by DANIEL MUÑOZ
Bayview’s constituency is somewhere between those two. The hospital is located geographically within the city limits, at the edge of Dundalk. It’s a blue-collar/no-collar neighborhood, with a lot of second-generation Eastern Europeans, Poles, Greeks, Estonians, Latvians, Slavic diners and bars, and a Baltimore accent that can be almost unintelligible to outsiders. And that’s a good description of one of my first Bayview patients a couple of weeks ago.
I’d been covering for another cardiology Fellow when I was asked to make the call on a larger-than-life character named Ray Jay. Ray was a forty-six-year-old, pony-tailed, busted-toothed contractor from the Highlandtown neighborhood. A heavy drinker and a red voter in a blue state, Ray cheered for the football team that he called the “Bawlamer Ravins.” After a typical Friday night of gambling, cigarettes, and a few lines of cocaine, Ray had decided to check in to Bayview because of “weird” chest pains—caution that was completely out of character for Ray, who later revealed that when he broke his arm, he didn’t go to the hospital until the next day, when his arm was bright blue and wouldn’t move.
But by the time he got to Bayview on Saturday morning, Ray could barely walk without leaning on the wall. His EKG was abnormal, and his cardiac enzymes were slightly elevated and still rising. Ray had been taken to the cath lab, where we had found a tight blockage in his right coronary artery. What now? A decision had to be made, and the cath attending and the cardiac ICU attending decided it was time for the Fellow—me—to step into the real world and make the call.
Given Ray Jay’s personal habits—cigarettes, cocaine, and general machismo—monitors, medicines, and watchful waiting is the cautious option. A stent might save Ray from a bigger heart attack, but the patient must take medications every day to keep it open. And Ray didn’t seem to be someone who always acted in his own best interests. But after a short conversation in my head, I decide to take a chance on Ray. I explained to him that a stent could fix the blockage, but if he doesn’t take his aspirin and clopidogrel—platelet-suppressing medications—he could clot off the stent and the whole artery could shut down, potentially bringing on a massive heart attack. “If we stent you and you snort coke, you’re going to die. I promise you. Your call, Ray.” He swears he’ll be good. Of course, I wasn’t sure whether to believe him. The cath team then stented him successfully. But for me, making the call myself was very different from observing and second-guessing someone else’s decision.
Having met and treated Ray means that I feel as if I have a slightly better grip on this patient population. From the sixty-year-old former steelworker who has smoked two packs of Camels since the seventh grade to his reasonably healthy younger sister who eats a bag of Doritos every afternoon while watching her soaps, Bayview patients tend to be more of an American cliché. These patients come in with shortness of breath, or fluid in the lungs, or pain radiating down an arm, not because it’s a world-famous hospital but because they’re sick and Bayview is in their neighborhood.
The first week of cardiac ICU is stressful. After the initial day one, week one introductions to the nurses, techs, and attendings, the focus is on making rounds with the team, seeing patients, and getting used to the cardiac ICU routine. The nature of CICU is stress. Nothing unexpected may occur…but it could at any time—the stress of potential stress.
I spend most of my time working with the residents, figuring out their quirks and foibles, who’s good, who might panic, and who won’t. Every night a resident is on call. If it’s one you trust, you sleep. If it’s one you don’t, you’re up all night with the pager dilemma. As the CICU Fellow, a quiet pager can worry me as much as a loud one. “What if they don’t know when to call me? What if they don’t recognize they need help? What if they’re not relaying critical information?” My job is to prep the residents so they don’t panic, so they do page me when they should and (preferably) not when they shouldn’t.
I want to be a good teacher, and I know that the best learning takes place in the urgency of the moment, not just by watching but by doing. And that is one of the stresses I’m managing—that intersection of teaching and urgency, or clinical treatment. This first week, that’s the toughest challenge for me—seeing things that need to be done now, knowing I could do them fast and right, whether it’s a femoral central line or a central line into the chest or neck, yet knowing I have a responsibility to try to pass the knowledge on to someone else, but without heightened risk to the patient. So, I teach. It’s stressful.
