Sitting next to him were his associates: David Asch, the straitlaced assistant echo chief, who thought almost as much of himself as Abramson did because he worked with the master, basking in reflected glory, which in his mind made him a bit great, too; Cindy Feldman, the only woman in the group, whose wicked humor and crazy blue eyeliner belied her astonishing clinical competence; and Richard Belkin, the anal-retentive associate fellowship director, who cared about the fellows only insofar as we reflected on him and his job performance.
The electrophysiologists sat two rows behind. The chief, Robert Dresner, an electrical presence himself—more rabbi than physician—spoke of the wonders of radio-frequency ablations, in which radiation-emitting catheters were threaded through veins into the heart to cure many common rhythm disturbances. Seated next to him was his assistant, Mitch Shapiro, a sharp and avowedly vulgar man with a neatly trimmed goatee, faintly canine in appearance, who took pride in saying outrageous things in the name of candor. (“What do you mean, ‘in my heart’? ‘In my fucking heart’ won’t hold up in a court of law.”) In attitude and deportment, Shapiro was a boxer dog. Their colleague, Jim Harwood, the token researcher, was sitting off to the side, probably thinking about the cellular ion channel research he’d been muttering about for years that nobody—perhaps including Harwood himself—understood.
Sid Fuchs, the cardiac catheterization chief, had the last word. Fuchs was a weird guy; word around the hospital was that his studio apartment was occupied by a massive train set. With arched eyebrows over narrow-set eyes, Fuchs resembled a bearded Art Carney. “Don’t mind my colleagues,” he told us fellows after everyone had said his or her piece. “In the end, cardiology is mostly a problem of plumbing.”
Whatever their idiosyncrasies, I looked up to these doctors. I wasn’t sure how much I had in common with them, but essentially I knew I wanted to be like them. Understanding how and why my grandfather had died, and what implications his premature death had for my father, my siblings, and me, was fundamentally intertwined with my decision to train in cardiology. The field was also fast-paced and exciting, as if flowing out of the steady beating of the heart itself. Just as important, the considerable effort of cardiology practice was balanced by tangible rewards for patients. Unlike neurologists, master diagnosticians who had depressingly little to offer their patients, cardiologists had been at the forefront of technological innovation over the past half century. This golden period had witnessed a hailstorm of life-prolonging advances, including coronary bypass surgery, coronary stents, and implantable pacemakers and defibrillators. The dazzling technological complexity of the field was reflected in the apprehension most doctors had in managing heart disease. The same doctor who felt comfortable treating diabetes, kidney failure, or anemia would consult a cardiologist for even a mildly abnormal electrocardiogram (EKG). The heart can kill quickly, without warning, faster than any organ, which inspired fear in even the most seasoned doctor. And so a fellowship in cardiology was like entering an exclusive club, a club that incredibly had decided to take me as a member.
Of course, I was nervous. Every new doctor should be. Cardiologists specialize in emergencies. The culture is pressurized. In neuroscience, there is the concept of the reflex arc, in which a threatening stimulus can effect a response without passing through the conscious brain—for example, when you see the taillight flash red on the car speeding in front of you and your foot automatically moves to the brake pedal. I was afraid that now, as a cardiologist in training, I would have to acquire a new reflex arc.
For the first few months of my fellowship, that summer of 2001, I spent a portion of every call night pacing back and forth in my living room, my armpits moist—and not just because of the broken air-conditioning—trying to memorize algorithms for treating the major cardiac emergencies; I might as well have been in the hospital. I often thought back to an experience I’d had in medical school. It happened during my first clinical clerkship in internal medicine at the beginning of my third year in St. Louis. I was working with a star resident of the internal medicine program. David, cardiology bound, was confident, competent, and quick. He thrived under pressure.
One afternoon, my team was called to the cardiac care unit (CCU). A patient, James Abbott, had just been admitted with excruciating chest pain that had started a few hours earlier. He was in his early fifties, extensively tattooed, just the sort of tough I wouldn’t want to meet alone in a parking lot at night, but right then he was whimpering. He kept stroking his sternum up and down, as if trying to rub the pain away. It was obvious that he was having a heart attack. He had all the classic risk factors: hypertension, high cholesterol, a history of cigarette smoking. His electrocardiogram and blood tests showed characteristic signs of low blood flow to the heart muscle. I don’t recall our examining him, but for this most common type of cardiac emergency, there is little diagnostic role for the physical exam.
A few hours later, we were paged back to the CCU. Abbott was now writhing in pain, and his blood pressure was dropping. David had a nurse get another EKG. He ordered an intern to prepare to insert a catheter into Abbott’s radial artery. Then he asked for an intubation tray to put him on a ventilator. “Check his blood pressure,” he told me.
As a medical student, I had measured blood pressure only a few times, mostly in my classmates. I carefully wrapped the cuff around Abbott’s left arm and inflated it. Then I let the pressure out slowly, listening with my stethoscope at the bend of his arm. “One hundred over sixty,” I called out.
