by Dr. Drew Pollack
Of the three years spent in PCOM, the last year was my most memorable. One day a week was spent volunteering in Mexico with the homeless, the poor, and the dying. This article will attempt to describe those experiences, and the lessons learned.
Prior to embarking on this journey of discovery, personal objectives were set. One of the most profound was to put myself into challenging situations as a means of eliciting feelings of being uncomfortable, scared, and overwhelmed. From this position, apply TCM techniques and theory learned in the clinic and classroom. Application would facilitate improvement of learned acupuncture skills of assessment, diagnosis, compassionate communication, and time management. Most importantly these challenges would serve to discover something deeper within myself, to explore the significance of death in relation to medicine, acupuncture, and my personal associated fear.
On a rainy morning in January 2016, a good friend accompanied me on the first of many visits to "Las Memorias." It was a large cinderblock building at the end of a dirt road on the East side of Tijuana, part drug rehab facility, part hospice, part Tuberculosis clinic. When we first entered the foyer, there were resident/patients representing all age groups; some lounging on a couch, some using their cell phones or on the computer. After introductions in the large, open common area where sermons were also held, we were brought to the hospice section of the facility. It was in this part of the building that we observed and treated the most severe cases of HIV/AIDS, however it wasn't until we got to the tuberculosis ward that we truly grasped how ruthless an illness can be when left untreated. We were given face masks as protection again TB infection and lead to a second-story room. Suddenly the terms "barrel chest" and "blue bloaters" were no longer medical jargon, but living breathing persons. Veracity of true illnesses were staring me in the face, challenging the intelligence of my decision to volunteer in such a setting. I was scared, and each of the patients exhibited signs of being scared.
I treated a man as he sat up in bed and gasped for air, unable to lay down because of his lung infection. He arrived a few days before and began antibiotics to treat his TB. I administered auricular acupuncture to calm him and slow his breathing. He was extremely sensitive, flinching with every needle. His right ear was feverish with hues of purple and red. The left side of his face was cold. His yin and yang separating, and mirrored on his face. His eyes darted around, unable to be still in his discomfort. He mumbled to himself, with a far off look in his eyes. When I sat down next to him and got his attention he kept asking me over and over if he was going to be okay. All I could reply was "yes" some-how, everything was going to be okay. The next week I returned to the Tuberculosis ward and he was gone. His lungs had failed him. These fragile patients, their experiences, and the mystery of death is what I found myself thinking about on the hour drive to and from my house to the clinic.
It is a gift to comfort someone during a time of difficulty, to lessen their pain, to listen to their story. Acupuncture offered me the unique opportunity to step into a new and strange situation, to be a part of something tragic and beautiful, to observe objectively, and give a gift to a community in need.
On January 28, 2016 the following excerpt was entered in my journal:
I remember Adrian as he is nearing death quickly. He is resting on his back, under covers, with his head turned sharply the right, vomit on his shirt over his right shoulder. His breathing is labored. I call his name and shake him. No response. He was at the hospital two days ago the other patients tell us. He has cirrhosis (of the Lv), Kd stones and ascites. No amount of acupuncture or medication can save him. He was taken to the nearby hospital, but the doctors sent him back to hospice. He hasn't taken medication in years possibly, and today he refuses food. It looks like he aged ten years in the last week. Thinner, darker. He moans occasionally. At this point what can I do? I needle his abdomen, yintang, and burn lots of moxa. The needles are of no consequence, its more to give me time with him, to pray with him. We are merely two souls. I play my role. He plays his. What his experience is, I have no idea. I palpate his abdomen which is swollen like a water balloon, his ribs bulging over his enlarged spleen. My last memory was of him sunbathing in a wheelchair, hiccupping. I don't think I will see him next week. With one death a whole universe ends.
Adrian passed the day after I treated him. The following week his bed had a new patient in it. And so on it went. Every week I returned to "Las Memorias", new experiences were encountered. New patients. New deaths. Often the story of how they ended up in the hospice had similarities. The person was in the US, usually Los Angeles, working, getting treatment for HIV, then got deported and dropped off in the streets of Tijuana. No more treatments, no access to medical care. Inevitably symptoms would start. Fevers, vomiting, diarrhea... three or four days in a row, all night long. Now in hospice, laying in a bed, under blankets and receiving IV fluids; they are without family, friends, and medication.
