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But things can and do go wrong. In any delivery of electricity, there’s a mathematical chance of inducing a faster or more unstable rhythm, and that can be life-threatening. The safeguard is a specific dose of electricity delivered at a specific time in the cardiac cycle, all synced by the machines. But nothing is perfect. The possible complications mean that we take precautions, but the precautions themselves can fuel trepidation. For a patient to get cardioverted, one of two factors must be established: The patient must have had a TEE (or transesophageal echocardiogram) within the last twelve to twenty-four hours that demonstrates the left atrium is free of clots. Or the patient needs to have been on blood thinners for the past four weeks, at a specific, therapeutic level, verified via a blood test showing that his or her blood is appropriately thin—the INR (international normalized ratio) level—and we have to take the measurement again after more time on blood thinners. If one or both of these preconditions is met, we can proceed. And roughly 90 to 95 percent of cardioversions are successful on the first shock.
After two or more shocks, though, the likelihood of successful rhythm conversion is low; the patient does not transition from AFib (atrial fibrillation) into normal sinus rhythm, and wakes up still in AFib. The danger in successfully cardioverting someone with a blood clot (perhaps in the left atrium) is that changing to normal sinus rhythm may dislodge the clot, pumping it out of the heart. The clot then becomes a loose cannon that can go to the brain and bring on a stroke, or to one of the coronary arteries and cause a heart attack, or to anywhere else in the body, for that matter.
Every time I meet with a patient for a cardioversion consent, I consciously remind myself, the process is not routine. I am preparing someone for what he or she is about to undergo—benefits and risks—and the way I present the information can make all the difference. It’s tempting to just gloss over it: “Here’s a long list of what-ifs and maybes, but everything’s going to be fine, so just sign here….” Tempting, but wrong. Unlike the on-hold recording, “Your call is very important to us…,” this is very important. It’s important information about an important procedure that the patient and family must comprehend. I make an effort to take a highly structured approach, clearly explaining the pluses and minuses: “During this procedure, it is possible, though unlikely, that you could have a stroke and your heart could stop, and, yes, you could die—though, as I said, such outcomes are very uncommon. The benefit of the procedure is that we may be able to make you feel better by putting your heart back into a normal rhythm. Now, if you are comfortable with this, you can sign here. Or you can ask me any questions you might have.” The gloss-over-it approach and the deliberate version both constitute informed consent but result in very different degrees of patient comfort. On a personal level, if something went wrong and the patient hadn’t been fully prepared, that would be my failure.
My goal is to get each person to understand what’s about to occur. Some require more time; some less. Some have questions; some would rather not know. You have to have an inner gauge and give patients what is needed. I don’t want to make the procedure seem as safe as getting a haircut, nor do I want patients to feel as if they’re about to walk through a minefield. Instead, I aim for balance. Still, this is one of those times in training when a Fellow can feel like an impostor. I’m informing patients of the risks and benefits of a procedure I’ve rarely seen, and never overseen.
A couple of weeks into the rotation, I’m speaking with a woman in her forties who is, in medical parlance, “scared shitless.” Despite the urgings of her cardiologist, she repeatedly put off coming in for her cardioversion. But now that she’s here, she dissects every word of the consent. “Wait, what does that mean?” “Hold on. Explain that.” “Is that common?” Without the cardioversion, she’ll continue to have debilitating palpitations just walking up the stairs in her house. With it, we have a decent chance to make her asymptomatic, or less symptomatic. But she’s so obsessed with the risks, it’s hard to know if she’s going to let us do it. I spend a long time trying to reassure her, using language patients respond to. “While we fully recognize this is not routine for you, we do these every day….We wouldn’t have you here unless we thought the chances of your getting better were far greater than the chances of anything bad happening.”
If you approach everyone the same way, either too routine or too fear-inducing, you’ll strike out half the time. You could say, “When an asteroid hits the earth, only one person in a billion gets hit.” And for sure, you’re going to get a person who says, “You mean it could happen?!” The challenge is you have about thirty seconds to figure out where to put the patient on the fear spectrum. There are no guidelines based on gender, socioeconomic indicators, clothing, age, nothing. Instead, you need to read the person, his or her facial expressions, understand the reasons behind the tenseness, and act on any clues you can get, fast. It’s a challenge, but one that involves responding to people and helping them get the procedure they need. This procedure sounds frightening; all this woman wants is a doctor to recognize and understand her fear, and reassure her. We go through each word of the consent form, point by point. Ultimately, she consents. And fortunately for her (and for her doctors), the procedure is a success.
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During week three, one of the attendings I work with is Dr. Richard, a wiry, wired senior faculty member, who does everything in a hurry. He even listens fast, sucking your words up, scanning for key facts, making hurry-up hand gestures so he can cut to the chase and get the problem solved. “Yeah, yeah, okay, let’s do it.” He’s also one of the high-IQ guys who went into electrophysiology because, to him, the arcane web of electrical connections in the heart is a thing of beauty—a Jackson Pollock painting or a schematic of wires and circuits. His passion for electrophysiology doesn’t tempt me to consider specializing in this field, but it does give me hope that I’ll be as excited as he is about whatever field I choose.
