The Heart's Truth: Essays on the Art of Nursing

First, Do No Harm

46 First, Do No Harm Milagros is an illegal alien, one of many who come to the women’s clinic. She has a valid-looking social security card, but when we check, we find that four other patients claim the same number. Last month, she used the last name Lopez. This month, she signs in as “Milagros Hernandez.” Then one of the nurses recognizes her. “Hey, Milagros,” the nurse says in rapid-fire Spanish. “Make up your mind, mi amor! Pick one name and stick to it. You know we won’t report you.” A few years ago, we saw few undocumented patients. Then, month by month, our census increased. Now, our appointment book holds only the names of women who’ve fled their homes in Ecuador, Colombia, Mexico, or Peru, leaving everything behind to follow husbands who are convinced life will be better in the United States. Here, a man can earn enough to send money home. Here, a pregnant woman can receive good medical care and have half a chance of delivering a healthy baby. When the language barrier kept us from delivering good care, we hired Spanish-speaking secretaries and nurses. The residents and I learned Spanish on the job. Today, the TV is always tuned to the Spanish station, and patients chat in musical variations of their Ecuadorian, Puerto Rican, Dominican, or Chilean tongues. Inside our clinic, cultures merge, sometimes painfully, but our patients’ illegal status isn’t an issue we speak about. Recently, Milagros was admitted to the hospital in her seventh month of pregnancy with out-of-control blood pressure. She’s stable, but we can’t discharge her. Milagros has no permanent home. Shortly after she arrived in this country, she discovered she was pregnant. Her husband abandoned her. She sleeps on the floor of friends’ apartments, moving every few days. She doesn’t speak English and cannot read or write Spanish. We tried to treat her high blood pressure by asking Milagros to maintain bed rest, but her friends wouldn’t let her lie on their floors all day. She can’t return to Ecuador, nor does she want to. She wants her new baby to have what the three children she left behind don’t have: food, first, do no harm 47 medical care, shelter. Milagros has been in the maternity ward for three weeks, a hospitalization she can’t afford. If we discharge her, her blood pressure might become critical; then we’ll have to deliver the baby prematurely. In that case, the neonatal intensive care unit will have to care for the baby, perhaps for months. If Milagros has no permanent address when the baby is ready for discharge, it will be placed in foster care. At high-risk conference, we try to decide what to do about Milagros. “We’d send any other patient home,” the attending physician says. “But,” the chief resident says, “every time we discharge her, she goes back to work and her pressure hits the roof. If she doesn’t work, she doesn’t eat. Morally, how can we let her go?” “Can’t the visiting nurses help?” one of the medical students asks. “Sure,” the visiting nurse replies. “But whenever we try to find her, she’s moved. If we call, no one answers. They think we’re the authorities.” And so Milagros lingers. If her pressure cooperates, she’ll probably deliver somewhere around her due date. If she finds a friend to volunteer an address and phone number, Milagros will leave with her baby. But “home” will still be a series of stopovers in already crowded apartments. Her only escape might be to find a new partner who will provide, at least temporarily, housing and food. In a few years, she may learn enough English to take the bus or make an appointment without help. Because her baby will receive welfare, Milagros will have some money for rent and food. When her other children are grown, Milagros may send for them—if she’s saved enough for their expensive, illegal, dangerous transport. For now, all she can do is pray that someday they’ll be reunited; that this child, a U.S. citizen, might find a better life. Before we admitted Milagros to the hospital, she always arrived in the clinic wearing the same skirt, the same shirt, the same thin sandals, even in winter. She survives at a level of poverty most North Americans can’t imagine. Like most of the...