I often reflected about the hospice between visits. About its simplicity. Behind a building, against a brick wall and under a sheet metal roof, a fire would be burning to warm water in a large pot. The residents would fill buckets to bathe. What if life wasn't about filling up a bank account, and going on vacation once a year to Cancun; what if this was the meaning of life… to be uncomfortable, to be challenged, to face the scariest situation you can imagine, and make it beautiful? I find it interesting to think about the notion that when a person is born, people cry with happiness, yet when one dies, people cry with sorrow. In the HIV hospice, when a person died, I often breathed a sigh of relief; their struggle finally over, at last the pain had ended.
A second excerpt from January 28, 2016:
I think about this place during the week, about the patients, families, and children who live here. I also worry. It’s a big risk. I could get sick. I could poke myself with a needle. I could get TB. This place is changing me, how I think about life and death. Then I get in my car and drive home, and it all seems to get forgotten.
Patient's families would often visit, today it's Jorge's family. Jorge is in his mid 20's. Last week he was having sever head pain, to the point of screaming, writhing in pain. The week before that he had 3 seizures. Today he is quiet. It’s nice to see Jorge so peaceful compared to last week. He is like a child now. He reaches for my face when I talk to him. I worry if his hands are clean. His eyes constantly turned sharply to the left. He can barely track my finger. He mouths something to me, but I can't understand his gestures. He doesn't recognize his father. His family is huddled together, whispering, deciding what to do, take him to the hospital or leave him in the hospice. I tell them about our efforts to treat him. They decide to take him to the hospital.
Due to lack of resources, and because patients commonly have drug addiction problems, patients often go without pain medication. Philip, like many patients at "Las Memorias," has a history of drug addiction, he is stick thin, like a holocaust survivor. As I needle him, he screams in pain. I remove the needle, but the pain remains. He begs for his pain medication. I massage the point and burn moxa. Again, he asks for his pain medication. Tears roll down his cheek. The volunteer in charge of distributing medication says he gets his pain medication only before bed. Its 12:30 pm. I tell him. He cries. No matter what position he has pain. He asks for more acupuncture.
February 13, 2016:
Last week I treated a man who is on oxygen. A small man, thin, his shoulders raise with every breath he takes, it takes a long time to say a full sentence. He had TB for 2 years and the scar tissue left behind makes it difficult to breath well. His oxygen tank is too big to walk with. He asks me for a small tank of oxygen to be more mobile. He sells loose cigarettes to the other patients, his only source of income.
February 18, 2016:
Carlos lays in bed. A sweet, middle-aged Mexican man missing most of his teeth. Last week he showed us the beginning of his Kaposi's sarcoma (KS) he has as a result of his untreated HIV. Two small dark round spots on the inside of his upper arm, and several more on his ankle.
This week we found that the lesions had spread, covering one third of the soles of his feet, no longer individual spots, but one continuous raised area. His false teeth won't fit any more, and he shows me a KS lesion in his mouth. He complains of abdominal pain. I can feel a lump just under the skin above the belly button. He winces as I palpate. It’s difficult for him to urinate. An obstruction, caused by the KS I assume. I don't check. KS develops on the connective tissue of the skin, muscle and bones and is one of several definitions of having AIDS. It is the result of herpes virus 8.
This is the second time he has gone through this experience. The first time was in the US several years earlier. It had become difficult to walk, crippled with pain. He says the sensation of the KS feels cold when it first starts, then like a stabbing pain. It had spread to his intestines causing stomach pain. Though undocumented, Carlos was able to receive chemo in the US. He got ill. Nausea and vomiting. He said the treatment was very bad but he survived. Deported several years ago, he no longer has access to treatment.
Now he waits, alone, no family, in a room with other people who are also very ill. Carlos begins to cry as we ask about his experience. He remembers the pain from the first struggle with KS. He's afraid of the pain. He doesn't receive the antiretroviral medication he desperately needs. He has no money; the hospital will turn him away without treatment. He is sure to die, a preventable death. His death will be slow and painful. It is hard to stand at his bed side while this grown man tells his story in tears. I am angry, but I don't know who to be angry at or with. I want to bring him back with me. Take him to a hospital.
March 17, 2016:
Paulino had no appetite for the last month, enough energy to speak just a few words. He kept losing weight, the skin on his face like tan leather, vacuum-sealed on a skull; two large dark eyes, surrounded by pure white. He was recovering from pneumonia. How he survived that with advanced AIDS was impressive.
I treated a pain in his back and hip the last time I saw him. He was coughing up phlegm again, into an old plastic Folger's coffee container. No matter how bad he seemed to be doing, his assessment of himself was always "fine". The last treatment I gave him, maybe two days before he passed, his self-assessment was "so-so", a significant but subtle sign that he was in trouble.
