Alpha Docs (12 page)

During the evening of his call night, outside the patients' glass-walled rooms, he takes me through each plan. The nurse and attending listen, and his plans seem sound. I'm halfway home when he pages me. A woman in her midseventies, a recent stent recipient, was experiencing worsening hypoxia (oxygen deficiency). He laid out what he intended to do and was calling because he wanted assurance that he was doing it right. He was. It doesn't warrant a U-turn.

The second resident, despite her book smarts—high IQ, very good med school, impressive CV—will rattle off eight different solutions to a single medical problem but be unable to pick one. She's the 800-SAT whiz who can't find her way home from the testing center but carries herself with total confidence because she doesn't know what she doesn't know.

By Wednesday, I am starting to lose patience with young Dr. Book-smart. My concern about her is greater because she is an aspiring cardiologist. This isn't a token cardiac rotation on her way to being a nephrologist or a pulmonologist. And if she's going to be a heart doctor, part of my job is to make sure she's a competent one. The ability not just to glean data but to synthesize it and be decisive is what separates a doctor from a computer. But how do you teach a human Google—all search, no discrimination—how to filter?

On our next case, she begins by giving me all the medical information a doctor could possibly draw upon—GI (gastrointestinal) issues, hematological issues, renal issues—but does not put those issues together. Meanwhile, the patient is in serious trouble, with severe underlying heart failure, bleeding from his gut, and anemia (low blood count). Still, the resident is checking every possible cause and effect, iron studies and B
₁₂
and folate as possible causes for the anemia. She is wasting everyone's time, including the patient's, by investigating irrelevant vitamin deficiencies and not zeroing in on the real causes.

I try to stick to the “velvet glove” approach. Either I fail or she doesn't get it. I cut in; I ask her pointed questions; I insist on decisions. When she hesitates, I push. I ask her to set out a treatment plan. Finally, I set out the treatment plan and get her to nod in agreement.

Fortunately, the patient responds to the meds and stops bleeding. His blood count goes up a little, which means we can return to worrying about his heart. Still, I go home frustrated with the resident, a little upset with myself for being impatient, and half hoping she'll go into another specialty.

Resident number three is much easier to work with: She's wise, likable, kind, caring, and combines a rosy outlook with competence and a willingness to ask questions. Though she has no intention of going into cardiology (she wants to be an oncologist), she has a good handle on the cases, a calm demeanor, and a way with the patients. I do notice she's a little tentative on the second-to-last patient, Mr. Morton, who is now in the cardiac step-down unit, an intermediate area for patients who are out of immediate danger but are not healthy enough to be transferred to a general inpatient floor/ward. When Mr. Morton first came in, he was in rapid atrial fibrillation—irregular heart rhythm—but since then, he's stabilized, and is on medication that controls his heart rate. I can see that his on-the-cusp condition is making her uneasy, but this uncertainty—and the connection to the patient that it implies—is a good kind of uneasiness for a doctor. It keeps you sharp and attentive, not complacent. We see one more patient before the end of rounds, and, all things considered, I feel pretty good about her assumption of the on-call responsibilities.

The only sleep I've had in the past two days has been a series of nonsequential naps, on sofas and chairs in the Fellows' lounge. I decide to go home and fall sound asleep, but am awakened when the resident who knows enough to ask questions pages me at 3:30 a.m. Mr. Morton, the patient she was uneasy about, has flipped from his steady, slow rhythm into a very fast rhythm. “It looks like rapid atrial fibrillation again,” she says. (Rapid AFib can be serious for certain patients, particularly those who are older and/or who have underlying heart disease. It occurs when electrical short circuiting in the top chambers of the heart triggers an abnormally fast heart rate. The heart goes into overdrive—a rapid ventricular response—which can be unsustainable in certain cases.)

I ask, “What's his heart rate?”

“About 160.”

“Blood pressure?”

“We're trying to get it. It's like sixty over palp.” This is serious.
Palp
means that the bottom number, the diastolic pressure, is so low the machine has difficulty even measuring it.

“Is he awake at all? What's his neurologic status?”

