When he was a kid growing up in Texas, before he ever dreamed of becoming a sports medicine doctor, Raju talked endlessly about rocks. His attention was always directed upon the earth. All its forms of clays, granites, and hard minerals called to him, and their assembly was seen as expressions of deep time unfolding. The ground could always be deconstructed in his mind into discrete formations. In middle school, he and his classmates were tasked with presenting some aspect of Texas history, and while everyone else focused on revolution, slaughter, oil, and football, he focused on the Balcones Fault that cut through central Texas. In his presentation, he discussed the layers of stratification of the limestone escarpment; the karst that filtered groundwater into aquifers; the oil deposits in west Texas formed from ancient ocean closures involved in the fault’s formation; and the topographic difference produced by the fault. His final point was that the fault effectively marked the boundary between the famed hill country of ranchlands to the west and the depressed Blackland farmlands sinking into the southeastern gulf. This dichotomy led to an intersection of economies at the fault that grew into three of the largest metropolitan areas in Texas, including San Antonio where he grew up. Over the years, his peers’ tolerance of his hyper-focus on geology grew thin, and so he pivoted to an obsession with basketball that was far more socially acceptable, and after that pivoted further to an obsession with medicine that was far more useful. But as he grew older and looked back, he realized he could never shake that initial obsession with the material earth. He could never shake it because it was the foundation from which all other things sprung. In the final analysis he was obsessed with rocks because he was obsessed with history. The entirety of society, and, indeed, the entirety of his life, were formed from the rocks through time in strata and rupture.
When he was a medical student rotating at a free clinic outside Odessa, he gave a long winding presentation to his attending about a seasonal agricultural worker with severe chronic lower back pain. Raju told his attending that the patient was having daily pain with movement out on the fields, particularly with bending down. Her previous physical therapy referrals and naproxen access had been disrupted due to her seasonal job changes and she was struggling to find relief. The patient’s husband worked construction in Lubbock and was often gone for days at a time, leaving her alone with her two elementary-age sons. This would have been fine, she had told Raju, if she weren’t working so much herself, harvesting the myriad fields of sorghum, cotton, onion, and sugarcane of the High and Rolling Plains northwest of the Balcones during the summer, then the infinite dairy farms in the winter. She had a brief stint at a meatpacking facility about a year ago, but working the line cutting sirloins by the second had exhausted her Epsom salt supplies and probably herniated another disc or two. Her dream was to work at an oil refinery closer to Lubbock that paid more than twenty-five an hour and would have allowed her kids to stay in the same school. But her English wasn’t good enough for those jobs, so in the end she taught her children on her own whenever they couldn’t be in school and otherwise committed to the harvest, living under the slanted arch of the sun whose tendencies of uncertain burns upon the mesa loams had become her own. But at that, the attending stopped Raju cold and asked him what he wanted to do about her back pain. Raju said he wasn’t sure, but they should definitely show her some exercises.
When he was an intern in Houston, he gave a short case presentation about a patient with knee pain. Raju first met the patient in a hospital where he was being treated for a clot in the lungs—but, as Raju was wont to do, he began the story from many years beforehand when the patient, a trucker based in the dusts of Amarillo, had no major medical conditions other than the occasional knee pains related to his occupation. He told Raju that he had hauled just about everything. He started out with short local hauls, moving cottonseed, sorghum feed, and packaged beef around the High Plains from three in the morning to sundown. The pay was not enough for his family, though, especially if he wanted his teenagers to go to college, so he switched companies and started doing specialized hauls like crude oil, automotive parts, fracture sand, sheetrock and other aggregates. He also started doing longer hauls of all sorts of freight, oftentimes refrigerated goods to big city supermarkets. He slept in his truck, stretched when he could, and otherwise managed the pain with daily ibuprofens, cigarettes, and slabs of arthritis cream applied at the burger stops and gas stations along the road. The days were long. Dust filled the pipes, and coffee became indistinguishable from oil. After about two months, his stomach erupted in acid and his stool turned vertisol black. He was hospitalized near El Paso for two nights, during which they put a camera down his throat and patched over three stomach ulcers that had been bleeding into his gut. He was discharged, but only a day later embarked on another long haul of engine parts along the interstate corridor eastward to Houston; then at the port, after reloading his truck with imported fruits and vegetables, he felt a sudden pain in his chest and collapsed to the ground.
