Pay it forward

I was in the drive-thru lineup to pay for my McDonald’s burger and shake. I must admit I was feeling a bit guilty. “No charge,” the girl said, “the car in front paid for it.” I was confused. “What, a stranger paid for my lunch?” I looked in the rear-view mirror—a camper van full of kids—and floored it out of there. I asked my wife; she said it’s called pay-it-forward. I decided to respond in kind. And that takes me to my first case history. Allan, 64, an overweight male with diet-controlled diabetes and an unhealthy lifelong smoking habit. He had been in the whiskey industry all his life, a distillery manager and blender—now retired to painting and gardening. After art class, he suffers a subendocardial MI. He goes home, and calls his GP (who makes a house call). He is put on ASA and propranolol and told to rest. This was a long time ago, of course. As time passes, he gets stronger. But, without telling anyone, he goes through a dozen nitro a day. He completes his LAD occlusion, and is taken to a large hospital for cardiac care. Soon after settling into the ward, he arrests and dies. His wife is devastated, his children confused and lives are changed forever. A light goes out in a community of friends, co-workers and family. His kids follow university careers, mostly overseas. His wife, Kathy lives another 34 years, bereft of a soul-mate and a retirement plan. Allan was my dad. At the time, I was 21, and studying mathematics. I enroll in medical school (Glasgow), emigrate (to Winnipeg) and become an internist looking after cardiovascular disease (BC). I have been privileged to help many people with acute and chronic mischief. I consider my role as tug-boat captain looking out for ships perilously close to rocky shores. I learned early on the importance of one life saved. Many lives were changed the day this man died. We sometimes forget that individuals are part of a complex network of people: Helping one often has a huge impact on others. That’s why I prevent stroke, retard dementia and renal failure, save heart muscle, and promote wellness. More than 45 years have passed since then. I am at home doing telephone consults after a lunch of a burger and a strawberry shake. I am rattled by a random act of kindness, when I start a conversation with Bob. Bob is a 76-year-old overweight, hypertensive, diabetic, non-smoker with dyslipidemia. He was referred on 17 July with a six-month history of exertional jaw and neck discomfort, resolving with rest. His medications were metformin, atorvastatin and candesartan. Our consult was on 23 July, a Thursday. His symptoms would come on with a stressful phone call, or walking short distances. His exam and EKG were normal. This guy needed risk stratification, sooner rather than later. So, I skipped lunch the next day, drove to the office, and examined him. I put him through a gentle treadmill test. His EKG showed ischemia within two minutes, just about when his angina kicked in. The test was stopped, he was given nitro, and he recovered. I typed up his consult, and drove him over to the Emergency Room. The on-call cardiologist admitted him to Coronary Care within the hour. I visited on the weekend to make sure he was OK. Medically stabilized, he was transferred to tertiary care for angiography on Monday. He had severe diffuse three-vessel coronary disease, and underwent 5-CABG surgery a few days later. I spoke to him by phone, to debrief, some weeks post-discharge. He had made an excellent recovery. I sensed he was confused—but pleasantly surprised—by the pace of intervention. Paid forward.

Casebook of a Community Internist

Pay it forward

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Blog Author

Hector Baillie

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