Surprisingly, Dr. Richard has a charisma with his patients that seems at odds with his training and his field. He’s all high-speed analysis, data, and deductions…until he walks into a patient’s room. And then he exhibits a stunning, and frankly surprising, bedside manner. You think he’s going to zoom by the patient with his EP-speak—“…blah-blah-blah, cardioversion, ablation, arrhythmia, catheter, consent. Fine. See you tomorrow”—but he downshifts, taking time, listening, caring. He leads the patient through detailed explanations, answers questions, reducing the most complex technology to layperson’s terms. Frankly, I wish he’d slow it down for the Fellows. Patients don’t feel dumb asking questions. We do.
Thankfully, there’s no such intimidation with the attending for the final week, Dr. Theodore. He was a cardiology Fellow at Hopkins, then an EP Fellow, a nice human being, who does little explanatory sketches. He’s methodical and patient, like a high school science teacher. In contrast to some of the others, he makes electrophysiology comprehensible. Seeing patients with him is a primer in translating the arcane to the basic, from Klingon to English, and doing it without being condescending. That’s an impressive skill, especially when you’re as smart in your field as he is. And he seems to appreciate my input. I generally don’t have game-changing EP observations, but he weighs what I say, factors it into the evaluation and decision making. I can’t say after the rotation that I’ll remember one particular case. But I will remember Dr. Theodore. I want to learn how he makes the jargon of his specialty accessible…even if I don’t necessarily want to practice in his specific field.
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Eventually, even when I get somewhat comfortable with EP, my gut tells me that it’s not what I’ll do for the rest of my life. Instead, I gain enormous respect for the mental firepower of people who eat, breathe, and sleep electrophysiology. They look at an abnormal heart rhythm like a puzzle to decode, and get very absorbed in it. But I don’t find it sufficiently fun. Medicine is not here to amuse me, but as a doctor, I define fun as intellectually stimulating with a human element, and,
for me, it’s not here. Learning how to get informed consent from a patient was probably the most enjoyable and most useful skill for me. It was the human interaction—rather than the electrical circuitry—that made the deepest educational impression on me.
Still, this rotation becomes a personal reminder that there are some parts of medicine that are so complex, so byzantine, and so abstruse that they’re the private domains of the wizards of that discipline. For the rest of us who hope to grasp the big picture of our field, the “whole patient,” we aren’t going to master the esoterica, nor should we. As a good cardiologist, I need only a rudimentary understanding so that I know when to refer a case to the right subspecialist, just as a primary care physician has to understand when to send a patient to a cardiologist. I suppose the rule is: Know what you know and what you don’t know.
10
ROTATION: NUCLEAR MEDICINE, PART II
A Christmas Present
The next rotation is the second round of nuclear. This one, like the first, runs two weeks, which is more than enough for anyone except those who want a career in nuclear stress testing. The first nuclear rotation, I knew almost nothing. I’d never read a scan, and never written a nuclear stress report. This time, I know the drill. As in the first nuclear rotation, I’ll read the tests with whichever attending is on, sometimes together, but often not. When we meet, he or she will point out details, comment on my interpretation, add some insight, and ask questions to make sure I get it. No pressure.
Still, I reflexively show up at 8:30 on Monday morning, even though the other Fellows have told me that there’s no reason to be there that early. But it’s day one, and I’m compulsive. Two idle hours later, I realize the other Fellows were right; there are no scans to read and won’t be until they’re fed to us by the clinics in the afternoon. The attending isn’t here. The door to the nuclear reading room is closed. I drink coffee and read newspapers, have lunch, and return emails. Then, in the afternoon, I go to the lab to meet the attending and get started.
The nuclear reading room is dim, illuminated only by the computer screens surrounding the console where readers—Fellows and attendings—sit in rolling chairs. Today I’m working with Dr. Ulysses, the uncrowned Hopkins king of reading nuclear scans. Dr. Ulysses started in nuclear before the training became formalized, and he has taken every exam and update since. He’s also a practicing cardiologist four days a week, not a full-time nuclear reader like some, and to me, that gives him added credibility. In clinic, he sees patients with heart issues, some of whom end up requiring a nuclear stress test. And since he reads scans (maybe not the ones for his own patients but for patients like his), he sees if there is a correlation between the suspected diagnosis and the scans.
When Dr. Ulysses reads the scans, he has an incredible eye for small detail, like an astronomer at a telescope who says, “There’s one of Jupiter’s moons,” but when you look, all you see are fuzzy white dots. Just when you think he’s not paying attention, he leans slightly forward, zooms in on one tile, and stares at it with his Superman X-ray vision. He quietly says, “See this?” and honestly, I rarely do. He points to the “before” tile of the same view, then back to the “after,” and says, “Right here.” Now I see it. His approach as an attending is, he watches you, and if you don’t screw up, he just keeps watching. Here and there, he makes a comment: “The anterior wall isn’t getting blood.” Otherwise, he weighs in only if he thinks you’re off. His silence or head nods are his way of giving the okay.