The stress is compounded by the fact that I am trying to be the teacher I would like to have as well. My attending for the first week is an excellent practitioner, but not an excellent teacher. And attendings need to be both. They need to know how to talk without being pedantic; to keep us interested; to question; to tease out our curiosity; to encourage but not allow a wrong conclusion; to make the case intellectually challenging, a Rubik’s Cube we can solve; and to create a tutorial learning atmosphere. This particular attending is all about detail—sometimes germane, sometimes not—and not a natural teacher. At the first case presentations, he almost immediately interrupts the resident during her or his presentation. Rather than cutting in to point out where the resident’s assessment is off or to contribute a relevant fact, he delivers an expansive footnote on exactly what the resident was saying, a minilecture on a point already made. Interrupting at the right time can be a great teaching technique. At the wrong time, it stops the momentum and undermines trust. Ideally, the residents should work their way through the potential scenarios, and find the answers on their own if possible—with the Fellow guiding and the attending providing an invisible safety net.
Still, letting the residents find their own way doesn’t always pan out, as I learn after working with Pat. She’s going to be a psychiatrist—and probably a good one, because she displays empathy, is smart, and can deal with me at my most impatient. One day, Pat tells me that she wants to learn to put in a central line. A central line (that is, a central venous line, also known as a central venous catheter, or CVC) is a catheter put into a large vein in the neck, chest, or groin, used to administer medication (such as vasopressors to treat critical hypotension), to get blood for tests, or to determine central venous pressure. Even with a topical anesthetic, the insertion can be painful. Wanting to learn such a delicate procedure is good, but on the other hand, it’s unlikely that Pat will ever have to do it again in her career. There is a real, live patient who needs one. I’ve put in many CVCs, and in most situations, I can insert one in minutes. Pat is going to have to know all about compulsive behavior, Oedipal complexes, anxiety, schizophrenia, and bipolar disorder. But after this year, she’ll never have to put a venous catheter into someone’s neck. Am I doing the patient a disservice if I allow her to do this one? Would I want my mother to have a central line put in by a psychiatrist in training?
Still, I want to be a good teacher. Pat and I spend forty-five minutes setting everything up, prepping the patient, me prepping Pat. We even step outside the room for a rehearsal because I don’t want the patient to hear me whispering instructions—“Okay, the next step is…”—and wonder, “Am I a lab rat?” I can’t let Pat flail around, just bruising the patient’s neck, and I need to give her a reasonable amount of time in which to try, whatever that means. How far should I let her go before stepping in? I wonder, why couldn’t she say, “Hey, I’m going to be a shrink. You do it and I’ll watch”? But she didn’t. She asked to do it. And I don’t want the lesson to be, “Don’t bother to learn outside of your field.” Instead, I find myself just wishing she weren’t so earnestly interested.
We’re gowned, in the room; the patient is comfortable that two good doctors are at his bedside, and I’m guiding Pat through it. To her credit, she’s not too aggressive, the unintended by-product of overenthusiasm, and she’s not too tentative, the result of first-time trepidation. So far, so good. But despite following the ultrasound pictures, she can’t seem to get the needle into the blood vessel. I flex my fingers as
if I had the line in them. I lean in, clench my teeth, and mimic the gesture of putting the line in. After her second and third attempts, I try hard not to say “No, let me.” I have to loosen my grip on the reins. It isn’t easy. But I know that others did so for me, and stay quiet.
The patient doesn’t know there’s a problem, but Pat does. After about twenty minutes, my mental time clock runs out. Calmly, professionally, so that the patient remains unalarmed, I say, “I’ll take it from here,” which is academic code for “You’re done. Give me the f—ing needle.”
Within forty-five seconds, I have the needle in the vessel, the wire threaded, the catheter inserted along the guide wire, and the central line in—a relief. You don’t want to take over and then struggle while the resident watches, nor do you want the patient to be the victim of two fumbled tries. (But you do mentally rehearse the failure speech to the resident, just in case. “This one was tougher than it looked….” And you hope the resident doesn’t think you’re a pompous jerk. There are already enough of them in medicine.)
