by DANIEL MUÑOZ
For the first several hours, I stay just to get to know a new group of patients, and because the resident on that evening is the competent-but-nervous type, which concerns me. At about 9:30 p.m., I decide I can leave in another fifteen minutes. At 9:45 p.m., the resident gets a call about a patient that the ER wants to send up to the cardiac ICU. She gets off the phone and says, “It might be helpful if you came with me,” which means: “Don’t leave.” On the way downstairs, she tells me about the patient: a sixty-six-year-old woman in the ER critical care bay who has a heart rate of thirty…barely life-sustaining. They had applied a temporary transcutaneous pacemaker to her chest to try to pace her heart faster, to get her blood pressure up. (When your heart rate is low, unless you’ve been training for cross-country, your blood pressure will also be low.) There are several reasons a sixty-six-year-old’s heart rate could be thirty, but they are all bad.
Downstairs in the ER, lying in a bed, we see Bunny, a classic, hard-living, beer-drinking, beehived “Hon”—what the locals call certain other locals, born and bred in Baltimore, often with big hair and a heavy accent. Next to her is her identical twin sister—same hair, same accent. Bunny is pale as a ghost, awake but confused, disoriented, and irritated—and, she says, exhausted.
Behind a curtain in the bay, I coax a coherent story out of her with some help from her sister. In the past two days, she’s gone from feeling like her old self to feeling as if she were carrying the weight of the world, and nothing relieves it. On her Saturday errands, she can normally walk the two blocks to the grocery store, carrying her bags or pushing them in a cart. But today she couldn’t even get herself down the stairs to the door. Realizing something is wrong, she calls an ambulance, and when they arrive, with her heart rate of thirty, conscious but woozy, she offers the patient go-to description, “I feel crappy.”
Now we have to find out what’s going on and why. Is it a heart attack? Is it from medicine she’s taking, perhaps in excess? Is it more mysterious? In a purely academic sense, this is a beautiful medical case (as in the art of solving a medical mystery). There are four challenges ahead of us. First, get Bunny out of the emergency room. Nothing good happens in the ER after thirty minutes. ER doctors are conditioned to be at their best right now—fight the fire, defuse the bomb, jerk the shoulder back into the socket, pound the chest, pull the tongue out of the throat, in the moment, but that moment rarely lasts more than thirty minutes. After that, unless the patient is threatening to die, the ER docs move to the next disaster. The second challenge is to make sure Bunny is stabilized. She has various devices attached: EKG leads on her chest, as well as pacing pads, one on the front, one on her back, all of which are keeping her heart rate steady. She isn’t getting big shocks from a defibrillator but rather minijolts every second to get her heart rate to sixty instead of thirty. She’s paced; that is, she has blood pressure…for now. The third challenge is to make sure Bunny has the attention of doctors, in a monitored setting, because she is clearly sick for reasons we don’t yet understand.
That leaves the big challenge, figuring out the “why.” I have never faced this exact type of case before, but I have now had an almost yearlong crash course in seeing people who have something wrong with their hearts and unraveling the mystery. You develop a detective’s instinct and methodology—a deductive process to go through the algorithms and arrive at initial conclusions, remain calm, and avoid panic. That’s the difference between July of last year and April of this year—the difference between a resident and a Fellow.
We transport Bunny upstairs to the cardiac ICU and continue to deal with the challenge of stabilization. Being paced through the chest is not a good long-term plan—usually, a transcutaneous pacemaker is used only for short periods of time as a bridge to another step—because the device can stop working and because it’s uncomfortable for the patient. The more definitive way is to place a transvenous pacing wire, which is done by inserting a large IV into the patient’s neck and floating a temporary pacing wire down the vein in her neck into the right atrium of her heart, crossing the tricuspid valve into the right ventricle, where the wire sits in the muscle and can pace the heart directly. It sounds invasive, but once the wire is in place, it’s considerably more comfortable for the patient, because the amount of electricity required to pace the heart from within the heart is far lower than the amount needed to travel from an exterior pad through the chest.
