by DANIEL MUÑOZ
16
ROTATION: CARDIAC CATHETERIZATION—INTERVENTIONAL CARDIOLOGY
The Closest We Get to Being Surgeons
Mind shift: another first day of another rotation, this time from the predictability of echo to the pressures of the cath lab. This is an eight-week rotation, all of it intense. The patients cover a wide spectrum, from those in for outpatient procedures because something is suspected to be wrong, to the emergencies in need of a cath immediately because something is known to be very wrong right now. As a resident, I’d been around cath and observed (from the other side of the glass), but now I will have the chance not just to watch but to do it. It’s highly specialized, the territory of the interventional cardiologists, who do one thing—invasive cardiac procedures. It’s as close to heart surgery as you can get without sawing open the sternum. You’re going directly into blood vessels, inserting devices that open jammed arteries to let blood flow through to dying heart muscle, immediately saving a life or prolonging it.
Cath is the sexier, higher-octane side of cardiology. But after a while, even the most miraculous-seeming procedures can be broken down to the basics—as mechanical, electrical, or chemical repairs. They’re each logical and practical, even if uncommon…including cath. I’ll deconstruct the procedure to see how it works and then go about conquering a new skill.
In contrast to some previous rotations, in cath I won’t be learning the procedure exclusively from one individual attending with whom I might bond or whom I might know from previous experience. There are ten different interventional attendings, and on any given day, two or three are doing caths. They are each impressive, but each quite different in teaching style and demeanor. The way you learn or how much you learn is highly dependent upon which attending is in the lab that day. A case in point is Dr. Calvin, in his midforties, a relative newcomer given the decade plus of medical training it takes to get where he is. He’s patient and soft-spoken, which is also notable because it belies the stereotype for such hotshots. Dr. Calvin seems to have trained his reactions to be the inverse of the situation, low-stress in high-stress circumstances. He’s excellent to work with because you feel you can do no wrong, or rather that he’ll enable you to feel you can do no wrong, and in case you do, he’ll calmly fix it.
Dr. Calvin starts with the elementary aspects, how to hold and manipulate the catheters. As a first-timer, my role as the Fellow is to “get access,” or insert the initial catheter into the femoral artery. Then, during the remainder of the procedure, I assist. Getting access can be unpredictable. You may get it right away…or not. Some of the attendings give you one or two tries, then step in and say, “Let me take it now,” and you feel lousy, especially when they stick the catheter in as if the artery were as wide as the Amazon.
On day three, my first turn comes. I make my attempt, but I don’t get it. Dr. Calvin just nods at me to make my next try. I miss again. He offers a pointer on how to guide the catheter. I get it. He says, “Not that hard, is it?” Instead of feeling lousy, I feel good. Pretty basic psychology, but pretty effective. The next two cases, I get in on the first try.
My experience is very different from the story circulating about another Fellow who took two tries, whose attending actually bodychecked him aside and didn’t give him another opportunity for weeks, by which time the Fellow was convinced he had artery blindness.
I hit plenty of arteries and miss a few, but I start to feel I’m catching on. Two weeks in, I’m working with another attending, this one not known for his tolerance. I have a patient whose femoral artery pulse I can’t find, which means I can’t tell where to stick the catheter needle. In this case, the man has a lot of “soft tissue” in the groin area where we go in; he’s substantially overweight. After I miss on the first try, today’s attending is literally breathing down my neck. I do not panic. Instead, I channel Dr. Calvin—patience and calm—feel around the excess flesh to be extrasensitive to the pulse, take my time, find the pulse…and go right into the artery. The heavy breathing behind me subsides.
I have my off days, of course. Around the third week, I’m zero for four on one patient. Dr. Calvin lets me keep going for a fifth and even a sixth try. Finally, in sympathy for the patient, and without destroying my ego, he says, “This one is tough. Mind if I give it a shot?” The next day I get the first one on the first try. It takes practice.
