Reflections on The Cantaloupe Knee and Self-Driving Heart Attack

Stefano Byer, M1, Class of 2022

“In examining disease, we gain wisdom about anatomy, physiology, and biology. In examining the person with disease, we gain wisdom about life.” 

-Oliver Sacks

“Stefano, I have an odd question for you – are these people that we’re about to help, these Dominicans and Haitians, are they really the same as we are?”

Whenever I bring a group of fellow Americans to the Dominican Republic for a medical service trip, I am asked this question in some capacity. Yet almost more troubling than the question itself is the fact that I don’t know exactly how to respond. The answer is yes – they really are the same – but replying ‘yes’ doesn’t flip a switch on or off for their perspective.

It is important to note that this is not an ignorant perspective, but a naïve one – whose only remedy, as is for all naiveté, is experience.

But a week-long service trip won’t catalyze elucidation of the nuances of human identity – nor will a month-long or semester-long trip. Perspective actualization is not time-dependent – one doesn’t achieve insight via an experiential FitBit – one must seek it.

Medicine is one of the most powerful lenses through which we can examine ourselves and those around us. It is through the avenue of medicine that one best discovers the beautiful and humbling universalities of the human condition.

We all exist within and are defined by the abstract and imperfect realm of medicine, free of the superfluous and extraneous weight by which we define ourselves – like nationality, job title, favorite soap opera, etc.

This rambling post will bring us in communion with the patients of two stories.

One of them will be abroad in a village, far from any hospital, and the other, stateside at the heart of a hospital, both teetering between recovery and finality – both human.

So let’s begin, as Oliver Sacks tells us to, by examining the disease and the person with disease.

2,000 miles southeast of Kansas City is the city of La Vega, one of the larger cities in the Dominican Republic that sits at the base of their northern mountain range. La Vega is home to about a quarter of a million people as well as a towering, industrially styled cathedral that is famous for the location of Michael Jackson’s wedding.

A treacherous and rocky hour-long drive into the mountains is the village of Los Velasquitos, where I was part of a team of healthcare students and professionals that ran a small clinic out of the village’s one-room schoolhouse for a month.

It was Friday evening, the sky was sprinkling us with our daily dose of rain, and our first clinic week was coming to a close.

My co-coordinator Virginia and I had just finished house visits in neighboring villages and were walking back to Los Velasquitos. The sun was about to set with a new moon above, so we were speed walking up and down the hilly and damp gravel roads. We were particularly famished after a long first week – a week of successfully mitigating disasters, or so we thought.

About one mile from our house we were approached by Rosa, a middle-aged Dominicana, who mentioned – in the most casual way possible – that her husband Juan had gotten in a motorcycle accident.

In that infinitely long split-second between hearing and responding to bad news, I recall reflecting what we were told was the worst thing that probably could go wrong: a motorcycle accident.

“You can see him now if you want, or – since it is late – you can see him tomorrow in clinic”

Virginia and I looked at each other and instinctively responded: “we will see him now”.

We followed Rosa into her kitchen where she, being the hospitable Dominican matriarch, began offering us coffee, cookies, and seats. We were a little more concerned with the well-being of her trauma patient-husband, Juan. When we asked where he was she called out for him, astonished, we saw him painfully hobble into the room and sit in his chair. Juan clearly had been in a motorcycle accident.

His knee: dusty, beyond swollen, and packed with gravel resembled a grotesque, necrotic cantaloupe.

The first thing I thought was I didn’t know gravel could get in there.

“Tuve que mover la moto por un choco en la calle”

~I swerved to avoid hitting a small dog chasing him in the road~

Juan had serious visible, traumatic injuries to his left elbow and right knee. Swollen, partially degloved – his wounds were open to the muscle and bone, packed with bloody gravel – this was serious. Yet, apart from the occasional grimace visible only by his quivering dark mustache, Juan showed very little pain – machismo and humility.

“I’ll visit you in the clinic tomorrow – go eat dinner, you must be starving”, he half-heartedly ordered.

We in turn told him we need to get him to the clinic now, but we had no idea how to get him across the quarter mile between his house and the clinic.

“Voy en moto”

~I’ll go in motorcycle~

Motorcycle?? I thought he was joking – but he was dead serious. Juan hobbled out of the house to his beaten-up moto.

Reflecting on this moment I realized the bravery required by the desperately ill, and the constraints that tower over the marginalized poor.

I watched as he stiffly buzzed into the dark, down the damp, gravel road – the same gravel imbedded in his knee and elbow. My jaw clenched, praying for his safe passage, all the way to the clinic.

The schoolhouse, with patient examination rooms crafted by sheets hanging by rafter-strung wire (MacGyver would be proud), didn’t have any lights that worked.

After tying a string to a flashlight and tossing it over a support beam, we cleared our makeshift waiting room so Juan could sit down, propping his leg over a small chair and his arm over a desk that we covered with soon-to-be-bloodied surgical paper.

First aid kit ready, Virginia and I each focused on one of the injured extremities. Given his relatively stable state of being, and so as to mitigate nasty wound infections, we prioritized clearing his injuries of gravel and dead tissue – instead of organizing immediate transportation for the nearest hospital.

