Alpha Docs (10 page)

The next day, after another twenty-four hours without the beta-blocker, Mr. Blue's heart rate is in the low sixties. By the third day, it's up to the midsixties, and he has a normal heart rhythm. The second-degree heart block is gone. Mr. Blue was discharged the next day, four days after being admitted—with a better pill-taking system in place, but without a pacemaker.

This is a humbling first consult because it makes me realize that my initial assessment was far too preliminary. The treatment plan quickly evolved from “Second-degree heart block, heart rate of thirty-five, serious symptoms, put in a pacemaker” to “No major problems, no light-headedness, no shortness of breath, just hungry, pretty soon we can send him home.” The “intervention” ended up being a very different variety than what I, or even the EP attending, Dr. Harry, originally thought we would need to do. It didn't involve putting anything in; it involved finding out the patient was unintentionally taking too much beta-blocker. Sometimes waiting is good medicine, and Dr. Harry had the wisdom to weigh the possibilities before acting. And I'm glad that I followed my instincts, that I also trusted my doubts were trying to tell me something. Mr. Blue is a classic example that a lot of medical problems are due to a lack of information—information that may not be immediately available from the patient…but that doctors can obtain if they have the time, the resources, and the inclination to do a little digging.

The rest of the patients I see during the rotation are mostly the quick in and out, like patients with atrial fibrillation, who are in for electrical cardioversions. Atrial fibrillation, or atrial flutter, occurs when the top chambers of the heart are whipping away at too fast a rate. The bottom chambers that pump the blood try to ignore some of the noise from the top, but can't and end up with a random, overly noisy beating of the heart that can cause symptoms such as shortness of breath, palpitations, and angina. Almost any exertion results in exhaustion, or the classic patient description of “I feel crappy.” Because the EP doctors specialize in mapping out the electrical network of the heart like a schematic diagram of house wiring, they can try to burn certain areas in an attempt to break the short circuits and get rid of the electrical impulse causing the abnormal rhythm. Cardioverting the patient, or directing an electrical current into the chest, can get the patient back into a normal or sinus rhythm, often improving or relieving symptoms and heart function.

My job is to meet the patients in a preprocedure room and talk to them, review their records, go through the consent procedure, where I describe what we're going to do, cover the risks and benefits, and get their permission to proceed. Then I page the attending to room 11, the procedure room, to obtain the official go-ahead. We sedate the patients so they're asleep but not “fully under,” while having them hooked up to monitors to track their vital signs—blood pressure and oxygenation. Once the patients are sedated, we put pads on their chest and administer timed delivery of electric shock, to reset the cardiac cycle. Again, with the go-ahead from the attending, I press a button that unleashes a two hundred–joule shock to the patient's chest. For the next second, everyone holds their breath to see if it put the heart back in normal rhythm. Despite being sedated and asleep, patients will occasionally let out a bloodcurdling shriek or string of profanity after being whacked in the chest by all that electricity. Fortunately, the sedating medications ensure that patients do not remember this, and once the sedation wears off, most leave the same day.

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.

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.

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.

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.

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 county 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.

Every doctor learns the Hippocratic oath in med school, and its implicit maxim, “First, do no harm.” It's an unusual vow. Rather than a promise to heal or do good, it's an admonition not to hurt anyone in the name of helping. I decide that sending a robust, symptom-free, firefighting father of three for a cath fails my clinical litmus gauge. I opt to do no harm—or, more accurately, to do the least harm.

But now we come to the crux of the issue: Do we do nothing more? What if that EKG is a clue to something? And what if we send Mr. Hawkins home and he dies of a heart attack that might have been prevented? It can be as challenging to care for the seemingly healthy patient as for the obviously sick because the healthy patient has further to fall. So I take a hybrid approach: I do not order a nuclear stress test, because I don't think it will tell us anything definitive, but I do order an echocardiogram and stress test with ultrasound pictures. The stress echo test isn't perfect. It can produce a false positive or false negative. But it can also provide a measure of diagnostic reassurance without difficult-to-justify risks for a healthy patient. This is one of the greatest challenges of clinical medicine. Since every decision carries risk, it's sometimes unclear which path offers the least harm.

Unlike patients I see during rotations and never see again, I am now involved in treating Mr. Hawkins. When he goes in for the stress echo, as I happen to be in the hospital, I witness the test itself, and not just the written results in his chart. This time Mr. Hawkins is on the treadmill for over seventeen minutes, which borders on the absurd since we rarely expect anyone to go more than ten minutes. And this time, the technician speeds up the track and raises the incline up to a thirty-degree angle. Mr. Hawkins still runs six miles an hour, and even says to the tech, “What else do you want me to do?” Most patients are panting and can't wait to get off, but he's chatting.

The value of pushing somebody is that you can compare the ultrasound pictures taken immediately after exertion to the ones you've taken when the patient was at rest. The longer the patient goes, the more reassured you are by normal-appearing pictures. And it looks as if Mr. Hawkins is fine. He's sweating, but that's normal. And his echo pictures are fine—his heart is functioning perfectly, and every portion of his heart muscle seems to be adequately perfused. We can't see the blood flow, but the normal muscle motion indicates it is adequate. Even though his EKG shows the same quirky wave, in some ways this is actually good, since it indicates that the abnormality isn't a sign of trouble, but is as much a part of him as his bushy eyebrows and oversized feet. In my medical opinion, Mr. Hawkins has had a false-positive EKG.

During Mr. Hawkins's follow-up appointment at the clinic, it's clear that he's doing fine but he's not happy at having been away from his volunteer firefighter's job; it's his way of carrying on the family heritage. If he's okay, he wants to go back right away. That requires an official doctor's letter to give him clearance. And that's a first for me, dictating a formal medical opinion in which I state, for the record, on Hopkins letterhead, that as a member of his medical team, after performing the appropriate tests on Mr. Hawkins, he has a clean bill of health to go back to running into burning buildings. And I, Dr. Daniel Muñoz, MD, have to sign it. Though I imagine this sort of ritual will become routine/commonplace as I progress into my career, right now it feels like a momentous act. I'm officially official.

Sometime later, I wonder how Mr. Hawkins is doing and decide to call his home to check on him. His wife answers the phone: “Doctor, you missed him by five minutes. The firehouse siren always seems to sound when we're sitting down for dinner.” That's my answer. All should be well with Mr. Hawkins—at least until the next time the county requires an EKG. Hopefully, the next cardiologist will know that, in Mr. Hawkins's particular case, a restrained approach might very well be the best way to “do no harm.” Mr. Hawkins is a case study in the Hippocratic oath, and an important reminder to gather the facts and then trust one's own clinical judgment rather than adhere to a strict algorithmic protocol of testing. Mostly, it's a reminder—again—that we're treating people, not data.

On my last day of nuclear, I'm working with Dr. Ulysses again. We cruise through the reports, and by 7:00 p.m., we're finished. I say, “See you tomorrow.” Dr. Ulysses reminds me, “The clinics are closed. Merry Christmas.” My two-week rotation on nuclear stress tests was only one week and a day.

Unlike the nuclear testing itself, whose results can be vague (but lucrative), my conclusions about it are clear. The technology behind the tests is impressive; so are some of the practitioners; but the disconnection from patients and the subjectivity of reading outcomes make me question their value, and, as a field, it clearly isn't for me. On the other hand, my midrotation clinic work further reinforces my affinity for direct patient interaction and longitudinal involvement. In fact, by the Sunday after Christmas, my mind shifts to my next immersion. In twelve hours, I'll be back at Hopkins's cardiac intensive care unit. Real patients who are truly sick, and who need constant medical care. I think I'm beginning to know what I like doing.