This week, Paulino is not in his bed. A patient informed me he passed Sunday. I wonder if the treatments helped. A woman with a penny-sized canker sore on her lower lip is there instead, waving at me, asking for acupuncture.
I treat the woman with the canker sore instead. Half-way through the treatment, without warning, she vomits; bile splashes off the floor, and I jump out of the way, escaping with a small amount of puke on my shoes.
A man in all black is sitting on the edge of his bed, arms and hands shaking violently, hiccupping, clutching a plastic bottle of cheap liquor in both hands, black under the fingernails. He gulps it like water on a hot day. The assistant director doses the medicine, he will die if he goes without alcohol for too long. He doesn't want acupuncture. His pulse is thin and rapid, he winces in pain with any touch. He vomits clear liquid into a trash can, then falls asleep.
If he wasn't going through withdrawal I wouldn't have noticed anything seriously wrong with him. No bloating, or redness in the face. He looks 50 maybe, a weathered face. He likely has HIV or else he wouldn't be here, but he is in too much suffering to answer any questions. Still I want to know, I want to ask what happened, how did this happen? How much alcohol does he drink on a normal day? Where are his family and friends? He may not be here next week, not dead, just gone, back to his old ways. Maybe panhandling, or washing cars at the line for a few pesos each. A Pitbull puppy wanders through the hospice, so we turn and smile, grateful for the distraction.
I recently found a quote. In the end these things matter most: how fully did you live? How well did you love? How quickly did you let go? I let go of many patients during my time at “Las Memorias”. Some got better, some didn’t. Others looked for someone else to help them -perhaps acupuncture wasn’t appealing to them; others passed beyond the threshold of this physical world to the astral. I am learning to let go.
Acupuncture is not just a way of making a living, it can be way of life, a path of self-discipline. I yearn to make acupuncture an expression of selfless service. I know I have failed, and I know I will continue to fail because I'm still attached to money. I ask myself if I had treated the patients in Mexico like I treat my patients now in the local clinic in NY? The answer is no. But I will not give up and I will continue to improve, and know that success will prevail.
As I look back on my experiences, in Mexico and this past year in New York, I understand how fortunate I am. I recently took a trip to Tulum, Mexico, about 2 hours south of Cancun. It wasn't the Mexico I knew when I lived in San Diego and crossed the border as a means to challenge myself and foster personal growth. I missed the gritty and dirty streets of Tijuana, something about it makes me feel alive, vulnerable, real.
One cannot be pretentious when faced with a terminal illness. The smiles I saw at the clinic were always sincere, no one had time for pretense. It was refreshing. Outside of the hospice setting, clients oftentimes arrive for treatment and lack introspection. They are afraid to broach a subject of concern and importance to them. Perhaps it’s a fear of judgement. When a person is dying however, suddenly nothing is taboo. Everyone becomes equal, the fear of being embarrassed is lost.
I often wonder why it is that I find it inspiring to be around dying people. I suppose it’s partly the lack of pretense paired with the subtle need to be reminded that life isn't all about the "American Dream", making money and being comfortable. I long to be with those who cannot live that life, who have nothing and nobody. Perhaps surrounding myself with challenging situations serves to remind me that life is fragile.
When giving acupuncture, I receive more than I could ever imagine. In life I try not to run away from things that scare me. I observe them, I have learned to welcome experiences. I used to fear death. Embracing the opportunity to volunteer at a drug rehab facility/hospice/TB clinic in run-down Tijuana seemed appropriate. Experience and meditation jointly provide sanctuary in this world of chaos. Yogis of India meditate by the crematory pyres as a means of overcoming attachment to the physical body. Tijuana was my meditation during my last year at PCOM. I was blessed with a learned skill that helps to ease suffering. Despite language barrier, communication was seldom lost. I was merely there to offer help to whomever was open to receiving it. To my surprise many people didn’t want my services, but oftentimes when their last days on this earth were approaching, they allowed me to sit with them, cry with them, share in the loss that we all must face one day. A quiet presence is what I offered during their final hours. These moments helped me to look beyond myself. Today in the clinic treating young athletes, I am able to feel their [physical, mental, or emotional] pain; simply being with them and sharing in it, just as I did in Tijuana, that pain is lessened. During challenging cases or difficult life situations, I return mentally to those experiences in Tijuana described above. I am reminded that life goes on in the presence of death, that there is always hope and there are great lessons to be learned in suffering and loss.
Every individual will pass through death. It is my belief that we have all experienced death many times. These experiences are something to be embraced rather than ignored. If we take time to observe, reminders are put in our path to remind us to reflect on the life we are living today. What we must ask ourselves is... How fully are we living? How much are we loving? How quickly are we willing to let go?