But the veterans seem to be able to get access every time. One of the older interventionists, Dr. Zachary, is beyond good—almost legendary. A former Vietnam Green Beret, cool under fire, Dr. Zachary is known to offer a dry joke when the situation is tense. My first time with him, I’m not hitting the artery. Almost inaudibly, he says, “Take your time, Dan. We have nothing else to do today.” It’s his style, but it can throw you. Later that day, while trying to find the pulse, I say, “I can feel it.” He replies, “That’s great. But the point is to be inside the artery. Let us know when you’re in there.” Battlefield humor, but with a point—get on with the procedure; there’s a patient who needs it and another doctor waiting for the results.
—
Around week three, I get a message on my pager that has nothing to do with cath. A second-year resident, one of the best in her class, and applying for a cardiology fellowship, is about to submit her rank list to the National Resident Matching Program. She wants to hear how I made my final decision. And, it turns out, we have a shared experience.
After a bit of self-conscious hemming and hawing, she reveals that she has come down to a mental tie between Hopkins and Harvard/Brigham and that she’s been contacted by each telling her she’s at the top of both of their match lists. When I share with her that I had a similar experience, she breathes an audible sigh of relief. She was reluctant to tell me for fear of sounding immodest. I confide in her that while, on the one hand, it was a wonderful choice to have to make, at the same time, it left me almost unable to decide. She has managed to stumble upon someone who can empathize.
I try my best not to tell her what to do but to frame the issue so she can decide wisely. On the pure cardiology side of the equation, either institution is superb, renowned, staffed with incredible doctors, equipped with state-of-the-art facilities and research. So I suggest she look at the nonmedical side. She’s a graduate of Stanford medical school, a second-generation Hispanic American, from a high-achieving family. Where does her family live? Is there someone significant in her life? Where might she want to live after training? Her family is in a suburb of Philadelphia, not far from Hopkins, and they’re close. She’s in a relationship with another doctor who is finishing a family medicine residency in Cleveland, about to go somewhere as yet undetermined. Hopkins is a powerful force. But she’s been at Hopkins; it’s like home, for better or worse. And Harvard is…Harvard, the biggest “brand” in academia. One other thing Harvard has is Boston, a great city. At Hopkins, we always have to say, “Baltimore is nicer than you think.” What Hopkins has is the medicine, second to none. She doesn’t have to decide today, but soon, within two weeks. The only advice I offer is to do not what lines up on paper but what “feels right.”
(Update: Three weeks later, I get a message from her: “I’m coming to Hopkins. Thanks for listening.”)
—
I’m at the halfway point of cath, and two lessons emerge. The first is “the contradiction.” Interventionalists (and occasionally other specialists) are sometimes nicknamed “procedure monkeys” by their peers because they’re highly trained to perform a single feat, almost to the exclusion of all else, and therefore could seem to possess very little humanity. Therein lies the contradiction. Often the attending who can be all-business—callous, or sarcastic, or temperamental, or unforgiving toward Fellows who miss arteries—is the same attending who displays the most sensitive, poignant bedside manner with patients and families. These doctors are human when they most need to be. It shatters an accepted prejudice. If you have ice water in your veins when you’re under fire, you must be ice-cold all the time. Not so.
What isn’t clear is how these doctors got that way.
In all of medical training, there’s no course or rotation called “bedside manner”…despite the fact that we may spend half of our days at bedsides. No one teaches you how to deliver a diagnosis, or treatment plan, or surgical outcome, or prognosis, or news of death to patients and families. You learn by watching. Or not. And after the case is over, there’s no review of those skills, no reflection, no “What did we learn, and how can we do it better?” The assumption is, we’ll learn it out of necessity. Good bedside manner isn’t just good care, it’s good business. It should be taught.
