From the exam-room door, I looked past the waiting room, across a dirt road toward shacks baking in the desert heat. It was noon in Baja, Mexico, and we needed to finish up soon to get back to California before sundown.
Our small group of doctors, nurses, translators, and pilots had flown to this little fishing village the day before to run our monthly two-day clinic. Some of the folks we treated had struggled over dusty roads for four hours to get to us.
We had one last patient. A volunteer brought in a woman who, I was told, was in her early thirties. She looked much older. In this part of the world, that is not uncommon. Conservatively dressed, she seemed unfamiliar with the clinic, a bit shy, unsure whether she should sit or stand, not knowing which of us to look at, my translator or me.
Through the translator I learned that my patient, Maria, felt very tired. She had been feeling that way for a long time. She had seen a local practitioner about it once before, about a month earlier.
“He told me I had anemia,” Maria offered. Looking at her, I had my doubts.
“How did he determine this? Did he do a blood test?” I asked.
“No,” Maria replied, shaking her head. “He looked at my eyes.”
Sometimes an astute clinician can pick up on anemia by noting pale coloration on the inner surfaces of the eyelids. But you’ve got to be pretty low in hemoglobin for this effect to be noticeable. Frankly, Maria did not look anemic to me.
I had no way of knowing who or how skilled the practitioner she’d seen was—a doctor, a shaman, or just some guy who set up shop and started treating people here in the Mexican outback.
“Did he give you a medicine for the problem?” I asked.
“Yes,” she said.
“Did you take it?”
“And did it help?”
Anemia, or low red blood cell count, can certainly make someone feel tired. The most likely cause of anemia in young women is iron deficiency due to menstrual blood loss, but Maria had noted no change in her menstrual pattern. There was no other bleeding, either. And she had never been anemic before.
Here at the clinic, where we were happy to have running water and electricity for part of the day, that kind of testing was out of the question.
My skepticism increased after I examined Maria, who lacked pallor, rapid heart rate, or any other sign of significant anemia. I knew there was no substitute for a blood test to establish the diagnosis, but there was no way to do that at this clinic. I relied on what experience was telling me: Fatigue serious enough to have brought this apprehensive young woman to me was unlikely to be due to mild anemia. So what was really going on?
A Menu of Miseries
Fatigue is one of the most common symptoms in medicine, attributable to problems ranging from sleep deficit to cancer. When a patient offers no symptoms other than tiredness to point the medical mind toward a particular organ system, a physician is obliged to comb through the entire gamut of symptoms with the patient, system by system. As I often tell my students, “When the symptoms point nowhere, you have to look everywhere.”
So we worked our way through the list—the menu of miseries, as I sometimes call it—but by the time we got to the end, nothing revealing had surfaced. At this point I would ordinarily consider blood work, X-rays, and other tests to try to sort out the puzzle.
But here at the clinic, where we were happy to have running water and electricity for part of the day, that kind of testing was out of the question. Besides, the nearest laboratory and radiology facilities were more than five hours away, on the other side of the peninsula, and the van would be here soon to take us out to the airstrip.