Bruits

Bruits

By

Leo de Natale

Illustrations by Vince Giovannucci

Ed “Boo-Boo” Clipner was a pleasant sort and stereotypical construction worker. In his late 50’s, he was 5’10 with a thick, short hairy neck. He weighed nearly 300 pounds. Often unshaven, “Boo” as his co-workers called him, was popular among his mates. A longtime cigarette smoker, he was obese and consumed anything on a McDonald’s or Big Burger menu. He had the classic beer belly and the predictable plumber’s crack. His wardrobe consisted of flannel Carhart shirts, Dickies work pants and scuffed Timberland boots. Boo was always reeking of tobacco, smiling with nicotine-stained teeth and wheezing. That’s usually the telltale sign of someone COPD-bound. The oxygen pack was perhaps a few years away.

Illustrations by Vince Giovannucci

Boo was oblivious to his self-destructive lifestyle. There are many psychological reasons why the Boos of the world choose to let their bodies dissipate.  The psychopathology usually involves insecurity leading to poor self-image.   Blue collar workers often display such traits.  Their work is physically demanding and often hazardous.

 Like many of his brethren, Boo accepted the risks.  The money was always good and there was a satisfaction  in pointing to a skyscraper and saying,  “I built that!”

The construction company for which he worked did, however, offer annual wellness examinations . Predictably, Boo neglected his health care benefits and in four years hadn’t been examined by his longtime primary care physician (PCP), Dr. Charlie O’Hara who’d recently retired. O’Hara’s office was at Bon Homme Hospital, a small regional hospital standing well in the shadow of Boston’s world class Massachusetts General and Brigham and Women’s Hospitals. It was considered average at best, its clientele tended to tradesmen and their families and the ever-increasing influx of illegal aliens. Bon Homme was not known for attracting the best and brightest MDs. His new PCP was Dr. Heeshwa Patel.

There’ve been numerous news stories about a physician shortage creating the need for many hospitals to hire foreign MDs who are graduates of third or fourth tier medical schools: New Dehli University, Zagreb College, the University of Naples. None of these medical schools could be compared to American Universities. In today’s world, however, these graduates were hired if they passed medical board standardized examinations. And this is how Boo and Dr. Patel (University of Bombay) crossed paths.

But Bon Homme was where the beloved Dr. O’Hara had practiced and Boo felt a certain loyalty. Along came Dr. Patel whose English was impeccable although his speech had that patois that was clearly Indian. He was tall, thin and swarthy. He sported a van Dyck beard hidden behind the ubiquitous Covid mask and was impeccably dressed with shirt and tie. The subtle aroma of sandalwood soap enveloped him. Dr. Patel exuded the appearance of a well-trained foreign physician. Before seeing his new doctor, Boo underwent the usual protocol.

“How ya doin’?, Dee Dee,” Boo said as he was greeted by the chubby veteran intake nurse Diane Diggins who usually took his vital health signs. The blood  pressure the pressure cuff was difficult to attach due his meaty biceps.

“Oh, Boo, you always give me a hard time with these tests,” she teased.  “Now let’s hop on the scale.”

“Ooooh, 315 pounds today,  Boo,” she said. “That’s really pushing the envelope. It was 280 last time you were here.   I’ll also test your cholesterol levels.  Your  pressure today is 185 systolic, 95 diastolic.  That’s too high, Boo.  Have you been taking your medications?”

“I’m trying Dee, I’m trying,” he said.

Dee Dee made no further editorial comments and entered the information into the electronic records computer.  She told Boo to return to the office waiting room. 

As is the custom today, there was a sea of patients awaiting their visits. Boo figured this was going to be at least a one-hour wait. And, yep, after two hours, Boo was ushered into an examination room.

He liked what he saw in Dr. Patel but he didn’t like the foreigner’s report.  He ran down the laundry list of conditions.

“Your blood pressure and obesity are concerning, Mr. Clipner,” he said with his clipped, distinct accent. “These are troubling numbers. I must ask you if you’ve been noncompliant with your daily drugs.”

“Well, like I told Dee-Dee, I try, Doc, but sometimes it’s hard,” Boo replied. “But’s what’s been really bugging me are my eyes.  Sometimes I can’t see, even with my “cheaters”.  He was referring to the cheap  drug store reading eyeglasses.  “They’re made in China and I think they’re crap. Can’t see good.”

 “Well, when was the last time you had an eye examination?” Patel asked as he conducted a perfunctory eye evaluation with an ophthalmoscope.

“Oh, maybe four, five years ago,” Boo answered. “I go to Dr. Megna here in town.”

“Well, I think it’s a good idea to see him,” Patel replied.  “I’m sure your health insurance will cover the examination.”

Patel was gagging after Boo left.  The smell of tobacco permeated the small examining room.  He grabbed a can of maple/cherry room refresher  to eliminate the foul smell of smoke, halitosis and body odor.  Patel was extremely fastidious.

Four weeks later, Boo was sitting in Dr. Megna’s office. The waiting room was small. It was an old-time optometry practice. Steven Megna was in his fifties and was second generation professional. Boo and his family had gone to old Dr. Megna, the father. It was a generational relationship.

