Alpha Docs (9 page)

I call Mrs. Werdna and tell her that it would be good for us to meet tomorrow: It is time for us to deliver our verdict. We could keep her husband alive attached to life support, but there is virtually nothing we can do to change his neurologic fate or make him better. Some families ask, “Does this mean he'd be hooked up forever?” We say, “Yes.” And they often say, “He wouldn't want that.” This leads to a discussion of withdrawal of care (i.e., ventilator). And because some people die not in seconds or minutes, but in hours or days following that step, I want the family to fully understand the situation. I also ask Dr. Young, a second-year resident from Hopkins who is on-call that night, to attend the meetings as well. I want the family and friends to recognize her as a familiar face. If Mr. Werdna should die on her watch, in the middle of the night, that 1:00 a.m. phone call shouldn't come from a total stranger.

Unlike our last meeting, this one has no rehearsal. We arrange ourselves around Mrs. Werdna, with Dr. Martin and the nurse sitting opposite her and her neighbors. Dr. Young sits at one end of the table, and I sit at the other. I summarize our earlier talk and then say, “Now, I've got to tell you that we don't have good news.” I pause, just as Dr. Martin did, to let this sink in. Whenever he says something highly consequential, he stops to allow people to digest and process it. He knows that nothing we say in the next ten seconds will be heard, not after that. I wait, then go on. “Despite everything we have done to support and comfort your husband, to take the best care of him we know how, whatever brought this on has caused a severe injury to his brain.” That's a lot to absorb—despite support, comfort, care, injury to his brain. Again, I wait for Mrs. Werdna's recognition and continue. “With the help of our neurology doctors—the brain specialists—and with our own experience, we can tell you that his brain is not going to get better…ever.” Mrs. Werdna is teary but does not break down. I try to channel Dr. Martin by holding Mrs. Werdna's hand as I go on. “One thing I can assure you is you are all in far greater pain than anything Mr. Werdna is experiencing right now. He is not in pain. He's not suffering.” Dr. Martin is there, and although I have appropriated his speech almost verbatim, he is fine with it. The unspoken message is: This is what I teach. It works. Take it; use it.

Through her tears, Mrs. Werdna says, “I want you all to know how much I appreciate everything you've done.” She pauses, then says, “I understand he's not going to get better.” Her neighbors nod. She asks, “What am I supposed to do?” She literally does not know what to do. Who does? Who has had experience with such things? Neither she nor I have ever been in this circumstance before. Despite my calm demeanor, I'm still struggling to respond when Dr. Martin says, “I agree with everything Dr. Muñoz has said. We are heartbroken and terribly sorry that you are dealing with this, that your husband has gotten sick in a way that he's not going to get better…that he's never going to wake up.” That last phrase, “never going to wake up,” gives finality to the scene. It's no longer when or maybe or probably; it's “never.” And “wake up” is the perfect, most empathic way to express this because it evokes sleeping rather than death. It is an easier image to deal with. “As Dr. Muñoz said, he isn't suffering, doesn't feel pain. The part of him that made him who he was, that was your husband for all those years, that man is gone. That part of him is in a better place now.” I know that I don't have enough lines in my face to pull off the phrase “in a better place now.” But Dr. Martin has invoked it to imply that Mrs. Werdna's husband has moved on, and now she can too. His words also free her from guilt, in case she's not in the room at the moment he dies. Even though his heart is beating, he's already gone. Dr. Martin has broken terrible news to Mrs. Werdna, given her permission to let go of her husband, and to do so without guilt, with simple and heartfelt phrases.

Where is the line between hope and hopeless? It's blurred. The moment of profound change is clear only in retrospect, if then. After twenty-four hours? Forty-eight? Three months? Our job is not just about administering medicine; it's also about managing expectations and treating the patient and the family, enabling them to accept the end. Some parts of the world make it simpler, empowering someone at a hospital to say, “It's over.” But that's not the way we do it here, at least right now. We do it case by case, doctor by doctor. And not all doctors are Dr. Martin.

When families can't let go, technology can prolong the demise of a loved one at staggering emotional and financial costs. We possess the scientific ability to keep someone alive. But the cost of maintaining a person in that state indefinitely is in the millions, to say nothing of the emotional costs. Sometimes families choose to do so for reasons of denial, or religious beliefs, or misunderstanding, or simply because they feel they have no right to “kill” someone who is alive, even if only artificially. And there isn't a lot we can do to stop it. That's why Dr. Martin is so impressive. He doesn't take away the family's prerogatives, nor does he fuel false hopes. He presents reality in a way that enables them to let go.

