Siloam Scenario (Part 3 of 3)

Morgan Wills writes…

In our previous two posts, we presented the case of a Vietnamese woman with arm pain who was noted to exhibit signs of a folk healing practice known as “cupping.”  So what is the relevance of this finding?  Is it just a curiosity of caring for patients from exotic homelands? 

Jina Hawk Lotze, Family Nurse Practitioner, educates a patient about carpal tunnel syndrome.

Well, such “X-factors” do make everyday problems at Siloam a bit more fun and complicated!  But there are important learning points as well.

First, an awareness of such practices by health care personnel can prevent some major problems.  Although not every folk remedy is benign, cupping is neither particularly harmful nor mean-spirited.  Unfortunately, some Southeast Asian immigrant parents who apply this practice to their children in the setting of minor illness have been unjustly accused of child abuse by well meaning but uninformed American health care personnel.

Second, we need a posture of humility and teachability in practicing cross-cultural medicine.  It is important to be continually learning about our patient’s social and cultural context.  The pursuit of such knowledge constantly re-frames the possible list of diagnoses and treatments.  As much as we want and can benefit from protocols in medicine, the bottom line is that each patient is ultimately an individual.  A truly whole person care plan will respect that unique, God-given particularity in each of us and keep the wonder in the medical encounter.

Third, this case is a reminder that all medicine is to some degree or another “cross cultural”—whether at an academic Medical Center or your neighborhood “doc-in-a-box.”  In the end, Cultures are the outward and systemic manifestations of a people’s basic faith commitments or worldview (a set of lenses for viewing reality, religious or otherwise).

We all bring our own understandings of “health”, “illness”, and “good treatment” to bear in the setting of illness.  We may see this reality more clearly in treating someone from a significantly foreign culture, but culturally-bound belief structures play into the care of less exotic patients as well.  Consider the degree of confidence (faith?) modern American patients put in antibiotics, stimulants, or mega-dosed vitamins.  Or the similar trust that the biomedical system implicitly places in expensive laboratory tests and imaging studies!

Whether and how to assess what we should trust in the wild world of health care is beyond the scope of this blog entry.  But the point is that our perceptions of health are affected by the influence of both faith and culture—and often in ways we don’t expect.  If the Siloam Institute of Faith, Health, and Culture does nothing else, it seeks to foster in its trainees increased self-awareness about their own worldview and how it influences the care of patients.  

We hope this leads to humble respect for both the benefits and the limitations of the biomedical model.  To the extent that this leads to a genuine openness to considering what the ends of health care really are, then the process of forming whole person caregivers has truly begun!

Siloam Scenario (Part 2 of 3)

 Morgan Wills writes…

Welcome back!  If you’ve had a chance to ponder our recent case, you may have made the following assessment:  This woman has multiple, scattered round, flat lesions of varying size on her right upper arm.  The color is a little difficult to appreciate in the context of her moderately dark skin, but appears to be a reddish purple, both homogenous and uniform, implying that they began at the same point in time.

Depending upon the time of onset, the differential diagnosis could include such possibilities as:

–          Mongolian spots (type of birthmark)

–          Hemangiomas (overgrowths of small blood vessels)

–          Eczema

–          Ecchymoses (medical speak for “bruising”)

–          And other complicated sounding problems such as phytophotodermatitis, erythema multiforme, and idiopathic thrombocytopenic purpura

At this point, the history can help to clarify the possibilities.  As Jina recounts, this woman was complaining of gradually progressive pain and numbness in her right arm, especially over the past four days.  The pain was primarily in her right wrist and forearm, with some numbness in her hands, and an aching feeling all the way up into the right shoulder at times.  She is a married mother of two and works a cleaning job in a nail salon, but adds, “I don’t do nails.”

The physical exam revealed some diffuse tenderness throughout the arm and positive Phalen’s and Tinel’s signs (reproducible numbness and tingling caused by compression of the median nerve at the wrist).   Clinical types out there will pick up on the likely diagnosis of carpal tunnel syndrome—a compression neuropathy of the median nerve. 

But what about the skin lesions?  Carpal tunnel syndrome does not explain them, but two pieces of the history do: the woman is unconcerned about the skin findings, and . . . she is Vietnamese.  Why would that make a difference?  Well, you see these lesions are actually bruises, and they are self-inflicted.

This phenomenon, known as cupping, is a common folk remedy in Southeast Asia.  The marks are caused by a lighting a match inside a cup or similar device to create a vacuum until the puckered skin surface is bruised.   A similar practice, called “coining,” involves rubbing a coin in heated oil up and down the skin until streaky bruises are created. [see photo of a previous Siloam patient below].  Both practices are performed to treat “wind illnesses,” ailments that result from lack of internal balance or harmony in a person’s life.

Fortunately, in this case Jina did not show alarm at the signs of cupping but was able to acknowledge the patient’s understanding of her own illness and also explain the nature of carpal tunnel syndrome as she understood it biomedically.  By building this bridge, Jina and the patient were able to establish trust and mutual understanding of how to relieve the pain through a splint and behavior change.  If and when the patient develops a more serious illness, the patient’s experience of such a collaborative relationship will be all the more important.

In our next installment, we will briefly explore the implications of this finding for the clinicians and health care professional students.  In the meantime, an excellent website to learn more about such practices—and other aspects of crosscultural health—can be found at www.ethnomed.org.