“So Boo, we haven’t seen you in some time,” Megna said.  “Are over-the-counter eyeglasses not working? Don’t forget, I’m not just checking your vision.  Your general health is important.  I haven’t received any information from your new doctor.  Charlie O’Hara was good about that.”

“I can see pretty good with my cheaters but it’s another problem I’m having, Doc,” Boo said.  “The vision sometimes fades to black and then comes back real quick.”

Megna’s diagnostic antennae  quivered upon hearing that.  Following his usual protocol, Megna began with a case history—changes to his medications, any flashes or floaters, problems with night vision etc.  Boo’s distance vision hadn’t changed much but he did need an change in his reading prescription. 

He, however, was more concerned with Boo’s report of fleeting blindness.  After arriving at a new eyeglass prescription,  Megna tested Boo for glaucoma and then instilled eye drops to dilate Boo’s eyes.

 Many patients disliked the dilation- it blurs their vision for several hours and creates temporary light sensitivity.

About twenty minutes later, Boo returned to the examination room, his pupils were wide enough that his irises were nearly invisible. Dr. Megna shone bright lights into the eyes. Megna worked quickly and inspected the four quadrants of the retina. He repeatedly looked at areas of the retina and noticed a yellow fleck situated at the intersection at two vessels in his right eye. Observation of such anomalies was now easier since the addition of sophisticated retinal cameras providing panoramic views. Megna had already made a preliminary diagnosis. He printed the camera photographs.

Saying nothing, Megna opened a desk drawer and grabbed a stethoscope. He gently placed the ‘scope on Boo’s right side of the neck and quietly listened. He repeated this on the left. He slowly removed the instrument and waited several moments.

“Well, Boo, I’m afraid I have some alarming news,” he calmly said. “There is a medical term called ‘bruits’ – that’s a French word meaning whispers – and what I’m hearing is a whooshing sound in both carotid arteries. That usually means you have significant cholesterol blockage in both vessels.”

“Did you say ‘broo-ees, Doc,” Boo asked.

“Yes but the spelling ‘b-r-u-i-t-s’ make some people said ‘brutes’”, Megna responded. “In any case it’s pronounced broo-ees.”

“Gee, the word looks like it should be ‘bruits’, you know like fruits,” Boo said.

“It doesn’t work that way with French words, Boo” Megna responded. “Trust me.”

He also explained the meaning of the incidents of temporary vision loss.

“In your right eye I can see a yellow deposit – it’s called a ‘Hollenhurst Plaque’” Megna explained while showing Boo the camera images. “It is cholesterol plaque breaking off from your arteries and causing temporary blindness. If the plaques become larger, you can go blind. We’ve got a serious situation. I’m being candid.”

In a calm, reassuring voice, Megna told Boo there’s a surgical procedure where surgeons delicately cut open the carotid arteries and remove  plaque buildup.  It’s risky surgery but the only method of reducing this method of stroke.

This dire situation quickly affected Boo.  Going blind!! he said to himself.  Holy shit!  All those Big Macs  and greasy food have taken a toll.

“I’m going to refer you back to Dr. Patel with a computerized report,” Megna said.  “I really think you should schedule surgery ASAP.  This is something you don’t want to mess around with.”

A visibly shaken Boo-Boo Clipner left the office and said to himself, I’ll call first thing in the morning. Meanwhile, Megna was saying to himself Patel didn’t perform more than a cursory check of Boo’s eyes and, for God’s sake, did not check for bruits! I did and I’m “just an optometrist”.

One week later, Boo returned to pick up his new eyeglasses.   The vision was much better.  Megna ushered him into the examination room.  He asked Boo about the surgery.

“I’m having the operation next week at Bon Homme,” Boo said. “Yeah,  the doc was concerned.  He’s recommending the surgeon operate on both eyes the same day.”

Megna’s jaw dropped. The procedure is called an endarterectomy. The carotid artery is quickly clamped off by the surgeon who basically roto-rooters the cholesterol plaques that are clogging the blood vessel. The technique has to be quick. The carotid artery is a main blood source to the brain and the cleaning must be thorough. A stray plaque can be escape upstream and cause a major coronary block that leads to strokes or death.

Dr. Megna had major concerns.  Most surgeons will perform one surgery and then wait a week.  More important, this delicate surgery requires top notch surgeons to perform the procedure at world class hospitals.  Bon Homme was a local hospital and Megna doubted many carotid surgeries were performed there.

“Boo, I want to give you some advice,” Megna said bluntly. “I really think you should consider a bigger hospital for this surgery.  But it’s your choice.”

“Naw, Doc, I been going to Bon Homme for years,” he replied. “I don’t like going into big hospitals. Of course, Dr. Patel ain’t doin’ the surgery. I’m seein’ a specialist.”

“Well, good luck but I wish you’d reconsider,” Megna replied while shaking Boo’s hand. Damned fool, he said to himself.

It was the last handshake.

 Two weeks passed.  Dee Dee Higgins arrived at work with a sad expression on her face.

“Oh, Dr. Megna, did you hear?” she asked. Boo Clipner died last night at Bon Homme. He had that surgery and died! He stroked out post-op. Just can’t believe it. He was such a character.”

Megna’s worst fears had been realized. People don’t listen and when they do it’s too late. Boo unfortunately had paid the price. RIP my friend as he stared at the stethoscope on his desk.