Alpha Docs (16 page)

Rotations are compartmentalized—end this one; start that one. But they're also cumulative—the impact of one adds to the next. You tell yourself to silo your reactions, but you can't. Sometimes, you need to get away from medicine.

I'm coming off of a combination of bedside and technical rotations. I finish Friday, pack Saturday, drive Sunday, fly from Newark to San José on Monday. By Monday afternoon, I'm on the beach, precisely 2,078 miles from work.

You can begin to think your hospital is the real world, and forget that it's far from it. You get an unrealistic sense of your importance and of where you work. Here no one cares that I'm a doctor, let alone that I work at Hopkins. No matter where you go in the world, medicine—real medicine, local healthcare or lack of it—stares you in the face. Travel to gritty cities and remote locales and you'll find poverty and people for whom some arcane aspect of cardiology is irrelevant. They need clean water and childhood vaccinations to survive. Traveling is a humbling reminder that nuclear stress tests, electrophysiologic ablation, stents, immunosuppressants for transplants, or the fact that I'm a cardiologist are all less important than the need for plain old medicine and good doctors. The Nobel Prize for stem cell therapy can't set a broken arm. More personally, my twelve years of training don't matter if I fail the most basic test of healing. Is that what I want? Is that what I'm choosing?

I'm torn between what I love and what could do the most good. I truly enjoy working with my patients—not just the medical details, but getting to know each person in a way that allows me to understand him or her. And I also enjoy the camaraderie of working as a team, and not only learning from your seniors but, in turn, imparting knowledge to others. And yet, medicine at a distance from one-to-one healing can ultimately effect more change. Research and studies can drive the innovations by which future patients are healed en masse.

Fortunately, medical knowledge has no shortage of applications—in science, business, politics, academics, government. Dr. Sanjay Gupta, trained as a surgeon, now works as an international medical correspondent, exposing and explaining health issues for CNN, a forum so global he reportedly turned down the chance to be U.S. surgeon general. Dr. Bill Frist from Tennessee was a practicing cardiac surgeon who then won a seat in the U.S. Senate. I may not love his politics, but I do like the idea of bringing a medical perspective to public policy. Even my own hiatus from medical training for a degree in public administration was driven by a desire to broaden the application and impact of healthcare knowledge. Men and women trained as doctors employing their medical knowledge in different, unusual, far-reaching ways. That's intriguing to me. Is that what I want?

As clichéd as it sounds, I still don't know what I'll be…what my calling is, what subspecialty best suits me. And I seem to be surrounded by people who do know.

I stare at the waves, lie in the sun, and weigh my life choices….

On my plane ride home, I'm trying to enjoy a little nap on board when I hear a thud from the back of the plane. I wish I could just not open my eyes, but I can't help it. Down the aisle, there's a man on the floor, not moving, and a flight attendant hovering over him. I get up and tell the attendant I'm a doctor. The man is a thirty-nine-year-old South American male, an architect, apparently, who'd been heading to the bathroom when he passed out. Now he's awake, confused but semialert. I ask a passenger to vacate a nearby seat and put the man through a cursory neurologic exam, take his vitals, and ask some questions. He has no medical history consistent with the incident—no fainting spells, no chest pain or palpitations, nor is he a diabetic with low blood sugar. He is dehydrated and didn't get much sleep the night before, but these symptoms could be cold- or flu-related. He does not appear to have an infection. The pilot comes back to assess the situation, and I tell him I don't think there's a need to divert the plane but it would be a good idea to have an EMS crew waiting when we land. I go back to my seat, and by then, we're ready to descend. Mentally, I feel as if I'm already back at work. Maybe I never left.

Veteran doctors will tell you that once you choose medicine, you're never away from it. The reality is that it is always there, waiting for you.

Postvacation, it's the first week of March, and I'm headed to Bayview for my second echo rotation.