Dr. Martin then lays out the process for Mrs. Werdna. “Everything will happen at your pace and timing. Now that we know he's not going to wake up, we can disconnect some of the machines to create a more peaceful place, a little less beeping and buzzing. We can leave the room and you can visit with him by yourself, at peace. Some families prefer a day or two….” It's clear that Mrs. Werdna is beginning to grasp the reality of her situation and accept the outcome. Nodding slowly, she says, “Doctor, you said he's not going to wake up. I trust you. We don't need any more time. I don't want to drag it out. I just want him to be comfortable.” She turns to the neighbors. They all nod in agreement. She asks for a few moments alone with her husband, then says she'd like a chaplain to come in for a prayer. Then she thanks us again. We step into the hall. I notice that the resident, Dr. Young, is teary. She turns to me. “That was the most incredible family meeting I've ever seen. How do you guys know how to do that?” I shake my head. The fact is, I learned most of what I know in the last three days from watching Dr. Martin.

Our next step is to remove the life-support machinery. We have the staff shut down most of the scientific “noise”—the alarms and monitors—around Mr. Werdna and take the breathing tube out so he'll look more familiar to his wife. The only equipment we leave is an EKG, because it will tell us when his heart stops beating. The staff also remakes the bed with a fresh blanket and pillows. The formality and the lack of medical clutter often help families say goodbye with dignity.

Mr. Werdna's heart stops beating about fifteen minutes after care is formally withdrawn. The ICU nurse is the first to know it via the monitor at her station. She alerts me and the resident and asks me to pronounce him. Technically, Mr. Werdna isn't dead until I have listened to his heart for a minute to ensure that there are no extra beats, watched him not breathe, and then written a confirming note in the chart. To me, these steps seem nonsensical, especially now, when the patient is unquestionably dead. I'm supposed to put a stethoscope on his chest as if I were listening for something that obviously isn't there, which is cruel, since the families will reflexively hope for the impossible. A family member might ask with a tone of confusion and irrational hope, “What do you hear? What are you listening for?” I see Mrs. Werdna sitting right there, next to the bed, and I decide to sidestep the macabre ritual. I don't touch the body or examine it. Instead, I look at the monitor at the station, see the flat line, then look at the EKG strip to confirm that it too is flat. The resident is watching when I pronounce Mr. Werdna officially dead: “He has passed. Time of death, 2:17 p.m.” Sometimes, following a protocol is not the right thing to do. Dead is dead. Worry about the living, the family. To me, this was the better way to do it.

One case. One doctor. One career moment. But these moments are something you have to keep in perspective. They're rare. You can't let the big moments overshadow everyday doctor work, or you'll compromise your ability to deal with the average crisis. The CICU is full of serious cases, but we're supposed to treat them all with the same gravity. The reality is, you have only so much emotional capacity. If a daughter says, “My father is light-headed,” you may think, “He'll be fine; it's probably nothing.” But it's not fine or nothing to her or her father. You have to resist your own reflexes. It's our job to separate these special moments from the everyday, but it's counterintuitive.

You can't walk out of a powerful end-of-life encounter and into the CICU to a patient who is sick, but not at death's door, and treat her in an offhand or casual way: This is what I tell myself as I walk in to see a sixty-two-year-old woman with heart failure due to valvular disease. What she has is not immediately life-threatening, but she's scared. We can medicate her and she'll be okay. But she doesn't know that. She thinks she could die. I talk. I explain. I listen. I read her signals. Am I getting through the way Dr. Martin did or even the way I did with Mrs. Werdna?

Throughout the next two weeks, I consciously invoke my mantra “Move on to the next patient. Focus. Move on to the next. Focus….” I want to treat all of these cases as important, not just the out-of-the-ordinary ones. But there's the community hospital challenge of case mix. Plenty of people in the Bayview CICU (despite its name—cardiac
intensive care
unit) just aren't that sick. You can move patients out of the unit once they're ready for a regular medical floor, but you can't control the inflow, the ones the ER doctors put there “just in case.” Hence the occasional Fellow's crack, “Just saw a guy in the unit who's in better shape than I am.” During the last week of the rotation, I see seven to ten patients a day, all told about forty-five patients. Two get stents. Two have open-heart procedures. Six are transferred to floors where they belong. Two die in the unit. Some are still there when I leave. I'm being a cardiologist—the day-to-day routine of practicing.