“Check the other arm,” David said. By then he was scrubbing Abbott’s arm with iodine soap in preparation for an arterial line. More people arrived, attracted by the commotion. I wrapped the cuff around the right arm and quickly inflated it, but when I let out the pressure, I heard nothing. Must be doing something wrong, I thought. I tried again while people jostled me, with the same result. Must be the noise, I told myself, so I shrugged and let it go. For a moment I thought to ask David to check the pressure himself, but he was busy doing more important things. So I stepped aside to give others access, before being quickly pushed to the fringe.
The next morning, David caught me before rounds. His face was pale. “That guy had an aortic dissection,” he said. A CT scan had revealed a corkscrew-like tear from the abdominal aorta all the way back to the heart. “The night resident picked it up,” he said. “He noticed there was a pulse deficit between the arms. No pressure on the right.”
I listened in silence. A pulse deficit is a classic sign of aortic dissection, but in the hubbub of the previous afternoon I had somehow ignored it. I thought about telling David about the blood pressure measurement I had taken, but I didn’t. Abbott’s dissection was by now far advanced, and surgeons who had been consulted said he would not survive an operation. He died eight hours later.
For weeks I couldn’t get over the idea that I was somehow responsible for Abbott’s death. If we had caught the dissection the previous day, there was a chance at least that he could have been saved. I eventually managed to convince myself that the death wasn’t entirely my fault. But that didn’t make me any less afraid of cardiac patients.
* * *
As a first-year cardiology fellow, the main reason you’d get called in the middle of the night was to perform an echocardiogram, using an ultrasound probe to take pictures of the heart, which residents were not trained to do. There were many possible reasons to do an echo urgently, but the most common was to check for cardiac tamponade: fluid accumulating in the pericardium, the sac around the heart, thus squeezing the heart and hindering its ability to fill with blood. Cardiac tamponade is life threatening; rapid collection of pericardial fluid or blood can quickly put the heart into a standstill. Without proper cardiac filling and emptying, blood flow and pressure plummet and a person goes into shock. (Christ, nailed to the cross, likely succumbed to tamponade after receiving a laceration to his heart by the lance of a Roman soldier.)
In 1761, Giovanni Battista Morgagni, an Italia
n anatomist, spoke of the dangers of cardiac compression from hemorrhage into the pericardium. He noted that puncture of a coronary artery on the external surface of the heart could cause blood to pour into the pericardial sac, squeezing all chambers. How serious the compromise depends on how quickly the fluid accumulates. The pericardium is like a balloon. When you blow up a balloon, you must generate enough pressure to overcome the tension of the rubber. It gets easier the second time because the rubber has already been stretched. Similarly, slow accumulation of fluid stretches the pericardial membrane, making it thin and compliant and keeping the pressure inside the space low. Rapid filling, on the other hand, before the pericardium has been stretched, can result in a quick rise in pericardial pressure that can push on and collapse the heart’s chambers, thus compromising blood flow. At that point, you would have to put a needle through the chest and into the pericardial sac to drain the fluid, which I had never done.1 As I paced the living room on those summer nights in 2001, it occurred to me that there was a curious analogy between tamponade and my first nights on call. I knew that my tolerance for emergencies would develop. I knew that a slow accumulation of experience would eventually deliver confidence and courage. But until it did, I was terrified that a patient I was responsible for would crash and burn.
Senior fellows had warned us that surgeons would request echos on flimsy grounds. A post-op patient might have a slight decrease in blood pressure, and they’d want an echo to rule out tamponade. A patient might have a slight increase in his liver enzymes, and the surgical fellow would say it was because of hepatic vein congestion—unlikely!—and want to rule out tamponade. Sometimes you’d ask for a patient’s vital signs, and it would turn out the patient had normal heart rate and blood pressure, and the surgical fellow—on call and under the gun himself—would admit he was just being cautious. In that case, senior fellows urged us to push back, question, cajole—“Dude, can’t this wait until morning?”—anything short of outright refusal, which could get you fired.
Most nights just the expectation of the pager going off was enough to keep me awake, anxiously rubbing my feet together in bed, waiting for the inevitable call. And just when my consciousness would begin to fade in the pale darkness, the piercing ring. You’d never know how long the beeper had been going off, just that the night had finally begun. I’d pull myself up, being careful not to wake up my wife, Sonia, quickly push the jigsaw pieces of my awareness back together, and then tiptoe to the living room to answer the call.
The first page I ever got was to do an echo on a woman with breast cancer who had become acutely short of breath. I started off by challenging the request—what were the patient’s vitals, how long had her pressure been low—but something about the surgical fellow’s tone told me to shut up and just go in. So I threw on my scrubs; grabbed my stethoscope; stuffed a $20 bill, a ballpoint pen, and my hospital ID into my vest pocket; and hurried down to the street to catch a yellow cab going downtown.