Echo at Bayview is similar to echo at Hopkins downtown, but there are some key differences. As a smaller hospital with fewer echo studies to interpret, Bayview has only one Fellow per each attending. With the right attending, this can be a great opportunity; with a bad attending, the rotation can be a little painful. I get lucky and draw Dr. Benjamin, an outstanding attending. Dr. Benjamin is in his late thirties, which makes him young for the position. He's in only his third or fourth year as a faculty member, and he did his cardiology fellowship at Hopkins so he knows exactly what I'm going through. He's a work-hard, play-hard guy like me; unlike me, he plays club rugby, and his boxlike shape is built for the rough game. I'm content to stay away from the scrum, but I like his stories. I get a kick out of the visual contradiction: He has the body of a wrestler but the brain of a professor. He's equally at home quoting from Chevy Chase movies or listening to Snoop Dogg while he explores the intricacies of transesophageal echocardiograms. Dr. Benjamin is a total cardiologist, with time in the echo lab, plus time in the CICU as an attending and time as a clinician—but what most interests me about him is that even though he has established himself, in some ways he is still deciding which area he wants to concentrate on or whether he even wants to settle in one area. He's not convinced he'll be a Hopkins “lifer,” and regularly mentions how he wants to know what it would be like to practice in a different setting, with different responsibilities and facing different challenges. He brings an unusual perspective to the career choice issue: He's doing what he loves now, but he embraces change in an evolutionary and growth sense, regarding his career as the journey, in motion, rather than set and jelled. It's an intriguing and appealing approach. One more way for me to think about what's next.

For the upcoming two weeks, I will be working alongside Dr. Benjamin on two different kinds of echoes. The TTE, or transthoracic echo, is the standard echo, where gel is put on a patient's chest and then a technician moves the probe around to capture images of the heart. The TEE, or transesophageal echo, is a more invasive echo in which a probe goes into the patient's mouth, down into his or her esophagus, and right behind the heart. These ultrasound images are as close to the heart as you can get without being in it, and although the procedure is more complicated, it can yield more information. The TEE is used when we're worried about an infected heart valve; or a blood clot in one of the chambers; or a “patent foramen ovale,” which is a particular kind of connection that exists between the left and right atrium. Essentially, the TEE is a more invasive look for certain kinds of potential problems. Downtown, first-year Fellows don't do them.

But Dr. Benjamin has an almost immediate trust in me, and on my second day, he casually asks if I've performed a TEE before. Even though my response is “Well, not exactly,” he keeps going: “You'll be fine. You're good at this stuff.” Being asked to assist in doing a TEE without experience is like being thrown in the pool and told you know how to swim; but I can sense that Dr. Benjamin is testing me, and I don't want to pass up the opportunity.

Before we do the TEE, we need to prep the patient with a description of the procedure. My job is to explain what we're going to do, why we're going to do it, how long it will take, and answer any questions the patient might have. The goal is to have an honest discussion about this procedure, but without making it sound like an outtake from a horror film. (I've heard a few prep talks that sounded like a scene from
Friday the 13th.
) I review the risks and benefits, and have the patient or family member sign the informed-consent document for the formal go-ahead.

The patient is Mr. Barlow, a seventy-two-year-old with a litany of heart issues. Today, we're looking to see whether he has any evidence of a blood clot in one of his heart chambers, the left atrium. Although the transesophageal echocardiogram is an invasive procedure, it is made easier by the fact that patients aren't fully awake—they're in conscious sedation, or a “twilight” state. The procedure starts with a series of IV infusions: First, there's Versed, the brand name for midazolam, a sedative in the benzodiazepine class. Then comes fentanyl, an IV opioid narcotic, both a pain and sedating medicine. The two drugs are complementary, making people sleepy enough that they won't be anxious and won't remember much about the procedure itself.

As Mr. Barlow is about to go under, we insert a bite guard with a ring into his mouth. We also spray the back of his mouth with lidocaine, an oral anesthetic, so that the probe will feel less uncomfortable. Inserting the probe is the most difficult part of the TEE: It has to pass into the mouth, through the ring, and down the back of the throat, before it dips down into the esophagus, a tricky path of bends, curves, and nerves and home of the gag reflex. And then I, for the first time in my life, pass the probe. Before inserting the scope, I yell the patient's name to make sure he's asleep: “Mr. Barlow! Mr. Barlow!!” No response, aside from his deep, relaxed breathing. I put the scope in.

I've heard that sometimes, no matter how much lidocaine you put on the back of the throat, no matter how sleepy the patient, the gag reflex is so conditioned, you may never overcome the patient's resistance and get the probe through. And I know if I don't get it on the first or second try, Dr. Benjamin will step in. (Later in the rotation, I see that sometimes even he encounters the gag problem.) But I don't want that to happen on my first TEE. Once I've maneuvered the probe into the patient's throat, there's the central challenge of getting all the views needed, at all the depths and angles. If I don't get them all, again, Dr. Benjamin will have to step in.

I snake the long, thin probe down Mr. Barlow's throat, taking pictures at different angles and depths, guided step-by-step by Dr. Benjamin's calming instructions. At first, it feels strange to operate from the other end of the probe. Dr. Benjamin coaches me through each maneuver, and I move slowly and steadily, following his cues. My hands are on the scope, but there is a sense of security in knowing that he could take over if something goes wrong. Fortunately, nothing does, and Dr. Benjamin never needs to step in.