I can tell that Pat feels lousy. On the way out, I pull her aside and reassure her: “You did everything right. Your technique was good. Your pace was good. It was bad luck more than anything. It gets easier with time.” I want her to feel better, but at best, she’s going to feel less lousy. And she’s probably not going to get better at it with time; she won’t get enough practice. Having a basic understanding helps her as a doctor, no matter her specialty, to see the procedure in action, to know what it is, how it works, and when it’s called for…just in case. But the reality is that she doesn’t have to be good at doing it.
The next day, it’s the end of week one. We do case presentations again, and again, the attending interrupts with minutiae. I think about how I’ve been teaching, how I’ve tried to be tolerant and gentle. I tried not to overlecture. But when I have to decide between letting the student fly the plane and taking the controls, I hear myself saying to Pat what I never wanted to hear as a student: “I’ll take it from here.” Is my approach better than the attending’s or just different?
—
Fortunately, I am working with a different attending during the second week, Dr. Martin. I had worked with him for a few days back when I was a resident, so I know that he is a good diagnostician and clinician. Unusually, he also has a PhD in economics: While practicing cardiology full-time, he went to grad school at night because of his interest in health policy and the healthcare system as it relates to socioeconomic issues. And Dr. Martin has another intangible going for him: He’s effortlessly cool. He doesn’t try to seem young or hip; he’s just a naturally appealing guy who is happy with himself and what he does every day—practice cardiology exceptionally well.
Rounding with him is like watching a virtuoso. Dr. Martin instructs more by example than by lessons, and his method is so low-key that it takes a while to realize that he is pulling the invisible puppet strings, gently guiding residents or Fellows to the right assumptions and decisions. But his strongest suit is his bedside manner. Communicating with patients and families is sometimes taken for granted in the high-tech world of today’s medicine, but it’s even more critical when the science involved can be so intimidating. Every doctor has to talk to families in sensitive situations. Most do it passably. Some overdo it and come across as too sensitive, over the top, like a bad movie actor. Some flip a switch—time to be sincere—and recite the script. But patients and families usually can tell the difference. Dr. Martin simply knows how to talk to people. He relates to the patients and their families, connecting with each one in a way that makes them all feel comfortable, no matter how dire the situation.
Case in point: I am at home late on Tuesday night when I get a call from the on-call resident about a patient coming into the CICU from the emergency room. Mr. Werdna, a retired plumber in his midsixties, was discovered by his wife, unresponsive, on the kitchen floor. When the ambulance arrived, the EMTs found the patient with no pulse, no gauge of how long he’d been down, without critical life signs, and with no apparent cause for the problem. The team intubated him “in the field”—that is, at home—and brought him to the nearest hospital: Bayview.
On the drive back to the hospital, I piece together what might have happened in order to get a sense of our options. Mr. Werdna may have had a primary cardiac arrest, which could have caused the loss of heart rate and drop in blood pressure. Or he might have had secondary arrest, due to a noncardiac event such as a seizure or stroke. In either case, during a critical time period, his heart was not delivering blood to vital organs, including his brain, and that may have done irreversible damage to one or more of those organs.
By the time I get to the hospital, his blood pressure and heart rate are improving. The twin goals are to keep him stable, with his systems running, and to put together a plan for his potential recovery. To try to fill in the blanks, I speak to his wife by phone. Mrs. Werdna is older than her husband by a good ten years, in her midseventies, evidently with poor vision and health issues of her own. In a shaky voice, she re-creates finding him, trying to rouse him, calling 911, the EMTs putting the tube in, and taking him away. She tells me he’d had a previous heart attack, and had been complaining of being tired the last few days but otherwise seemed all right. I try to convey the gravity of the situation to her, but over the phone there are no physical cues, so I can’t tell if she understood or if she was still in denial or shock. I ask her to come in for a meeting, to prepare for what may be a negative outcome. Vulnerable families can’t be expected to absorb an inundation of medicalspeak, so I put it in the plainest language I could: “He’s our sickest patient in the cardiac intensive care unit.” She says she will come in the next morning.
