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.