The Spirit Catches You and You Fall Down
It's time now to take a look at a clinical case from two cultural perspectives. First, we will look from the perspective of the culture of Western medicine and then from a Hmong cultural perspective. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, by Anne Fadiman, is a remarkable exploration of the challenges doctors and patients face in understanding each other. Cultural beliefs about health and disease are intimately linked to how patients and their physicians understand and communicate with each other. Fadiman describes in passionate detail how the clash between Hmong belief and culture and the culture of American medicine shaped the care of Lia Lee.
Lia Lee's Clinical History
Lia Lee was born at Merced Community Medical Center (MCMC) on July 19, 1982. At the age of three months, while at home, Lia suddenly had an episode in which her eyes rolled up, her arms jerked over her head, and she lost consciousness. During the next few months of her life she had at least 20 more seizures.
On October 24th, Lia Lee had a seizure at home and was brought to the MCMC emergency department (ED) by her parents for the first time. At the time of her arrival, the seizure had stopped. Because no Hmong interpreter was available, Lia's parents could not explain to the physician what had happened at home. She was noted to be congested and have a cough; an x-ray was done, and she was diagnosed with early broncho-pneumonia. The parents were given a prescription for ampicillin and discharged.
On November 11th, Lia had another seizure and returned to the ED. Again, she was diagnosed with pneumonia and discharged.
On March 3rd, the third time she was brought to the ED, she was seizing. According to the ED note from that visit:
"The patient is an 8-month-old Hmong female whose family brought her to the ED after they noticed her shaking and not breathing very well for a 20-minute period of time. According to the family, the patient has had multiple like episodes in the past, but has never been able to communicate this to the emergency room doctors on previous visits secondary to a language barrier. An English-speaking relative available tonight stated that the patient had had intermittent fever and cough for 2-3 days prior to being admitted. Family and social history unobtainable secondary to language difficulties."
Lia was discharged on March 11th with instructions given to an English-speaking relative for ampicillin 250mg bid for her aspiration pneumonia, and Dilantin 20mg bid for seizures.
Between the age of eight months and four and one-half years, Lia Lee was admitted to MCMC 17 times and made more than 100 outpatient visits to the ED and pediatric clinic at the Family Practice Center. Because she continued to have seizures during that time, Lia's medication was switched from Dilantin to pheonobarb, then Dilantin as well as phenobarb. Consulting neurologists later added two additional anticonvulsants, Tegretol and Depakene. Lia was also treated intermittently with antibiotics, antihistamines, and bronchodialating drugs because of her frequent lung and ear infections.
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