This procedure—inserting the transvenous pacing wire—is not done frequently. And I’ve never done it. I have to make the decision—there’s no attending present to make the call for me—and I have to decide fast. I weigh the data. In the ER, they drew blood and sent it for analysis. Now, forty-five minutes later, the test results come in and might suggest an explanation. Bunny’s blood counts are normal, including the white blood count, meaning it’s probably not a raging infection. However, her electrolyte panel shows substantial indications of acute renal failure. Her kidneys, though not functioning at zero, are much worse than when she last visited the clinic. The red flag is the level of potassium (K) in her blood. The heart relies on normal levels of potassium—not too much or too little—to conduct and function properly. Normal K level is between 3.5 and 5.0 (lab measurement units). The 5.0 to 6.0 range will get the attention of the clinic doctor; above 6.0, you need to be in the hospital. Over 6.5 and you’re flirting with danger. Bunny’s is 7.2—trouble. There’d been a delay from the lab on her K number because it had to be double-checked, and whenever there’s a double check, you can bet the number isn’t going to be normal. Okay, her 7.2 makes some sense; her slow rhythms are almost certainly from potassium overload. Probable conclusion: Fix the K; don’t put in the wire.
Before I rule out the wire option, though, I want to talk to the attending. My instinct says that Bunny is being paced through the skin and she’s not terribly uncomfortable. On the other hand, putting in a pacing wire is a central line procedure, meaning floating a wire down into somebody’s heart, and that can lead to complications, puncturing the wall, maybe causing an arrhythmia. But I need to vet my conclusion, because my N (numerical sample size of experience) is currently zero. I call my attending at home and say, “Sorry to wake you, but here’s the situation….” I walk him through the case and my conclusion, and he says, “I concur completely.” More important, he doesn’t say, “Two hours from now, check in and let me know what happens.” He trusts my take. (I could have made the decision without his blessing, but I wanted to run it by him that night to vet it, and I want to teach the resident the right way to do things.)
It’s now 12:45 a.m. We have to get the potassium level down. There are only a couple of basic ways for the body to physiologically get rid of things: urinate or defecate. There’s also vomit, but it’s not preferred by patient or doctor. One route, despite Bunny’s sick kidneys, is a large dose—eighty milligrams—of the IV diuretic Lasix. The other route is a nasty-tasting medicine called Kayexalate, which gets the bowels to eliminate potassium from the GI tract. Given the severity of Bunny’s condition, she gets both. The Kayexalate takes a while, but with the IV Lasix, we hope to see a response fast. And even with her renal function at 15 percent of normal, within forty-five minutes, she is urinating into a Foley catheter, about five hundred cubic centimeters, or half a liter. We send off another blood test for potassium.
We’re reasonably confident of the results because we’d done a short-term maneuver to, at least temporarily, move the potassium from the blood cells into tissues. We’d used an IV cocktail of calcium and insulin, plus sugar, or dextrose (so the insulin doesn’t make the sugar drop and cause hypoglycemia). With that combo, Bunny’s heart rate had come up right away and didn’t require as much pacing…but that effect will last only until the cocktail is out of her system and the body reverts to its previous state. The temporary result was a clue that we’re on the right track.
I use the blood test waiting time to think a few steps ahead, a now-ingrained behavior from fellowship. If this works, ok
ay, but if not, then what? The most surefire way to de-K patients is to dialyze them. At midnight, I tell the resident, “Call renal to discuss the case because we may have to do an emergency dialysis session.” I could call the kidney doctors myself, but the resident needs both the experience and the middle-of-the-night pushback; it’s all part of her training.
Within the hour, the renal team arrives and puts a dialysis catheter in Bunny’s femoral vein. Her potassium level comes from the lab, and it’s 6.5—down but still high. As quickly as we take the potassium out of her system, it seems to come back (which is a clue to what triggered it in the first place but we don’t know that yet). There’s still not enough progress. I speak to the kidney doctors about readying the dialysis machine.
In the meantime, we give Bunny an additional 120 milligrams of Lasix. This time she puts out about eight hundred cubic centimeters of urine, almost a full liter. We test again sixty minutes later, and her potassium is down to 5.9. The dialysis isn’t needed yet. If a sick kidney is making urine, it’s probably getting better. An hour later, Bunny’s K level is down to 5.5. Her EKG shows she’s generating her own rhythm—heart rate at sixty-five—no longer totally reliant on the pacer. We turn the pacer off, and Bunny’s heart rate remains at sixty-five. Her blood pressure is coming up too. It’s 3:30 in the morning.