The second lesson is not as surprising: You learn differently from different attendings, depending on their styles, patience levels, and amount of leeway they give the Fellow. Personally, I like Dr. Zachary, despite his hardened exterior, but some Fellows don’t. My gauge of an attending is whether he or she (a) pushes me, (b) shows me something new, (c) isn’t dull. Dr. Zachary does all three. Another attending, Dr. Delano, is crotchety, anal, and controlling, but if you can tolerate his manner, he can impart some valuable cath lessons. The bottom line is, they don’t all “teach” in the textbook sense; some just do what they do, the way they’ve always done it, and it’s up to the Fellows to figure out how to extract the lessons…even if it practically requires surgery.
And then there are actually some attendings you’d rather not learn from.
Given a choice…
—
By weeks five and six, I am getting better at caths. Early in the fellowship, people asked me if I was going into cath as a career. Everyone has heard of caths; famous people get them; they’re in the news. The truth is, doing caths sounds exciting, like flying in the space shuttle, but in reality, who knows?
Until a month ago, I had seen caths but never done one. When you’re a resident, you can go to the cath lab and sit in the control room behind the thick glass and view the procedure on screens. But you might as well be watching the Discovery Channel. It’s a lot different from being in the room and passing the catheter into an artery, or missing and sweating beneath your mask.
Now I’m doing them, going from virgin to immersion in a matter of days. With some attendings, it’s a good immersion, and with others, not so good, and you don’t have much choice. But there is one guy I’d like to avoid: Dr. Rutherford. I had a negative experience with him as a resident, coincidentally in a cath-related clinical situation.
I was the resident on call in the cardiac ICU, on a thirty-hour shift. Mr. Robbins, a patient with unstable angina, had come in, was cathed in the evening, stented in two major coronary arteries, and admitted to the cardiac ICU. At 2:00 a.m., I was summoned to his bedside because he was having an active groin bleed. He’d called the nurse because he felt something warm on his leg—and it turned out to be blood. From the site where they had gone in with the catheter, a half liter of bright red was squirting onto his bedsheets. The situation wasn’t complicated: Unless immediate pressure is applied, the patient can bleed out and die. It’s not sophisticated treatment; but it’s physically demanding, and it works. The cath Fellow wasn’t around, so I had to do it myself. I applied pressure to Mr. Robbins for a solid twenty minutes. The bleeding stopped. Afterward, I paged the Fellow, but he didn’t call back, probably because he was sleeping.
The patient was fine, good pulses in his feet, and we had no concern for other vascular damage. We had Mr. Robbins lie flat for the rest of the night to ensure he healed up appropriately and checked his blood counts regularly to make sure he didn’t need a transfusion to replace the lost blood.
The next morning I was on rounds with the CICU team—the ICU attending, the residents, and the interns. That’s when Dr. Rutherford, the interventional attending, appeared. As is the protocol, we stopped everything to discuss this case. Without a hello, he fired at me, “What happened with Mr. Robbins last night?” I recounted the events. “He had a bleed from his puncture site, about four hundred cubic centimeters of blood, discovered by the patient and his nurse. I held twenty minutes of pressure, and there was no subsequent bleeding or hematoma after that.” A by-the-book answer. Rather than ask anything further about the treatment, Dr. Rutherford homed in on a technicality: “Why is there no event note in the chart?” An event note is a documented record that recounts an unexpected incident with a patient. Event notes exist, to a great extent, for legal purposes. But Dr. Rutherford was relentless and condescending: “You’ve got to write an event note in that situation.” I hadn’t slept for a day and a half, needed a shower, and most important, I was confident I’d done the right thing for the patient, so I was in no frame of mind to be lectured on event notes. But Dr. Rutherford repeated it once more. Rather than being thanked, I felt scolded.
My CICU attending was a very good doctor, but evidently averse to confrontation, so it was up to me to look out for myself. I responded, “Now that the patient is fine, it would be my pleasure to write an event note. I did page your Fellow at 2:30 a.m., so you may want to let him know everything is okay, because he still hasn’t called me back and it’s now 10:30 a.m.” Dr. Rutherford grunted and walked away. That afternoon, before going home to bed, I wrote a two-and-a-half-page event note, recounting in meticulous detail what had occurred.
