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Coração / Heart



               Maria came to us with sleep apnea. At least, that was the top candidate on my list of differential diagnoses. I was only a first-year medical student in my fourth month of training, but had been working in the same clinic long enough to pick up the tell-tale signs of daytime sleepiness and shortness of breath. She’d likely had it for decades, judging from the snippets of Portuguese Creole that I managed to pluck out from her narrative before the hospital-assigned interpreter mangled her replies through a clipped and faithless English, tinged with the Ecuadorian Spanish that he himself was using to communicate with her. The primary care doctor that she had been seeing for years at the community clinic had ignored her persistent complaints of snoring through the night and falling asleep at her job. She brought them up every visit, every year, but the doctor had only ever asked about her medication list, hearing, and blood pressure, which by now had all ballooned to a list of thirty-odd drugs, an interminable ringing in her right ear, and a terrifying 157 over 102.

               As I asked about her social history, there seemed a bittersweet distance beyond the answers she gave, as though she were not truly present in this windowless exam room on a gray November Tuesday. She talked about her old life in Cape Verde. I listened as she explained why she left her home country, what had happened so many years ago. “Although, something is calling me home, now,” she said. A resilient wisdom percolated her words as she spoke about her years in America, all of the struggle she had endured and the independence she had claimed. Still, she told her story as if it were not her own, but one that she had once read in a novel written generations ago and that had left in her an indelible impression of sorrow at the fact that such stories could ever be told.

               As she answered my questions about her social history, she let out a large cough that jolted me back across the Atlantic and into the exam room. After asking whether she was experiencing any other symptoms, I was fairly certain in my assessment of obstructive sleep apnea. I stood to wash my hands at the sink as I explained that I would try to listen to her heart and lungs—I accidentally let the “try to” slip through. So much for instilling confidence. The interpreter chewed up my words and spit them at her while checking his cell phone to see whether lunch was any time soon and if the Patriots were headed toward the playoffs this year. He left off the “try to,” and for once I was thankful for his inattention. Maria, staring at the floor as she had done for most of the visit, silently nodded her assent.

               I placed the diaphragm of my stethoscope to her chest and heard a rustling noise. I assumed that I had caught Maria’s blouse under the diaphragm, and I repositioned the stethoscope directly onto her skin. The whispering in my ears persisted as I held my breath to be certain. It was unmistakable— a heart murmur, whooshing and gushing with every beat.

               It was my very first heart murmur. If my math holds, it was Maria’s one billionth nine hundred eighty-six millionth seven hundred sixty-eight thousandth, or so. Of course, that all depended on when the murmur had actually started in her lifetime, and did not account for any moments of joy or shock or sorrow that had punctuated those years and that would have sped it up or slowed it down or even stopped it altogether for an instant. Such a figure certainly did not account for how frantic her heart must have beat when she rowed from Santa Maria to Sal Rei under the obscurity of night to get away from the one she now only called ele. Him. 

               To this point I had always assumed that heart murmurs were myths—ogres and dragons dreamt up by Littmann to market their newest and most powerful stethoscopes, or by the newly minted residents that wore such stethoscopes draped around their necks as medallions of their expertise while they retorted, “It’s there, you need to listen, don’t they teach you anything in school these days?” But there was Maria’s, as loud as the crashing sea that lay between here and home and now and then, as fluid as a broom pushing back the puddles of torrential rain that had fallen the night before, each night before. Atrás, it whispered with every beat. Once ago.

               Stunned at the sound and the fact that I had found it, I continued with the rest of the exam, trying to mask my shock and hold composure like I had been taught in school. I listened to Maria’s lungs over the rhythmic bounding of my own heart in my ears. They sounded clear to me. I thanked Maria for her time and explained through the interpreter that I would report my findings back to the doctor before we both came back to see her. As I was opening the door I heard a tudo bem eke out from her parted lips, an “okay” ever softer than the thundering whisper in her heart.

               I was eager to share my diagnosis with my attending and demonstrate to both him and myself how much I had learned in just the first semester of school. I found him in his office and presented Maria’s case to him, gliding through her paroxysmal nocturnal dyspnea and her hypersomnia. Everything flowed effortlessly until the social history. I didn’t know what words to give her story or her sadness, or how to describe the once ago that echoed in Maria’s heart every single second of her life. They hadn’t taught us the Latin or the Greek for that yet. I decided to leave it out; she was here for sleep apnea, after all. “Lungs clear to auscultation bilaterally,” I rattled off to him, regaining my rhythm. “Cardiac exam revealed significant murmur at the aorta.” He lowered the week-old copy of the New England Journal of Medicine he had been studying, his graying eyebrows peering up over the cover at me. I knew he would be impressed.

               We went back into the exam room together. He took the lead, repeating many of the same questions from before and covering the ones I hadn’t thought to ask. He probed through Maria’s smoking history, asked whether anyone had ever told her she snored loudly while she slept. She replied that she lived alone, like I had told him. Hadn’t I told him? He turned to her as he asked whether she ever felt depressed or anxious.

               She paused before lifting her eyes from the floor and gazing at the doctor: “Well, I am sad a lot of the time.” My attending looked away from Maria, glancing at me with a concerned look that asked, “Did you know this? Did you contract for safety?” My heart sank, earlier thinking how proud he would be at my findings but now devastated that I had choked trying to communicate her story. She had shared her heart with me and I didn’t have the words to do it justice, not even to flatten it into a snappy clinical buzzword or two. I had called it a murmur, and I had moved on. The attending shifted back to Maria and asked her whether she ever thought about hurting herself or anyone else. “No, never,” she replied matter-of-factly. Her gaze had returned to the tiles under her feet. “I am just sad a lot of the time.” Somewhat hesitantly, he typed a lowercase n into the box for “suicidal ideation” before moving down the review of systems. 

               Finishing his questions, the doctor listened to Maria’s heart and lungs adeptly and without the plodding of my own exam. I marveled at his skill as he placed his stethoscope perfectly at each auscultation point on the first try, without the awkward shuffling of my own exam. He gave me a thumbs up when he too had heard the murmur in Maria’s chest. Moments ago, that might have made me feel proud and competent. But now, all I felt was guilt, as if the heart were something of mine rather than hers to share.

               Wrapping up, the doctor explained to Maria what he had discovered—she didn’t react when he told her of the murmur. He told her that he would order a sleep study as well as an echocardiogram to look at her heart. And then he placed his hands in hers, and he thanked her for inviting us into her life and trusting us to help. “I am here for you, however you need it,” he offered sincerely. For only the second time in the visit she looked up at him, and in English she whispered, “Thank you, Doctor.” In an instant, I saw that exam skills and diagnostic prowess were not enough to treat Maria or connect with her in the way she deserved. I may have heard her heart, but she needed someone to listen to it and honor it, too.

               As we all stood up to leave, the interpreter had already beat us across the room to the door and held it ajar, eager to make it to the cafeteria before the lunch hour had passed. The doctor caught him just in time, asking him to let Maria know that we were going to do everything we could to treat her sleep apnea. The interpreter clucked out a few words to her before darting into the hall, not waiting for a reply. “Oh, and her heart,” the doctor added, but the interpreter had already vanished. He turned to Maria and said “corazón,” pointing at his own chest and using the little Spanish he had picked up over years of medical practice.

               “Coração,” I offered—I knew that one, at least. And your heart.

               She gave a quiet chuckle at my pronunciation as she smiled and started to walk toward reception.

LOGAN BRICH MD’25 loves lists, irony and the Oxford Comma.

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