Bunny’s body is sending out cautiously optimistic signals. She was ash white; now she has a little color. She wasn’t able to communicate well; now she speaks in full sentences. Her sister and her girlfriends see the difference. Medically, her potassium is coming down, and she’s generating a heart rhythm on her own. What the textbooks say should happen is happening.
One last potassium check: 5.3, trend line in the right direction. At 4:00 a.m., I leave, seven hours later than I expected. Driving home, I wonder: If I hadn’t stayed that extra fifteen minutes, and if the same events had transpired, would the resident have called me?
And one other question haunts me: “How did Bunny’s potassium get so high?” That question is there, still unsolved, but it will wait, and can wait, until morning.
—
Unfortunately, morning comes just a few hours later, at 7:00 a.m. Bunny is still in her own rhythm. Her potassium is in the 4s, normal for anybody. She’s essentially weaned off the blood pressure–supporting medicine. All good. Since her K is now down, the resident asks, “Did we put the dialysis catheter in unnecessarily?” I reply, “Absolutely not. We did the safe thing by being prepared to dialyze her the moment her potassium inched up rather than having to spend an hour and a half getting it in later, when she might have been truly vulnerable.”
Now we need to answer the “How did the K get so high in the first place?” question. If Bunny had suffered through her symptoms one more night at home, she likely would have arrested and died, with the death perhaps chalked up to “natural causes”—which, given what we subsequently find out, would not have been natural at all.
We search through Bunny’s medical records, reconstructing events. She has a baseline history of some congestive heart failure and a propensity to retain fluid. To combat it, she was on a diuretic, oral Lasix, to keep fluids balanced and the heart appropriately unloaded. She’d seen her primary care doctor three weeks before, and her blood work showed that her kidneys were functioning at only 70 percent, which was new for her. Her doctor concluded she was getting too much diuretic, which can dehydrate, and with dehydration, the kidneys can start to shut down. The doctor then, logically, decided to substantially cut back the dose of the diuretic. But what wasn’t addressed was the fact that, like many people on diuretics, Bunny was also on oral potassium to compensate for the potassium she was urinating. Her doctor cut the oral diuretic but didn’t cut the potassium. So when Bunny continued to take her supplemental potassium, together with other medications that raise potassium levels, she accumulated it in her system until it caused a disaster. Unfortunately, this information was not in her records since her primary care doctor is not in the Hopkins system.
But Bunny actually helped us piece it together, in a way. She proved one of the two rules attributed to an apocryphal resident, way back when. Rule 1: Patients always lie, whether they mean to or not. Rule 2: When patients are too sick to lie, their families will lie for them, again purposefully or not. What the rules mean is that usually without any intention to mislead, people tend to present the facts selectively or even falsely, either because they want to look like good, conscientious patients, or because they don’t want to present bad news, or because their memories are limited, or some combination of all those elements. As a result, the lore goes, you can’t rely on what patients and their families say. You have to listen past the words, to what was not said.
This woman told us she had taken a diuretic, but she didn’t tell us the dosage had been reduced, nor did her sister. And she didn’t mention the potassium at all. But in our search for whatever we didn’t know, what might not have been told to us, her sister did give us the name of Bunny’s primary care doctor and had his office send us her records. There was a note saying, “Diuretic likely causing dehydration and lower kidney function. Cut back diuretic.” Attached was also a list of medications, including the potassium, but no notation to lower the potassium dosage. And we found that she was also on a blood pressure medicine that can, in the event of kidney failure, make the patient more likely to have high potassium.
Mystery solved. Good outcome for the patient; good learning for me and for the resident. Even in situations where I don’t immediately have the answers, I’m developing a set of skills that enable me to cope with whatever presents itself. I have a sense of being outside myself, watching myself handle a challenge. And I’m pleased. That may sound cocky, but it’s not. It’s a relief. It’s good to know that the clinical training we’re getting is working.
Early Monday morning, I do the return handoff to the CICU Fellow, after my two-day cram rotation in the Bayview CICU, and go back to finish up cath.