Three o’clock in the morning in my neighborhood was when the rats came out, and the mere threat of one of those monsters darting out from sidewalk garbage was enough to make me stand in the middle of the empty street. The storefronts were mostly unlit, save for a few randomly glowing windows. A speeding taxi quickly came to a screeching halt to let me in. We took a roller-coaster ride down the FDR Drive, under bridges and through tunnels, the concrete walls rushing at me as shadows of the metropolis reflected off the dashboard like colonies on an agar plate. In the distance you could see the high-rises on Roosevelt Island dotted with lights, like a yellow pox, and beyond them the Brooklyn Bridge and the smokestacks of the Lower East Side. In my mind, I went through the different ultrasound views I’d have to show Dr. Abramson the following morning. Did I remember how to adjust the frequency filters and sweep speed? Abramson, the echo chief, could be tough. His merciless interrogation at an early-morning conference had already made a first-year fellow faint and drop to the floor.
The driver let me off in the lot behind Bellevue. Here the rats were even bigger, moving almost randomly, like leaves propelled by gusts of wind. The hospital rose up to the cloudless sky like some sort of gothic hotel. Looking up at the building, I could only imagine what life-or-death drama was awaiting me. At the entrance, young hipsters with black leather jackets and lip rings were sprawled on the sidewalk. In the lobby, the air was stale, slightly smoky. I quickly flashed my ID badge to the burly security guard. Then I jogged over to the echo lab on the second floor to grab a bottle of Aquasonic gel and the bulky Siemens machine, which I steered down narrow desolate corridors to the surgical intensive care unit.
Three thirty in the morning is a strange time to be awake, the nexus between night and day, when things are supposed to move slowly and trying to speed them up seems almost obscene. When I pushed through the double doors of the surgical unit, it was like entering a casino, with flashing lights, chiming bells, and its share of lost souls. Family members were loitering in the hallways or sitting at bedsides, keeping vigil. The faintly pleasant smell of disinfectant and talcum powder wafted through the corridors. I poked my head into the conference room looking for the surgical fellow. The room was littered with printouts, X-rays, and the detritus of the previous evening’s meal. No fellow. I plodded to the nursing station, where a young woman was inputting data into a computer. Without looking up, she pointed to a room at the corner of the unit.
I maneuvered my echo machine into the tiny space between the patient’s bed and the wailing monitor. The woman had a willful look, as if she were trying not to appear panicked, even though she obviously was. Short wispy hair stood up on her scalp like newly germinated grass. Her eyes darted back and forth, like a scared child’s, even as she insisted that she was fine. Her blood pressure, the monitor above her bed informed me, was dirt.
The body attempts to compensate for a rapid drop in blood pressure (called shock) through a number of mechanisms. There is increased sympathetic and reduced parasympathetic activity in the autonomic nerves, speeding up the heart rate and increasing cardiac output. Salt and water are reabsorbed in the kidneys. Small peripheral arteries constrict to shunt blood away from nonessential areas of the body, like the skin and skeletal muscles, to vital organs, such as the heart, kidneys, and brain. Gas exchange in the lungs is impaired, causing blood acids to build up and the breathing rate to increase.
All these changes seemed to be happening in my patient at once. In the jaundiced light she appeared pale, the color of bone. Her heartbeat sounded like a galloping horse. She was quiet, because she could not talk and breathe at the same time. When I applied the echo probe to her bandaged chest, where a breast tumor had been surgically removed, even I could tell that a massive amount of blood had accumulated in the pericardial sac. The heart looked like a small animal confined to a tiny pool, like one of Richter’s rats stuck in a swimming jar, struggling to get free. The right ventricle was compressed like a pancake. It was almost a relief to finally see the thing I’d feared and face it. I ran out to tell the surgical fellow, and almost immediately he was in a sterile gown, and I was being asked to step to one side, out of the way but still close enough to hold the echo probe in place to guide the drainage needle via ultrasound.
A nurse threw a blanket over the patient. The fellow tore open a surgical kit. The woman had stopped moving under the drape. She was either being extremely cooperative or sinking into shock. After numbing the skin below the breastbone with lidocaine anesthetic, the fellow pierced it with a six-inch-long needle, directing the tip, with the aid of my ultrasound, directly at the heart. The right ventricle sits most anterior in the chest, protected only by the pericardium and a thin layer of fat. I remembered what our anatomy professor had told us: if we ever had to push a needle through the chest wall, the right ventricle is the first structure we would hit. On the echo screen the needle tip entered the pericardium, scattering the ultrasound into a white halo, like a white sun in a hazy black sea. The barrel of the syringe was pulled back, and maroon-c
olored fluid burst into the plastic column. The fellow removed the syringe from the needle, and the bloody effusion trickled out. Then he pushed a catheter through the barrel of the needle, attached it to a drainage bag, and quickly stitched it in. Within minutes, the drape was off, and as best I could tell, the patient had regained her color. Her blood pressure was now almost normal as bloody cancerous fluid drained into the bag.
A few minutes of delay, arguing with the surgical fellow or waiting longer for a cab, and the woman would surely have died. The surgical fellow, a pleasant Indian man, was grateful. It turned out that he himself had had heart surgery as a child (he pulled down the V-neck of his scrubs to show me the pasty, indistinct scar at the top of the breastbone). We got along well after that night, a kinship born, as is common in a teaching hospital, out of facing a harrowing experience together. It was my first time confronting a live, beating heart in an emergency. And for a few more months, at least, I never argued another echo request.
Heart--A History Page 5