When he was a senior resident on an away rotation in Austin, Raju chatted to a few colleagues about a patient he had seen in clinic with wrist pain. She had grown up in a neighborhood east of the Interstate I-35 corridor that ran parallel to the Balcones fault line, in the same house as her parents and her grandparents. They had all lived their entire lives choked in blocks of smoke and neglect east of the corridor, but their family recipes kept them above despair. Her family was known in their neighborhood for their brown sugar barbecue sauce and dry rub recipes. Folks would always say she should open a restaurant one day, but she was too busy working. After high school, she worked various kitchen and sanitation jobs while also taking night classes at the local community college. She eventually became the first in her family to obtain an associate degree, which she got in Office Administration and Technology. For about twenty years, she worked at the University of Texas as an administrative assistant in the School of Nursing. Over all those years sitting at her desk in prolonged flexion, though, she developed carpal tunnel syndrome. It could always be managed with braces and occasional steroid injections, but the job itself numbed her skull. Just after her forty-fifth birthday, she returned to the world of food and eventually found work as a line cook and occasional pit master at a local acclaimed barbecue joint. But it was the food service industry that truly destroyed her wrists. Oil burns aside, each shift seemed to short-circuit another nerve. Within a couple years she had underwent multiple surgical releases of both hands. And after her fourth surgery, she finally quit the kitchens. When she was last in clinic for a steroid injection she had a desk job once again, Raju said, working for the city in restaurant and food truck ordinances.
When he was a sports medicine fellow just outside of Dallas, Raju gave a lecture to program residents about shoulder pain, highlighting a recent clinic patient with rotator cuff impingement. The patient had first noticed the pain during a morning workout class. She was an ICU nurse who had trained in Austin but was working in Fort Worth at the time, in the middle of a rough stretch of shifts. She noticed the pain return when doing a turn, and from then on, she became progressively more nervous about her duties, particularly bathroom assists and codes. Even before her tendons had sheared against bone, the demands from her hospital administrators and patients had made her dread coming into the hospital every day. So she quit after she got married. Shortly after their wedding, she and her husband were tasked with overseeing a new operation for her husband’s family: raising Wagyu cattle on a two-thousand-acre tract of grassland outside Waco that the family business had just acquired. It was a stark yet welcome change from city life. But after years tending to the ranch and rearing four kids and purchasing supplies in town and managing the small garden and chicken coop and laundry and endless housework, she came to Raju in tears, struggling to move her arm, much less lift her kids. The ultrasound again demonstrated an evident partial-thickness tear of the supraspinatus, and she asked him then if it was finally time for surgery.
When he was an attending living back in Austin, Raju saw a patient in his clinic who was having some right elbow pain. The patient had developed medial epicondylitis while playing pickle ball with his colleagues at his previous job at a digital advertising firm. He had since left the firm to start his own company—a private equity firm that invested in local farms, ranches, restaurants, and delivery platforms—but in doing so, he had exacerbated his epicondylitis playing increasingly more golf with clients and business partners. As part of his company’s mission to connect local businesses, he also found himself driving long distances to meet face to face with suppliers and he noticed that even gripping the wheel would fire up his elbow. While imploring Raju to help him, he insisted on showing Raju on his phone a list of all the best restaurants in the city where he had connections and could offer discounts. In particular, he mentioned a barbecue restaurant with locally sourced Wagyu beef from a ranch with which he had just partnered. He said the meat was unlike anything he had ever tasted. Raju largely went through the motions during the encounter, since the elbow pain seemed quite mild. He noted on exam the patient’s mildly reduced grip strength and right elbow pain elicited with flexion against resistance. He gave him a brace and some exercises, and in exchange, the patient showed Raju how to access a free digital coupon to obtain a discounted meal at the barbecue restaurant he had mentioned.
Shortly thereafter, Raju finally got his dream job working for the San Antonio Spurs. To celebrate, he took his wife to that acclaimed barbecue restaurant and ate their famous Wagyu suadero tacos. And with that first bite of brisket, it was as if he could taste all the ailments of labor that created it. He chewed as if directed by the structural flows of rock that flavored the meat. Each person who was part of the Texas culinary history felt like a geologic stratum of society itself, connected through their work to each other and to the homeland earth. Their histories of illness were therefore no different than their histories of labor, which in their effort resembled the straining upheaval that created the continent itself. Raju paused in his meal. He sat back and reflected on his career. He wondered whether he had lost his connection with that firmament of Texas rock and soil, with the passion of his youth, and with the stories he had relished and recited along the way. He wondered if he could find his way back, back to the earth and back to himself, in the subsequent bites of smoked meat.