18
ROTATION: PREVENTIVE CARDIOLOGY, PART II
Working with the Guru
I’m ready to start preventive…but it turns out preventive begins with me. After a two-day break for mountain climbing in a New Hampshire hailstorm, I report to my rotation hacking and dripping. A nurse spots my symptoms and sends me to the ER for a flu swab, which means sitting and waiting like any other patient, which is a good empathy experience, but I wouldn’t mind being taken to the front of the line. Finally, I’m released with a diagnosis of a “cold,” and instructions to try not to sneeze on anyone.
With almost a year of fellowship behind me, I’m a different doctor on my second preventive rotation than on the first, but one thing is the same: the attending, Dr. Franklin, the preventive guru.
I meet him at Hopkins downtown at 8:00 a.m. in the outpatient center. We hit the day full throttle with a packed panel of patients. I see five; he sees my five plus another six of his own. The morning is vintage Dr. Franklin. In three and a half hours, he talks to every patient, adjusts his or her cholesterol medicine, checks the patient’s progress, and does whatever he can to prevent a heart attack, all the while marketing himself and his field.
In preventive cardiology at Hopkins, he is the brand. The world knows it and comes to consult him. This morning we see a sitting member of Congress, unnamed but of Meet the Press level; then the chairman of the board of trustees at an Ivy League school; then the former chair of a medical department at Hopkins, now head of an international healthcare consulting firm (Franklin is a doctor’s doctor); then the founder/CEO of a defense-contracting conglomerate in northern Virginia. The CEO is sixty, responsible for a billion-dollar enterprise; his board and shareholders are betting a lot on his body and heart, so there’s only one guy to see. The list goes on. Some people are famous, some are rich, some both, but what they have in common is Dr. Franklin, the master. He doesn’t ask just about their heart; he asks about their business, or the government, or their golf game. It’s a studied but ef
fective form of personal interaction. And the celebrity aspect can’t help but be enticing.
Personally, I find it a little uncomfortable dealing with patients who think they’re important. But Dr. Franklin seems to be able to shoot the breeze and yet maintain attention, focus, and objectivity. Not everyone can do that. These people are used to being treated differently, and that can be dangerous, even affecting the quality of service. We’re all human. If Bruce Springsteen walks in, we’re going to say, “Holy shit, it’s the Boss,” and want to text everyone we know. Even Dr. Franklin is a bit of a stargazer, but he also seems like a star himself. His office is a photo gallery of Dr. Franklin and Somebody Famous.
Monday of week two, our first patient is a venture capitalist who splits his time between Silicon Valley and Maryland’s Eastern Shore, travels two hundred days a year, meeting clients and making deals, but doesn’t take time to stay in shape and now gets winded going up a flight of stairs. His primary care doctor discovered he has high blood pressure and high cholesterol and tells him to see a cardiologist. Who else but Dr. Franklin?
At lunchtime, I walk outside and am reminded of the Big Contrast. In East Baltimore, people are living marginal lives, some with drug problems, some working hard but barely making it, most with little or no health insurance. And all the while, shahs, politicos, and honchos are being escorted through Hopkins’s doors. The contrast is stark. And unfair.
I ask myself, if I attain some level of success professionally and financially, will I maintain the compassion to care for the person whose life is unlike mine? I can do it at thirty, but could I still at fifty? I see colleagues—with good values—who seem to grow callous, or at least resigned to realities they can’t change. The system has made it harder to take care of the disadvantaged, uninformed, uninsured person. It may be spiritually fulfilling, but there’s little upside, and plenty of downside—financial, time, prestige—for the hospital, for doctors, for the healthcare system. Is the poor person less deserving of good care than the affluent? Of course not, but it’s a challenge. And it’s amazing—and revealing—how grateful people are when they’re treated with dignity, having gone through much of life without it. It’s equally amazing, and upsetting, how often the overprivileged may take good care for granted. I try to be as understanding of the tanned, rich scion as of the average Joe. Both have the same physiology inside, the same heart disease. Both need the same tests, the same drugs, the same stents or surgery. One of the takeaways from preventive is to ask the identical questions, try to react the identical way, stay focused on the medical issues, not celebrity, golf games, or airplanes. There’s a credibility you gain by not treating patients as if they’re special, but by going right to matters of health. Treat them all as patients—the average guy, the poor, the rich, the star—all just people, sick or worried about getting sick. They are people who are scared and want care.