Gloved, forceps in hand, we meticulously plucked the tissue-embedded bits out and into an emesis basin – one of those plastic kidney dishes – while dousing his wounds with antibiotic solution. After half an hour of manually cleaning his engorged knee, we approximated the tissue, glazed it in antibiotic ointment and wrapped so much gauze around it that the cantaloupe knee now resembled a burrito.

I looked for Virginia, who had succumbed to Rosa’s culinary pressure and moved on from trauma to eating cookies dipped in tea. Rosa was more concerned about our state of hunger than her husband’s multiple wounds. We determined that we should notify our attending physician – who, thank God, was a retired orthopedic surgeon.

Virginia reminded me that “the difference between a med student and pre-med student is that, if need be, the pre-med will run a mile at night to wake the attending”. And so, the asthmatic pre-med student, yours truly, ran a mile in the dark to notify Pat, our orthopedist, that he needs to stop reading Game of Thrones on his kindle and attend to a patient in need – which is hard to do while wheezing and sweating profusely.

Pat and I power-walked to the clinic.

After examining Juan and having his fair share of Rosa’s cookies, Pat shared/blessed us with his diagnosis: a hemarthrosis.

The prefix ‘heme’ is shared with other words like hemoglobin, the oxygen-binding protein that makes our blood red; the suffix arthrosis is another name for a musculoskeletal joint, such as a knee. A hemarthrosis is, in other words, a bloody joint.

This means that when Juan landed on his knee, not only was his knee joint crushed and superficial tissue split open, but that some arteries within the knee were bleeding into the knee joint’s capsule – this pathology is exacerbated by hemophilia, a susceptibility to excessive bleeding, which of course, Juan had.

The pace of the night slowed down and as we made plans for Juan’s transportation into La Vega in the morning, we realized Juan had an old surgical scar on his other knee.

He told us it was from the last time he dodged a dog in the road…

From a public health perspective – I’m not sure whether the solution is removal of motorcycles or dogs.

I’ll never forget Rosa or Juan, probably the calmest trauma patient I’ll ever have. I won’t forget my star-lit night run and prying Pat from his kindle. I’ll never forget that cantaloupe knee and all I learned from that night, thousands of miles from home.

Just like I’ll never forget walking across the bridge at my medical school’s hospital. I was taking a prolonged study break and decided to check out the new glass-enclosed walkway that lets people connect between the ER and the specialty surgical center while being three-stories above the road.

Which is exactly how far I was from the self-driving heart attack I witnessed. Purple light, the kind created by the mixture of flashing red and blue police lights, shot up into the walkway like flames. Peering down I saw a car had hiked up on the hospital lawn, skid marks telling the story of the car’s rapid deceleration. Immediately I thought the culprit was a drunk driver, so I stuck around to watch the events play out – far more entertaining than reviewing antibiotics.

The driver stumbled out, his foot caught by his car, he twirled like a falling dreidel onto his back. I thought he must’ve been really intoxicated or …

he was having a heart attack.

One of his coronary arteries, the coffee-straw-sized vessels that provide the heart with the essential blood it pumps the rest of the body, became clogged by a fatty-scar tissue dam that had been building up over years.

Arteries are like rivers that perfuse the surrounding tissue with life-giving oxygen. Place a dam across that river, and life downstream withers.

That last bit of passageway in the almost completely occluded coronary artery became sealed. His oxygen-starved heart tissue signaled imminent demise and the pain pushed him to drive to the emergency room.

Reflecting on this moment I realized the bravery required by the desperately ill, and the constraints that tower over the marginalized poor.

The driver took a wrong turn and didn’t make it to the emergency room.

Now staring upward, he saw his fate.

And I, peering downward, saw an end of life scene; a dying driver on a gurney centered amidst concentric rings of life-saving personnel. Paramedics, acting in synchrony, were the first ring, directly tending to the driver. The second ring was composed of anonymous auxiliary personnel, offering assistance where they could. And all were fully encircled by emergency vehicles that covered the desolate scene with a shroud of flashing lights.

The driver’s eyes and mouth were skewed open as the gurney was drawn into the ambulance, his cut shirt exposing a bare chest that housed his dying heart, pounded on relentlessly by a paramedic. His eyes reflected a night sky doused in blue and red.

Whether the driver walked out of the hospital a week later or was carted out the next day, I do not know.

What I do know is that Juan returned to the village two weeks after his hospitalization.

Visiting him and Rosa, I was now able to enjoy her cookies, coffee, and conversation.

This rambling post has presented the story of two people from different parts of the world – an urban American city and a remote Dominican village.

Yet even though the people presented were in similar predicaments, the place mattered little. The physical and emotional presence of others mattered more, and physiological constraints mattered the most.

I offer these stories as an opportunity to reflect on how we define ourselves and those around us.

It is because we all teeter on that fine line between finite life and infinite death.

It is because when we use the lens of medicine, we can see each other divorced of what we stand for and can better see who and what we are.

It is because today, in these trying and divisive times, it is imperative that we see and value and know that the lines we draw are but imaginary.

So yes, we really are the same.

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