Manuel

"He's all heart," the radiologist said as she looked at the x-ray. "I honestly don't understand how he's still alive."

Perhaps you've seen a chest x-ray before -- the ribs and vertebrae in white, the air-filled lungs nearly black. That bright-white structure in the middle is your heart, of course. As a rule of thumb, the distance across the heart at its widest point ought to be about half the diameter of your whole chest on the x-ray. Manuel's heart was bigger than that -- a lot bigger. It nearly filled his chest cavity from wall to wall. And the normally black lungs had lots of white streaks, x-ray signs that they were filling with fluid. Manuel's heart was failing. He was born with a defect of his aortic valve. That's the one in between the business end of the heart and the aorta, the big artery that carries blood to all parts of the body. Every time his heart beat, some of the blood that was squeezed out leaked back into the heart, making it work harder and ultimately stretching its size. When heart muscles are stretched and stressed, for a while they get bigger and stronger -- like a body builder in the gym -- but too much stress and the muscle just quits pumping effectively. If you have heart failure, you're tired all the time and even walking from your bed to the closet can make you hungry for air. The test of heart function showed that his pumping efficiency was less than 20% of normal. Death was not far off.

We were asked to talk with Manuel about his goals of care -- what he was hoping for, and how he might achieve that. I did his interview with a Spanish interpreter; I do speak a little Spanish, but not enough for a serious conversation about issues of life and death. Manuel had been in the country for two years, working at a food processing plant and sending money home to his family. Originally he had told the hospital he was from Puerto Rico -- therefore a U.S. citizen, therefore in the country legally, therefore eligible for assistance through Medicaid if he needed it. But as we talked, he came to tell us that, in reality, he was from Guatemala. His Social Security number was a fake. He was in the country illegally -- undocumented.

With the interpreter's help, I walked Manuel through the physiology. I explained how the heart is structured, what was wrong with his valve, and why he had such trouble working at his demanding job. "The medicines will help you feel better, but they will not cure you," I said. "A new heart valve, an artificial heart valve, might work, but it may be that the only thing that will really help is a heart transplant."

An undocumented person in America is not going to get an artificial heart valve, let alone a transplant. All of us in the room -- Manuel, the interpreter, and I -- knew that. Manuel seemed to take the news stoically. He said he wanted to call his family in Guatemala to discuss things. His inclination was to return home to be in familiar surroundings when he died. The next day he said his family had asked him to keep working for a little while longer if he could, and then to come home. He was discharged with the usual heart failure drugs, a clinic appointment that he might or might not keep, and the knowledge that time was terribly short.

The interpreter is from Latin America herself, and in her position she has dealt with countless undocumented people seeking care at our facility. We talked about Manuel with heavy hearts. His family needed the money; that's why they wanted him to keep working. He had crossed two international borders -- from Guatemala into Mexico, then into the United States after a journey across the length of Mexico -- to get here, no doubt with the assistance of coyotes, professional smugglers. Coyotes are known for charging high prices for their "services" and for telling immigrants that failure to pay will bring harm not to them, but to their families back home. What will happen to Manuel's family, the interpreter and I asked ourselves. Is there an outstanding balance on his account? Will innocent people die because a poor man accepted the gigantic risk of traveling thousands of miles in search of a better life? What is the right thing for the richest country in the world to do?

I myself am the grandchild of immigrants, and this post is not intended to advance a particular stance on our current national debate about immigration. But Manuel remind me that, ultimately, we are all deeply interconnected, and that discussions about medicine cannot be separated from our larger view of who we are and what we believe. The 19th century German pathologist Rudolf Virchow is quoted (some say misquoted) as saying that "medicine is a social science, and politics is nothing but medicine writ large." Sometimes, though, it's the other way around. For Manuel, for his family, for our inability to treat him with the best we have to offer, medicine is nothing but politics writ large.