Once the probe is removed, Mr. Barlow slowly awakens as the sedation wears off, and while we write the report. Even that's different than at Hopkins downtown. There, I viewed the scans on the computer screen and wrote the report in the small, dark room. Here, I performed the procedure myself and saw the results in real time. I'm viewing and mentally writing the report as the test occurs. And perhaps the most impactful difference is that I've been made to feel as if I have real responsibility here. Granted, it's a responsibility overseen by Dr. Benjamin, but I've been given the chance to “do” rather than just “see.” I'm accountable. The patient is in my hands. This difference alone makes the rotation considerably more meaningful.

Over the next few days, Dr. Benjamin has me do transesophageal echoes on a regular basis. Working with him makes echo exciting, and it helps me understand echo's important role as the forward line of troops/observation for other doctors. We look for blood clots in the chambers of the heart, because a clot in the left atrium means that a cardioversion (an attempt to get the heart back into normal rhythm) can send the clot traveling up the arterial highway and cause a stroke. We check for infected heart valves, something you can't always see easily on a transthoracic echo—you need to be as close to the heart as possible to clearly visualize certain valves. When we're not doing transesophageals, we're in the echo lab (listening to Dr. Benjamin's rap music), going through the studies together. This is a rare opportunity to learn. There are thirty to forty transthoracic echoes done at the hospital by the techs each day but only two or three transesophageals, at most. And he trusts me to do them.

I didn't think I'd be saying this after my first echo rotation, but my second echo rotation is truly exciting. From first reading in the morning, to getting TEE consents, to doing them, it is one of the most impactful experiences of my fellowship. And it's all about the contrast: bedside versus textbook, hands-on versus hands-off, patients versus pictures. This rotation is healing. In the largest sense, to me, this is medicine.

One TEE is particularly memorable, to put it mildly. Garrett is a young utility lineman, burned during what was supposed to be a routine job. He now lies in the burn intensive care unit, with third-degree burns on more than 50 percent of his face, chest, and arms. I've never seen anything like it, frankly, almost monstrous. He's attached to a breathing machine, and because of the damage to his skin (normally a protective barrier between our bodies and the outside world, keeping infections and toxins out), he's now fighting major issues with infection. The ICU doctors need us to determine whether Garrett has an infected heart valve. They also need any evidence we can find of heart failure, because on top of everything else, related or not to his burns, he is now experiencing low blood pressure.

First, we have to get permission from Garrett's family. This is one of those medical situations where each procedure is only one small piece in the patient's total, complex, multilayered condition and care. Even so, the family's first question is, “Is this test going to get him better?” This is a difficult question to answer. Tests don't make people better. If he gets better, it will be over time, with myriad treatments for the myriad interrelated consequences of his body's burns. The real answer to the family's question is that doing the TEE won't make him better, but failing to look for an infected heart valve could kill him. Instead, I reply, “Checking his heart valve is a necessary step in treating Garrett's overall condition so that he can begin the healing process….” The family gives us the go.

The indelible imprint from this experience is the human one. We doctors are sometimes expected to act as emotionless scientists. Examine, probe, go in, do your procedure, get the information, operate, implant, remove, medicate, write in the chart, send the patient home, see the next one….But sometimes, on a purely human level, a patient's condition is just so sad, awful, and unfair—and we feel it as much as anyone. This poor man looks like a horrific casualty of war, and his physical pain is palpable. It hurts to see his family see his pain. And now we have to shove a probe down his throat. As I pass the probe, I try to get a sense as to whether I'm causing Garrett any additional discomfort, but it's impossible to know. Everything about his current appearance screams discomfort. He's sedated, on a breathing machine, with burns that make him appear as fragile as any patient I've ever met. Move by move, we get the pictures we need, as gently as possible, trying not to disturb him. Thankfully, the test shows that there's no valve infection. But the Hippocratic oath's implicit dictum does run through my mind as I do the test. “Do no harm.” Are we following it or violating it? It's a wrenching case for me and even for veterans such as Dr. Benjamin.

Some aspects of medicine are exercises of skill; some, of mind; a few, of both. The real crux of medical acumen is often the combination of the test results and the action—what you know and what you do with it. The attending can point to where you need work, to what will make you more adept at performing a test or at reading it, or to a technique or tip, or even back to an early classroom lesson. Your job is to go where he or she points and do it.