I stay overnight, help put in the central line and the arterial line, and get two hours of sleep in the on-call room. By morning I’m not looking or feeling too fresh, and I am in need of a shower and clean clothes. But I’m in no position to complain; the important thing is that we have managed to stabilize Mr. Werdna and that he is showing small signs of improvement. His blood work is improving, his kidney function gets better, and his elevated liver enzymes start to drop. His heart does not seem to have sustained catastrophic damage, which suggests that perhaps it wasn’t his heart but possibly a seizure, some kind of aspiration, or a major neurologic event such as a stroke that caused his collapse.
There are less promising signs, though. Mr. Werdna is on a breathing machine without sedation. Normally, being on a breathing machine is both unnatural and uncomfortable. Having a tube in your throat is a decidedly unpleasant sensation; many patients thrash or open their eyes when they are intubated, necessitating the administration of sedatives for safety and comfort. But Mr. Werdna is showing no such physical responses—no jerking motions, nothing. And he has a continually low heart rate. This suggests that he might have an anoxic brain injury, which occurs when oxygen flow stops, starving the brain so it fails to perform. Hypoxic is partial oxygen deprivation; anoxic is total deprivation. The greater the deprivation, the worse the damage is to the brain, including potentially permanent loss of cognitive and physical skills. Recovery is possible but is determined by the brain parts affected, unpredictable at best, particularly at these early stages.
Dr. Martin comes in, and as the resident presents the case, I scrawl a little drawing on a scrap of paper. At the end, Dr. Martin asks what I think we should do. I hold up my rudimentary sketch of the brain. He nods. We aren’t being irreverent. It’s a picture of the situation; nothing else takes priority over the brain. And all of Mr. Werdna’s organs seem to be recovering except his brain. I walk the team through a plan for the next twenty-four to forty-eight hours, explaining to the resident and the nurses that we have what appears to be perhaps an irreversible brain injury. Our job is to keep the brain alive and to give it its best chance at recovery under admittedly challenging medical circumstances. The other organs are secondary concerns at this point.
Afterward, I explain to Dr. Ma
rtin that I’d called the patient’s wife the night before to set up a meeting for today; he agrees to join us. I meet Mrs. Werdna by the unit desk when she and her neighbors, who drove her, come in. I recognize her immediately—something about the catch in her gait, an older demeanor, and a frail voice. I go up to her, and her first question—“Is he getting better yet?”—makes it plain that she didn’t fully comprehend our phone conversation. This makes a sit-down meeting—before she sees him with a tube in his lungs, IVs, a central line in his neck, electrodes on his scalp to monitor seizures—even more crucial. As I walk her down the hall, I make a combined medical and “neighborhood” diagnosis of how to deal with the situation. It isn’t prejudice or gut; it’s science. We turn into a small conference room and sit.
In the room are Dr. Martin and the CICU nurse, along with Mrs. Werdna, her neighbors, and me. I begin, “Mrs. Werdna, when we talked last night, I threw a lot of information at you, so I think we should go over it.” I can tell she doesn’t want to hear it; she knows it’s bad. Meanwhile, Dr. Martin is watching me to see how I handle it. He mentioned before the meeting that he wanted me to start by setting the stage very realistically. Mrs. Werdna’s husband is not likely to recover. With severe neurologic injury, the best he can hope for is to remain on life support for a few days. She’s trembling, and I start to worry that she may fall apart. I go slowly, but not too slowly, because I don’t want to drag it out. “Your husband is very sick, critically ill.” I let my words sink in and then say, “We’re providing him with life support right now. When you see him, he’s going to be hooked up to a lot of equipment.” I purposely use terms such as critically ill and life support, and I look for comprehension in her face.
In fact, Mr. Werdna had not suffered a massive heart attack (as his cardiac enzymes have returned to normal levels). The unhappy truth is that Mr. Werdna’s body and brain had already begun to die on the kitchen floor, a process that was interrupted only temporarily by the paramedics. The body has remarkable resilience, an ability to recover in almost every organ system—lungs, kidneys, liver, even the heart. The one organ that begins to die quickly, with little chance of bouncing back, is the brain. And blood flow to Mr. Werdna’s brain had been cut off for five or more minutes—the danger zone.