When I am away from the hospital, I try to put it in perspective, a hierarchy of what's most important, what's less so. I can never do it when I'm there. I run in the mornings and have conversations in my head. Did I handle that case right? Did the resident? What would I do differently next time?

On Friday, the final day of the rotation, Dr. Martin stops me in the hall for an end-of-rotation talk. He asks, “How do you think things have gone these last two weeks?” I don't answer quickly, remembering how he uses waiting to make sure to say the right thing. “Dr. Martin, I'm not a sunshine blower or a yes-man, but I want to tell you that I really appreciate your approach….” I detail what I've learned, how his methods and style of communication made the rotation more significant, how it all made me a better Fellow, and how I want to challenge myself further as a result. When I finish, he's surprisingly effusive: “Dan, you get it. You understand the complexity. You're going to be very good with people. In fact, you already are.” He goes on, “The house staff likes working with you, and you're well respected.” Then he offers, “If there's anything I can do to help you in your career, I want to do it.” Medical training doesn't have many moments such as this. Usually, it's all classrooms, labs, clinics, charts, patients, and treatments—and being congratulated by one of the greatest teachers I've met so far is a meaningful moment for me.

This rotation opened my mind about Bayview and about drawing conclusions in general—both thanks to Dr. Martin. Here's a physician who had world-class training and who then chose to practice at Bayview. And he practices very good medicine here. Just when I had all my prejudiced notions about how the branch office couldn't measure up to the “real Hopkins” neatly in place, I end up having probably my best rotation experience. Lesson: Don't make a diagnosis until you get all the information. I'll carry it with me.

Another lesson I will take with me is the experience of latitude Dr. Martin gave me in managing the team—teaching, directing residents and nurses, laying out patient assessments, treatment plans, family communication. On rounds, at the end of each resident presentation, he'd invite me to lead: “Dr. Muñoz, what would you like to do here?” He was always supportive. If he did add something substantive, he'd low-key it—“And you might consider this…”—never taking credit. It was as if I were the attending, except I had a great attending to back me up. To turn the cliché around, I was performing with a net, a very good net.

This is also the first rotation that has given me a hint of the kind of work concentration I might want long-term. I like CICU challenges, the pace, the range of cases, the doctor-patient interaction, not just scans and readouts but doctor to patient, plus the element of teaching. Is this a glimpse of my future? We'll see.

Another rotation finished, another one beginning. Last Friday, I was deep into the human side of cardiology—people with heart problems. Today, I'm back in the tech world, starting a rotation in EP—electrophysiology. It's one of the sharpest contrasts in the fellowship, exceeded only by following consults (all about patients) with nuclear (all about pictures).

EP is the electrical study of the heart—in the vernacular, doctor as electrician. Commonly, you see an electrophysiologist for a pacemaker or defibrillator, but there's considerably more to it. The heart is a muscle, but it's also a highly choreographed electrical symphony, sending out impulses, which, when unsteady, cause short circuits. If there's any heart rhythm disturbance—an irregular electrical signal that causes symptoms or potential danger—it often requires evaluation by an EP (electrophysiologist).

The parameters of an arrhythmia (abnormal rhythm) are expansive. There are two clinical subsets: “bradyarrhythmias” and “tachyarrhythmias.” Bradyarrhythmia, or bradycardia, is a heartbeat that is slow, sixty beats per minute or less, usually because of blocking of electrical impulses in the heart's conduction system—simply put, wiring gone bad. There are trained Olympic athletes or some young, very fit people who have very slow resting heart rates. But in an ordinary person, if the rate falls below fifty beats per minute, symptoms such as fainting, shortness of breath, dizziness, light-headedness, chest discomfort, palpitations, and possibly death can occur.

Tachyarrhythmia, or tachycardia, is a heartbeat that is inappropriately fast, usually over one hundred beats per minute in an adult. If the heart rhythm is too rapid, it means the heart is in overdrive, working unsustainably hard. The heart may not have enough time to fill during ventricular relaxation (that is, the time span between contractions) and may pump an inadequate amount of blood to the brain or body. In certain vulnerable patients with little to no reserve, the immediate result can be serious: hypotension (low blood pressure) and a dangerous compromise in perfusion of vital organs (that is, delivery of sufficient flow to feed and support the organs, particularly the brain). The eventual result can be worse: organ failure or death. The job of the electrophysiologist is to identify and determine which of those heart rhythms is relevant and potentially dangerous, and what needs to be done.

