A Prescription for Song

“iBuenos dias a todas! ?Como estan mis queridas mujeres hermosas?”1 I sing as I glide into the hospital room, anticipating slightly less enthusiasm from my audience. Surely enough, the onslaught begins. With my question, I open the floodgates, and begin to field complaints and requests and questions from four patients simultaneously. It is the start of another day in Santo Domingo, where, as a member of the medical mission Operation Walk Boston I am helping a group of indigent Dominicans as they navigate total joint replacement surgery. I focus my attention on the patients in Beds A and D who are in their first postoperative day; I have to manage their pain. As a native Dominican I anticipate minimal if any difficulties with communication. Still, despite having accounted for the subtleties of this culture, where stoicism raises pain thresholds, skepticism regarding medications abounds, and opiate-naivete is common, I feel clumsy trying to provide adequate relief. “Las quiero a todas sonrientes y comodas cuando entren los cirujanos—me tienen que hacer quedar bien”.2 A chorus of laughter fills the room as a silent understanding settles the matter. Of course they would be good, they assure me, I am their guardian angel. “Dona J, vuelvo por usted enseguida”.3 With my bilingual checklist in hand and two curious local medical students to escort me, I make my way back to Dona J’s bedside after checking on my other rooms. I am reminded of my privileged position as an American student; of how many pieces had fallen into place so that, rather than learning from the foreign nurses, I am teaching the locals. I perch myself by the patient’s side, so as to ease some of her anxiety with my proximity. We go through my checklist: no dentures, no hairpieces, nothing by mouth since midnight, held medications. I collect her vital signs, all within normal ranges, with the exception of her blood pressure. A blood pressure of 170/90 mmHg, however, is no novelty for this patient, despite treatment with multiple antihypertensive medications. In a matter of minutes, Dona J is sitting on a wheel chair with her pillow, blanket, chart, films, thermometer and completed checklist, all piled on her lap, ready to enter a cold operating room where she will be cut open and worked on by complete strangers. Still, in true Dominican fashion, she is more concerned about el nido de pelo4 on her head; she could not possibly go into surgery with tangled hair. Seconds before she is taken away, I grab her brush and provide grooming services. Dona J and half of her belongings are whisked down the hall toward the operating rooms. After rounding with the team, I begin to march through my list. Medications are given. Pain is controlled. I am about to finish prepping my second pre-operative patient when I am told Dona J was sent back from the OR. Oh no! What did I do? What didn’t I do? Apparently my new friend had made it all the way to the operating room before a blood pressure of 240/120 mmHg cost her another day of valgus knees. Upon entering the room I look to Dona J, who simply sighs. I reciprocate with a sigh of my own. “?Y que paso , Dona J?”5 I share in her disappointment. “Ay Maria, ?que te digo...?”6 she begins. She goes on to explain how she gets “these crises” where her blood pressure shoots up. She assures me the only thing that works to relieve these “crises” is linden tea, half a lime, and passion fruit juice. While I poke and prod, trying to understand and fix, she insists that these remedies offer better results than my evidence-based interventions. I re-check her blood pressure—her systolic blood pressure remains in the 210 mmHg range. In the moment, I become impatient with her insistence and sluggish speech. I think her naive for being so convinced these herbal remedies could be more effective than all of the expertise of our team of trained American professionals. I leave Dona J disappointed, sinking into the bed while she tries to fight the sedatives administered in the pre-operative holding area. Her giant pouting lips are the last thing I see before leaving the room. I resolutely chase down the physician on the floor; we would control these pressures and Dona J would have new knees. After discussing our options, we decide on furosemide as an initial intervention. Within minutes I have re-checked Dona J’s pressures and am infusing the diuretic, hoping she at least returns to her already elevated baseline. After noting no improvement in Dona J’s blood pressure, I request another consult. With the doctor in the room, I find myself increasingly focused on the biological processes and clinical interventions, readily assuming the role of an overeager, inquisitive medical student, forgetting to include the subtleties I perceive as her nurse in my analysis. The doctor patiently listens to her explanations of the aforementioned “crises” while synthesizing pertinent clinical information. Feeling guilty about my own reaction to Dona J, I tell myself I would be able to perform with an equal amount of grace if I had not been hearing about her “crises” and her tea for the past three hours. While we converse, Dona J mentions singing as yet another remedy for these “crises”. “Si es cantar lo que usted necesita, pongase a cantar, porque tenemos que hacer todo lo posible por bajar esa presion de usted.”7 I half-jokingly comment. Later, while we are discussing the next steps in the management of her hypertension, she tentatively interrupts our conversation to ask, “?Les importa si canto?”8 I am both unprepared for and disinterested in her request at the time; my initial reaction is apathetic. But my internist colleague expresses considerable enthusiasm for our patient’s proposal, which instantly piques my curiosity and begins to remove the clinical blinders I had been sporting for the last few minutes. I note how my near infatuation with subjects I had not yet mastered kept me from paying attention to the individual I had turned into a math problem. With our blessing, Dona J begins to sing her canciones religiosas9 and fills the room with her rich voice. We take a seat and marvel at the inspiration that appears to transport Dona J to another place. The tension that held her complexion in a tight knot appears to melt away with her spiritual tunes. Her breathing slows to fit the cadence of her heartfelt melodies as she loses herself in the words. Two songs later and joined by a medical student, we sit in awe. “Estoy seguro que le ha bajado la presion,”10 the doctor tells her. I make my way to her side and obtain an unspoken go-ahead to quantify this nearly palpable change we had just experienced. As I begin to inflate my cuff, I find myself wondering whether or not I expected to see a change. A few minutes ago I had been skeptical of anything not involving a complicated chemical formula and a litany of adverse effects. Embarrassed, I recognized the patronizing nature of my thoughts. I should have known then it was silly of me to believe that a plethora of pills could truly offer a better solution in an environment where alternative treatments are not only commonplace, but necessity. Now, having witnessed such artistic expression of faith, I question whether a song would offer better outcomes than a dose of a strong diuretic or calcium channel blocker. After frantically inflating the cuff into the 200 s, convinced I am failing to hear the systolic reading, I let it deflate down to 182 mmHg, where I distinctly hear a first “thump”. I wait for the thumping to fade in disbelief, already resolute on obtaining a second measurement and having someone double-check. We get 180 mmHg. A comment is jokingly made about how we will now prescribe religious songs for management of her hypertension. At this point, I have embraced the 30-point drop in Dona J’s pressure and find myself humbled by the experience. Despite the mixture of emotions, I cannot escape a distinct feeling of guilt. Guilt for having discredited the interventions my patient had told me would work all along. Guilt for having failed to listen to my patient. Guilt for having insisted on being an American-trained professional when I most needed to be a Dominican-reared caregiver. Guilt for having become fixed on the structure and objectivity of science while failing to note the overwhelming resilience of the human spirit. “Cuidara tambien de mi,”11 she sings, without stuttering or hesitating. The next day, Dona J underwent uneventful bilateral total knee replacement. Her blood pressure was well controlled, and she sang intermittently throughout the remainder of her stay, to the delight of her patient roommates and the medical staff—especially me.