Dr. Rutherford strikes me as the type who can be fine when all is calm, but when there’s stress, he can obsess over details instead of focusing on the key issue, not a good trait for anyone who deals with pressure—a fireman, a cop, an astronaut, or a doctor. Honestly, given a choice, I’d rather not cath with him.
So far I haven’t cathed with him, and I won’t today because it’s 5:30 p.m. Time to clean up, change my shirt, and make sure there are no coffee stains on my tie. This is a big night.
—
Tonight is Johns Hopkins Medical School graduation. Not only are degrees conferred, but awards are given to students and faculty, one of which is voted on by the graduating class. Across all specialties—surgery, medicine, pediatrics—the students select the resident who has contributed the most to their education. In February, during my consult month, I’d been notified it was me. I’m very flattered.
In contrast to my own graduation, instead of sitting with the 130 people about to walk across the stage, I’m one of the people on the stage, one row back from the CEO of Hopkins Medicine and right behind the commencement speaker, Dr. Denton Cooley, one of the deities of cardiac surgery. My parents insisted on coming for my ten seconds in the spotlight—unfortunately for them, sandwiched into the middle of the three-hour ceremony.
It was worth the entire evening to hear Dr. Cooley. “It feels like just yesterday that I was in your seats, graduating a mere sixty-five years ago.” The crowd laughed but got the message. He might be almost ninety, but he’s as sharp as ever. His speech was fatherly and wise. Work earnestly and ignore the naysayers. He exhorts young doctors to do what they’re passionate about, not just what’s lucrative or the newest flavor. What makes the speech powerful is his passion, the passion he’s maintained for over half a century. He leaves the graduates feeling that if they choose an easy path, he’ll be personally disappointed. And you don’t want to disappoint this legend who performed the first successful human heart transplant in the United States, and the first implantation of an artificial heart in the world, whose teams have performed more than one hundred thousand cardiac procedures (hence, the title of his memoir: 100,000 Hearts), who has won every imaginable award, including the Presidential Medal of Freedom; and, not coincidentally, he graduated from the Johns Hopkins School of Medicine.
An hour into the evening, it was time for my award. The CEO of Hopkins Medicine made the announcement and shook my hand; the vice president handed me a framed certificate; and my parents were proud.
But the effect of Dr. Cooley’s speech, on the night I received the award, was profound. This medical icon put it in perspective. You got a nice honor tonight. Keep at it and someday you might truly accomplish something. This award says that I do what
I do pretty well. Dr. Cooley said, in effect, that it’s just a start.
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Back to cath for the home stretch—the final two weeks. Put simply, more caths, more practice, more hits, a few misses, more learning, more subtleties. As it turns out, I never had to cath with Dr. Rutherford. Maybe he didn’t want to cath with me either.
Cath is over. All in all, I like it. Again, I have to say, I don’t know if this is the one thing I want to do every day, forever. It scares me sometimes to think maybe that one thing doesn’t exist. Maybe it won’t have to be “one thing.” Maybe things I like, such as cath, can be in the mix. I don’t have to check that box yet. But I will….
17
WEEKEND COVERAGE
A Virtual Two-Day Rotation
On weekends, you push the rotation “pause” button from Friday until Monday. Then, you either have two days off or you have “coverage,” meaning duty at one of the hospitals in the system, in one particular department.
In the middle of the cath rotation, I cover the Bayview CICU one weekend, and the experience turns out to be the equivalent of an entire rotation in forty-eight hours. Sometimes you can take in as much in two days as you do in two months.
Friday afternoon, I go to the Bayview CICU and get a sign-out—the list of seven patients and their conditions—from the Fellow heading out for the weekend. My job is to make sure those seven, plus whoever comes in the door, get through the next two days. Monday morning, I’ll pass the baton to whichever Fellow is on.
The better part of that Saturday is routine, rounding with the residents in the morning, putting plans in place for the patients in the afternoon, and fielding new patients as they come in. Technically, I can leave at any time the pace allows, as long as I’m prepared to come back. This weekend, I end up never leaving.
