Family Medicine Vital Signs

By Ali Etman

He sat slumped over in a lobby chair, his eyes staring at the ground, waiting for his name to be called. He was a thin Eritrean man in his mid-30s with coarse, curly hair and dark bronzed skin. Before I met him, the social worker assigned to his case had briefed me on his history and his lifelong struggles with his feet. Upon calling his name, it was impossible to miss the limp and the small children’s sized shoes he was wearing. Trying to stay objective, I assessed his gait from behind as he hobbled to the interview room.

As we waited for a Tigrinya interpreter to be phoned in, I examined his body language. He had sad eyes and showed minimal emotion. His responses were brief, and his English skills limited. I couldn’t stop thinking about how Arabic his facial features looked, which eventually made sense to me as I recalled the proximity and trade history that existed between Arabia and East Africa.

The interpreter introduced himself, and the social worker began his line of questioning. The social worker quickly realized that he had no interest in discussing his mental health concerns and turned the interview over to me for the medical section of questioning. I sensitively dug into his story, careful not to trigger any raw emotions unprocessed from his experiences as a refugee.

“So, what’s your biggest concern today?” I asked loudly so the interpreter could hear me.

“My feet,” he muttered quietly in Tigrinya.

He went on to explain how he doesn’t have much memory of the accident that maimed his feet. He was only three years old at the time, and the details of the incident were later revealed through direct family members who witnessed it.

When our client was a boy, a combustible device was thrown through his family home’s window. The fire spread quickly through the house. It’s unclear whether everyone survived the fire, but in the escape effort, our client was severely burned below both ankles.

For almost the entirety of the second half of the 20th century, Eritrea endured a long battle with Ethiopia for independence. It was a civil war that left tens of thousands in its wake. Our patient was fortunate to survive.

Midway through the story, he pulled out a lunch bag filled with all of his important documents. He sorts through them and hands me a group of photos. They were photos of what remained of his feet. He was missing all ten toes, which we later learned were removed for unclear reasons by German surgeons on a mission trip to Eritrea. I assumed that his toes had become nonfunctional due to the thick fibrotic scar tissue that replaced his once burned skin, limiting his mobility severely. On the bottom of his feet, two white lesions could be grossly appreciated on the medial and lateral surface. It was unclear if this was bone or calluses formed from new pressure points following the removal of his toes.

I had never seen anything like his case. I was fascinated by the pathology yet profoundly saddened. His life would be forever changed, negatively impacted in virtually every single aspect. And at that moment, I mourned for the life he could have had.

He went on to tell us he has to work a physically demanding job to support his wife and children. He has not told his employer of his disability in fear of being fired. He comes home, unable to walk from the sheer pain in his feet. And come time for sleep — the one moment each day he can escape from his life of pain — he lies awake restless, the burning sensation in his feet serving as a nightly reminder of the trauma he once endured.

“You know,” he says, “my brother and I were talking the other day. We used to tell each other that once we made it to America, all our problems would disappear. I would get my health back in order. We could have a brand-new start. But to be honest, life in America is just as difficult.”

His eyes filled with tears. And so did mine. All we could do at this visit was prescribe him gabapentin and schedule him an appointment with a podiatrist for an orthotic fitting. It was the best we could do with the resources available to us. But deep down, I wasn’t satisfied. I wanted his problems fixed NOW. I hated the idea of him suffering between appointments, especially since he had no means of transportation to get to them. I grew frustrated with the bureaucratic hurdles preventing him from getting the care he deserved, as I tried to make sense of my role in all this as a future primary care provider.

I think about him often and wonder if he’s still in pain. Is the gabapentin we’re prescribing him even helping? I hear the Arabic-influenced Tigrinya from his lips. We are more alike than we are different. And while I can never know his pain or relive his trauma, I must make any effort possible to connect with him in a way that makes his care more personal. While my ability to fully help him has its limitations, I feel it is my responsibility as a provider to be aware of all the resources available to me – and uncover those still unknown – to help my patient reclaim his life. Only then can I make a difference.