just yet. We sit in silence after she nods, and we stare at each other. I'm sure she's analyzing me as much as I'm trying to analyze her. Her eyes are scanning me softly, but her posture is firm, she holds her head up high, and she moves to get off the table. Silence fills the room as I watch her move towards the door, her steps are slow, and it feels like her body is willing her to stay back but her mind is resolute. Her hand goes toward the doorknob and begins to turn it, I can hear the busy chatter of the hallway start to enter the exam room and I panic. I yell out "Sarai! Did you need a new physical for college?" She said she's a sophomore and it's mid-April so it's unlikely, but I had to do something. She backtracks and closes the door once again. She looks at me and her eyes are speaking but I don't understand what they're saying. In fear that I've missed my chance, I tell her "It's super quick. I just need to document everything we just checked. Heart, lung sounds, abdomen, but I'd like to get a proper listen, right on the skin, if that's okay".
Sarai sits on the examination table and takes off her light outer sweatshirt. This time her posture is a mixture of defiant and frightened. Without her sweater, I can see that her clavicles are prominent, her skin looks dry, and she looks to be swimming in the tank top she's wearing. Perhaps it fit well before, but now it seems 2 sizes too big. I listen to her heart sounds and now there is a change. Before I heard the calm "lub dub, lub dub" that we're all used to. Now Sarai is tachycardic and she has a slight tremor. I feel her body quietly shake against my stethoscope while listening to her heart.
"The ticker is ticking! It sounds great, just a little fast, but no worries. Would you like some water or a lollipop?" She shakes her head no.
"Okay, if you change your mind just let me know! Next, I'll listen to your lung sounds. Do you mind if I take a listen under your shirt? I just need to place my stethoscope against your back to hear the air coming in clearly."
Sarai's eyes have glossed over, her left oral commissure does the mildest of quivers, which she immediately suppresses, and she responds "Yes, that is fine." in a defeated tone.
I place my stethoscope under her shirt and listen to each lung field. I'm looking at the exam room while listening for any abnormalities when I notice four round faint bruises on the back of her arm. I take note but I continue listening. I look at her other arm and it has the same four bruises in a linear fashion. It seems as if someone grabbed her by the arms and left a mark. Perhaps she does Karate or Jiu Jitsu, which could explain the marks or maybe she was about to fall, and someone grabbed her tightly.
Next, I ask to repeat the abdominal exam. I've already palpated and listened to all quadrants before but ask her if it's possible to repeat it but this time directly on skin. She looks at me sternly and my heart shatters in my chest. I never considered what I would do if I found something bad. She lifts her shirt and exposes her abdomen. Slightly below her umbilicus and traveling into her pelvic area is a large bruise in various stages of healing. It is one bruise but looks like the conglomerate for many small bruises.
We both stare at each other in silence. Her lips quiver but she stifles it once more.
"You know I'm on track to graduate Magna Cum laude for engineering? Having a baby wouldn't have worked out anyway...." I take a breath.
"If he didn't care about me, he would have left me after I told him. Instead, he made sure I didn't do something I would regret."
I try to slow down my racing heart. I think about the day I found out my wife was pregnant and how I was so scared that anything might happen to her. I think of my Elia fussing all night and can't imagine her growing up and facing these horrors. I sit down on the chair and face Sarai.
"I will never judge you, Sarai. But I'm concerned for your safety. If you need resources for domestic violence, I can give them to you. If you need a safe place to sleep tonight, I can try to find one. This is a small community, you don't have to do this alone."
She interjects "I know what I'm doing, and I know the man that he is. He likes things to be correct. What would our families think? We need to do things in order. Graduation, marriage, THEN a baby."
I sigh, I know that I can push Sarai away from safety and resources if I continue. "Okay Sarai, as your physician, I will be here when you need me. You call the office day or night, and someone will pick up the phone. If you need resources, you ask at any point. Do you understand? You are not alone."
She nods and once again the room is silent. I look at the time and it's 12:45 pm. I hand her the physical that she didn't need and silently watch her walk out.
I go to my car, turn on the AC, and recline my seat. I think about the laws that I need to research regarding domestic violence in my area, I think about my wife and children, and I think about Sarai. I feel a knot in my stomach, and I start to constantly swallow. I run my hands through my hair and look for my phone. I have a missed call and I dial back.
"¿Hola bebe, como estas?"
" Todo bien." I sigh and then I gulp while trying to swallow.
"¿Seguro?" and I start to cry.
About the Author: My name is Katherine Joana Guzmán. I am an MS3 at SUNY Upstate, I am currently interested in Psychiatry and Pediatrics. I am passionate about helping the Latino community navigate the medical world in any way that I can; and I am also highly passionate about mental health, domestic violence, and abuse. My mom and dad are from El Salvador and their values have shaped me into the person I am today.
About the Work: This short story narrates the day in the life of a primary care physician facing the trials and tribulations of his own life and becoming exposed to the horrors of others.
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