“He's groaning and not making sense.” She's trying to be composed and process her steps. Mr. Morton has a completely unstable heart rate, and he's groaning, almost babbling, because his blood pressure is so low his brain isn't getting enough blood flow. She starts to say, “Dr. Muñoz, do you think I should—” but I cut in: “I want you to put the phone down and shock him right now. He's in an unstable rhythm. Shock him with two hundred joules. Now.” She says, “Okay.” I add, “Page me or call me as soon as you're done. I'm on my way.”

I'm almost to the hospital when she pages me to say, “We shocked him; his heart rate is seventy; he's got a good blood pressure. He's annoyed because he hurts from us shocking him, but he's awake and talking.” The patient is stable again. The resident knew when to call, and she knew what to ask. Though I had to direct things over the phone, I had a good partner on the other end. Her ability to sort and relay accurate information helped me make the correct management call, and possibly save a patient's life. She knew what to do but just needed confirmation. That's the way it should work.

And then, just when I start to feel as if I have a good grasp on this rotation, a case comes along that flips all the lessons upside down, turns good medicine inside out, and screws up the predicted outcomes.

Stella, age fifty-nine, has an unfortunate combination of high blood pressure, diabetes, bad cholesterol, and obesity. Stella is also a widow, her husband having passed away two years ago, and mixed in with her other symptoms, she shows some residual grief and depression. Depression is a wild card; you never know how it can affect a patient. And then there's her weight. She's under five foot five and weighs 285 pounds. We say that patients such as Stella are “older than their age,” a euphemism to soften the reality that Stella is even unhealthier than she looks.

Her diabetes has eaten away at her peripheral blood vessels, resulting in a loss of circulation in (and amputations of) her toes. Stella has what doctors call a “trifecta” of risk factors: (1) diabetes, (2) high cholesterol, and (3) sugar or high blood pressure. Her comorbidities—that is, her other diseases—are conspiring to erode previously healthy blood vessels all over her body. While a toe infection is what brought her to her local hospital, once there she began to experience episodic chest pains, which are much more alarming than her necrotic toes.

The medical team at the outside hospital hooked her up to an EKG, which showed several potential abnormalities that raised concerns about ischemia (portions of the heart muscle not getting enough blood), but not necessarily a heart attack. Stella has signs of unstable angina, chest pain that is unpredictable, and not related solely to exertion. After a day or so without improvement at the community hospital, her doctors move her to Hopkins.

During her ambulance ride to Baltimore City, Stella developed increased chest pressure and diaphoresis (sweating) as well as nausea. The EKG en route indicated ischemic changes (abnormal changes to the electrical pattern of the heart's contraction) that correlated with her symptoms. The good news is that by the time Stella arrived at Hopkins forty-five minutes later, things had calmed on her EKG and she was temporarily symptom-free. However, given her chest pain and our concern for an unstable coronary syndrome, she can't go directly to the vascular surgeons for her toe removal—she has to get “cardiac clearance” before anyone can operate on her.

The first thing that strikes me when I see Stella just before 11:00 p.m. is that she doesn't seem afraid. She's just exhausted, frustrated, and near tears. On quick examination, it's clear that another toe must be removed. Even with antibiotics, the toe is bright red, ugly, and ulcerated. As sick as she is, and as many times as she has been through these amputations, she finds it hard to deal with the loss of another toe.

The first three minutes with a patient are crucial in forming a picture of a case. Observation, visual clues, and nonverbal signals often yield more valuable clinical information than pointed questions. I ask Stella about her chest pain and other symptoms because I'm trying to arrive at decisions on tests, what to do right away, and what can wait until morning. Through it all, she tells me she doesn't want to lose another toe. Privately, I think, “That's the least of your problems,” and instead, I try to shift her attention to what's critical. I want to interrupt, “Your heart is the issue tonight,” but I also don't want her to panic.

At the moment, since she's not having chest symptoms, we put Stella on cardioprotective medicine overnight and plan for a cath with coronary angiography—X rays of the coronary arteries with dye shot through to illuminate them—for the morning.

