Shuffle: Off

Much of medicine is like listening to an iPod on shuffle. One minute I am interviewing a talkative 73 year old about her breathing problems and long list of medication refills. The next room over, I might encounter a shy 2 year old, clinging to her mom’s leg. Shuffle in some diarrhea, some dental pain, some fancy new medicines with lots of Z’s and X’s in their names and some old school procedures like suturing up a hand. In other words a day can take you from Beethoven to Brittney and back with the knock of an exam room door. The ER is a shining example of this randomness. Things happen, hangliders crash, hearts attack, and the doors are never locked. People come and go all day. And despite the inevitable frequent flyers, most are brand new customers. Like hearing that good song on a shuffling iPod….and never hearing it again.

But some albums just require listening in the right order. Pearl Jam’s Ten or Pink Floyd’s Dark Side of The Moon, for example. Maybe they have a message, certainly they have a flow. Before the days of shuffle, the end of one song would have you humming the beginning of the next, before it started. A certain level of expectation is then satisfied when sure enough, it plays. Life is certainly more random, but sometimes in primary care medicine, while often a day is chaotically scheduled, sometimes it feels like listening to an album in the correct order.

Even as a “short-timer” student, inhabiting the clinic for a few months I have a case in point:

Seeing a pt for her last 2 or 3 prenatal visits, and then following her to the hospital for post term induction. Learning to read her “bad strips”, and then watching her c-section. Doing a newborn exam on her little baby boy, a bit banged up from delivery, with a possible broken clavicle. Seeing everybody back in the office a few days later for a weight check, then assisting with his circumcision a few days after that. I could anticipate the next song. If I hung around for a few years, I could anticipate a few colds, maybe some asthma. Lots of shots. Throw in a broken arm from snowboarding, some questions about puberty, and a weird rash. If I hung around for a few years after that I might anticipate some low back pain, a consult to an expert in Portland, and some advice as he starts his own family.

So while an individual day might have that feeling of shuffling through 20 gigabytes, the overall picture has an underlying rhythm. And while, impossible to truly anticipate the next song that will arise in a patient’s chart, just experiencing the album in order is satisfying.

Heart Medicine

Dried mud clumps start in the hallway and lead into the exam room, where I find two men sitting. The first is a heavy set Hispanic man, with bulging arms and chest likely from a life of hard work. Just south of the muscular thorax is a similarly bulging abdomen, this likely from a life of hard eating. He wears a tight generic Wrangler shirt that appears to want to pop. He is round, but strong. Saying his name, “Rolando”, I shake his calloused hand and offer, “mucho gusto.” He eyes me with distrust, but that’s OK.

I turn to the man sitting next to him, an Anglo. He is tall, with thin gray hair. His skin is tan but Anglo tan. He spends a fair amount of time outside, surely. He wears a zippered fleece and while his boots are also contributing to the trail of dirt, his jeans are new and clean. He’s el patron, the boss. “Mucho gusto, Jeff.”

Sorting through the history and the reason for the visit is the first challenge. It is generically listed as Health Maintenance Exam, but the patient immediately launches into… Chest Pain. Pressure. Aqui. When those words are spoken they seem to just float there, waiting for me to attach them to something. My heart rate rises. I scan his chart and after a few more questions, understand that he suffered a heart attack in November and presents for continued angina. Worsening. When he walks in the house. When he does dishes. Pressure in all the places you don’t want pressure. Radiating to all the places you don’t want radiating. But at least the initial Chest Pain. Pressure. Aqui. is attached to something. I can slow down.

Jeff wants to know when his employee can get back to work. I want to know when he can get back to a cardiologist.

I’ll admit my initial thought was that this orchard owner was just trying to get his “help” back in the fields as soon as possible, despite the consequences. I assumed he just wanted medical clearance for Rolando so he could enforce a return to hard work. I couldn’t have been more wrong.

It turns out these men have known each other for over 25 years. They consider each other friends. They know each other’s families. Admittedly, there is a lopsided role of power, finances, and access to healthcare. One owns thousands of acres and (like me) probably pays somebody to change the oil in his car. The other is a poor immigrant from Mexico with ill-fitting clothes and no car. But what’s not lopsided is Jeff’s evident compassion for Rolando. He wants to make sure no further damage is possible to Rolando’s heart, while at the same time helping get him out of the trailer that he is trapped in, a prisoner to his chest pain. He wants to advocate for his employee, helping him get a cardiologist appointment. He will drive him to Portland. He is helping with the cost of expensive medications and consults. While miles apart in their background, today finds them sitting next to each other in an exam room. And in the end, they both have mud on their boots.

We were able to increase some medications that will likely extend the exertional capacity of Rolando’s heart. Not in heart failure, the problem exists in the coronary arteries, not the pump itself. He has a stent in one of the offending arteries, but another one was, for lack of a better term, unstentable. We gave our blessing to try some work, as tolerated. Stay off the big tractor for now. With close follow up, we will see if the medicine change helps him.

But Rolando may eventually need a bypass, meaning open heart surgery. If he does, I suspect that in a hospital in downtown Portland there will be two sets of muddy boot tracks, where there might have only been one….or none. And that is the heart medicine that might be the most important.

Best Reason to keep a Brightly Colored somewhat Sporty Looking Jacket in your Car in One Sentence or Less.

So when you are travelling through windy* and windy* but gas-station-less Columbia River Gorge at a high rate of speed on Monday morning trying to make it to work on time and you suddenly notice that your gas-light-less car is on empty and then 3 minutes later realize that you are sputtering to a halt on Interstate 84, you can put this jacket on and represent yourself as an obviously not crazy one-toothed psycho hitchhiker and make yourself appear as a much more benign skier or PA student in distress, so that this one guy will pick you up and drive very fast to Hood River without functioning seatbelts in his car and then this couple with a rental car with Ohio plates and rental skis will pick you up and take you westward to your car, thus making it possible to still make it to your cold rental house, shower, shave and make it to work with 4 minutes to spare.

*windy as in breezy
*windy as in curvy