The second day, my attending is Dr. Thomas, who is more intense and obsessive than Dr. Ulysses. She has read scans day in and day out for the past ten years, and will for the rest of her career. She stands behind me, watching me read, and mumbles, “What’s that?” I mumble back, “What?” She points: “There, at the septum.” She zooms in, “Hmm,” then checks another angle. We both stare at the images. She says, “Maybe…or maybe not.” That’s the capsule story of nuclear—and even the experts aren’t sure when it comes to reading inconclusive pixels. The images don’t shout at you. They whisper, hence the adage that “nuclear medicine” is “unclear medicine.” Different attendings look at the same images and draw different conclusions. But the conclusions matter. They help determine whether a patient goes for a more invasive procedure.
I’m not suggesting that doctors should practice without the benefit of technology. Obviously, technology makes the practice of medicine infinitely better, when and if the technology provides a measurable aid. But just as EP attracts electrical engineering geeks, nuclear is a magnet for lab junkies, the ones who love anything technological, and the more complex the better. But sometimes it feels as if we’re using technology simply because we possess the tools even when we cannot rely on the findings. To me, this seems starkly different from tests such as cardiac catheterizations that carry clear risks to the patient but also tend to yield unambiguous, actionable results. When I’ve ordered stress tests in clinic, the tests were attached to people, patient histories, and my own impressions. But nuclear’s only setting is the reading room, a room sealed off from the reality of the patients. Maybe divorcing the patient context from the test interpretation makes it more objective, but it strikes me as counterintuitive.
This unreliability of nuclear becomes obvious when the fifth reading falls into the gray area. I think it might be something; Dr. Thomas thinks not. I start to write it up her way, but then she looks again and says, “Actually, there might be something there.” We bring in another attending, who agrees with Dr. Thomas’s original assessment, so that’s what we go with. Somehow, all of this guesswork would be okay if the computer were an arbiter. If a doctor could say “It looks like X” but the computer could counteract with “It’s Y,” then at least we’d have a fail-safe. But the computer does not diagnose; our subjective, maybe/maybe not readings are the only arbiters. I write up the consensus conclusion and send it to the clinic, where the referring cardiologist now reads our findings, probably trusts them blindly, and acts accordingly. Was there something there or not? I don’t know.
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Fortunately, in the midst of the nuclear rotation, I also spend time at White Marsh for continuity clinic. This means that, along with the attending, Dr. Andrews, I’m actually seeing real cardiac patients with real problems, and not just scans or photo slices. Funnily enough, one case during continuity clinic ends up altering my view of cardiology because of the tests we do not do—a peculiar lesson to learn in the middle of my second nuclear rotation.
My first assessment of Mr. Hawkins is a visual one—a tailored, pinstripe suit on an athletic frame. He wears a perfectly knotted red-and-black tie, silver cuff links, rimless glasses, and his body language clearly says, “I mean business.” I take a history, and my first impressions are confirmed: Mr. Hawkins joined the U.S. Navy at twenty-two, rose to a military command position by his early thirties, and retired at thirty-five. He put himself through law school, and now works as a nine-to-five financial planner, and spends his weekends and nights as a volunteer firefighter (his father and grandfather having been firemen). He keeps up with his five kids, jogs a few days a week, and can carry fifty pounds of firefighter’s gear into a burning building. As a result, he is in exceptional cardiovascular shape, regularly clocking three-mile runs in eighteen minutes. Eight years and forty pounds after the navy, he’s hardly a typical cardiac patient, with no prior heart disease; no hypertension, diabetes, high cholesterol, or tobacco use; and no family history of heart disease.
So why is he here? In order to remain a volunteer firefighter, Mr. Hawkins must undergo routine stress testing at the county health office. During his last test, attached to EKG leads, he lasted fifteen minutes: 50 percent longer than the average forty-three-year-old male, and reported no symptoms. But during peak exercise, his EKG waveforms changed, and seemed potentially indicative of ischemia—arterial blockage of adequate blood supply to the myocardium during heightened physiologic demand.
The question posed by the co
unty administrators is, “Does the wavy line on graph paper mean he has heart disease?” If Mr. Hawkins has ischemia, he’s displaying zero clinical indications: no chest pain, nausea, hypotension, or unexpected dyspnea (shortness of breath). As Mr. Hawkins retells his tale, I act as if I’m listening, removing my glasses and putting index finger to temple, even though I know the details from his chart. I’m using the time to think, “What path do we take?”
Do I steer Mr. Hawkins toward the route of least harm or toward a more aggressive one with potential pitfalls? The waveforms in his EKG are abnormal and could be clinical grounds for ordering an advanced test to better define the architecture of his coronary arteries—a cardiac catheterization. But a cath is invasive and carries the risks of bleeding, stroke, heart attack, arrhythmia, and even death. It’s not a casual decision. Nonetheless, our system of overregulation, coupled with a fear of litigation, can result in a healthy patient becoming a lab rat. For me, the ultimate gauge is, if the patient suffers complications from tests, whether I can look back and say that ordering them was the right thing to do. If the answer is no, then I don’t order the tests.