Stella gets through the night, and the next day is a Saturday. I don't have to look at a calendar; it's because the rest of the hospital is so quiet. When you're in the ICU, you can't necessarily tell what day or even what time it is. The sense of time or day you do get comes when you walk down a hall into the non-ICU world. Suits and ties—weekday. Short sleeves—Friday and weekends. Empty corridors—late night. Quiet—Saturday or Sunday.

After Stella is taken to the cath lab, the cath team calls me and my CICU attending to show us what they found: coronary disease with one particularly tight-looking, critical stenosis (narrowing) in her right coronary artery. It's a discrete lesion, meaning you can see where it begins and ends. The only blood flow running past it is a thread in a focal section that's fairly proximal—that is, upstream—in the vessel. With Stella still on the table, we agree the only course is to implant a stent to hold the artery lesion open, hopefully solving her angina issues and clearing one hurdle to her going to the operating room for her toe-related issues.

At this point, we have to decide which type of stent to use. Ideally, we'd opt for a drug-coated or drug-eluting stent, a DES, versus a bare metal stent because the DES tends to remain open longer. That means there's a lower likelihood of scar tissue forming inside the stent, since scar tissue formation can lead to a narrowing of the artery over time. But with the DES, for a full year, patients have to be on both aspirin and the drug clopidogrel, which together act as platelet inhibitors that help blood flow better and prevent clotting. Bottom line: If you're just getting a stent, it's better to get a DES. If there's planned surgery in your future and you can't risk excessive bleeding, it's better to use bare metal and be on the aspirin-clopidogrel combo for one month (as opposed to one year), with only a daily aspirin required after the first month. Stella, who will need to have her toe removed, is getting bare metal.

The stent goes in and I leave to see other patients in the CICU. The cath team pulls out the catheters from her groin vessels, and twenty minutes later, Stella is back in her room, with the nursing staff reconnecting her to various devices. Five minutes later, a nurse tracks me down and says, “I can't get a blood pressure on her.” Stella's blood pressure is so low that we can't get a reading at all. In the room, Stella is conscious but ghostly pale. Her heart rate is about one hundred, much higher than when I left her in the cath lab. But her blood pressure is now reading sixty over thirty: dangerously low. I try to ask about other symptoms, but she keeps moaning, “My back hurts….”

With her pressure that low, she could develop a clot that might block off the stent, causing a bigger heart attack. But despite the low blood pressure, Stella is not that tachycardic—that is, her heart rate is fast but not alarmingly so. She could be (a) bleeding as a result of the cath, but also (b) having a “vagal response.” When a patient is in a lot of pain from a cath procedure, and/or gets moved in an uncomfortable way, he or she may experience a vasovagal response akin to fainting and losing blood pressure. We give Stella IV atropine to try to reverse a possible vagal response, but it does nothing.

And so far, we've had no luck in changing her blood pressure, which indicates Stella might have a rapid onset internal bleed. If so, that could lead to the leg compartment swelling, the result of hematoma (large blood mass) somewhere along the catheter's path inside Stella's body. Normally, hematomas are easy to spot, but Stella has a great deal of fat around her groin area, making it tough to determine.

There's also a distinct possibility that Stella may have one of the most feared complications, a bleed we cannot see from the outside—a bleed into her retroperitoneum, or the rear area of the abdomen. This would explain her back pain, because an RP bleed can be extremely uncomfortable. And its damage can be far worse than a bleed into the leg simply because you can't see it. Stella has just had needles in her groin for her catheterization, and her weight probably necessitated several attempts to find her artery. Any one of those needles could have sheared or nicked blood vessels and caused an RP bleed. To make matters worse, the RP is a very inaccessible part of the body. It's harder to stop a leak you can't see or easily reach.

There's no time for head-scratching and theorizing. We call the blood bank and tell them that we have a patient with major, ongoing blood loss and that we'll need a continuous supply of blood until her situation changes. The only thing we can do is try to keep up with her blood loss—transfusing blood and pouring fluids into her until the bleed stops. The attending grabs a gown and jams an enormous IV into Stella's leg to get the fluid in now. There is almost no conversation. This is not a teaching moment. Stella's condition is far too critical.