Of all the rotations, this one feels the most foreign to me, the most daunting, because the people who typically do EP have intimidating intelligence. EP doctors tend to be electrical engineering majors, the type who never left their dorm rooms and whose senior theses had brilliant, incomprehensible titles. EPs have to be part physicist, part engineer, part biologist, part wizard, and able to integrate all of those roles. Plenty of cardiologists, if they're honest, would likely admit to not comprehending the pure science behind electrophysiology. And at this point in my training, my exposure to the management of funky heart rhythms has been modest—the term
funky
itself a dead giveaway.

Fortunately, in electrophysiology, you have a lot of bosses. Instead of one principal supervising attending for the entire rotation, you have one per week, over four weeks. Part of my job as a first-year Fellow is to carry the EP consult pager, which means that I will be acting as the first line of contact. A typical call on the EP-1 pager could be an issue with a patient on another service (hospital department) who has a pacemaker and the team wants to know if it's working properly. Simple, straightforward stuff. Except that I don't know what is or isn't working right, even though it is my job to try to decipher what the heart rhythm is, what I think needs to be done, and then hand the case off to a senior EP Fellow or the EP attending. It strikes me as perversely funny that when other doctors anywhere in the hospital have an EP-related question, they will call me—like giving a kid those plastic airplane captain's wings and saying, “Go fly the plane.” I have nothing to qualify me except my official EP-1 pager.

My first EP consult call comes in at 10:00 a.m., when the resident on one of the medicine service teams leaves me a message: “We admitted this guy overnight with an abnormally slow heart rhythm. We've got to know, does he need a pacemaker?” This is exactly the kind of scenario I feared: A doctor is asking something I know precious little about, and it's important. So I do what any prudent person would. I call the resident and say, “I'm happy to see the patient. Thanks for the consult. Get back to you shortly,” which is code for “I don't know yet, but I will.” In other words, I stall.

I'm not worried about coming up with the right answer. There are places I can look: textbooks, journals, published guidelines. There are people I can ask: the EP experts. I'm concerned about sending a message of uncertainty to the doctors and perhaps to the patient or the patient's family. And the best remedy for temporary ignorance is immediate diligence, to overdo the digging and learning, and get smart. Fortunately, my approach is possible because the pace of EP is generally measured and sane. My pager is not beeping like a broken car alarm. There's plenty of time to ask questions, review the medical literature on the subject, and ultimately confer with the attending. Whereas general cardiac consults can be a much faster-paced rotation, with less time available to “look it up” when you don't know the answer, the EP consult caseload tends to be slow and painstaking, like untangling marionette strings.

According to the chart, the patient is a seventy-seven-year-old man. My initial impression from the door is that he looks uncannily like Blue, the elderly frat member from the movie
Old School.
Our Mr. Blue lives in a little apartment complex, with neighbors and friends who look after him, but he's fairly independent for his age. He was brought to the hospital by an EMS (emergency medical service) team after a neighbor found him dizzy and light-headed, unable to get out of bed or walk without almost falling over. The ER doctors immediately noted that his heart rate was thirty-five rather than in the normal sixty to eighty range—and Mr. Blue was no Olympic decathlete. At his age, a heart rate of thirty-five could be a life-threatening emergency, but what matters most is whether his heart is generating enough perfusion. The way to find out is not that complicated: “Sir, how are you feeling?” If his only answer is a moan, it's a clear indication his brain is not being adequately perfused. If he can look you in the eye and says, “Doc, I'm fine. The ambulance brought me in because I haven't been feeling so hot,” that's a temporary confirmation that, for the moment, his brain is getting adequate blood flow.

Fortunately, the resident reports that Mr. Blue is able to converse. His blood pressure is okay, about 120 over 70. More important, he's awake, alert, and seems oriented to the place, time, and situation. He's passed the superficial tests. Nonetheless, somebody who's seventy-seven with a heart rate of thirty-five doesn't get sent home even if he is clinically perfusing. Instead, Mr. Blue is admitted to the cardiac step-down unit, which acts as an intermediary stage between a regular floor and the CICU. There, a first look at Mr. Blue's EKG reveals some amount of heart block, or in EP terms, a degree of “conduction abnormality between the top chambers and the bottom chambers.”

There are three basic degrees of heart block. First-degree block is less serious, and it will appear on the EKG as a prolonged interval between the first and second wave of the cardiac cycle: a delay that shouldn't be there but may cause no immediate harm. A lot of people live asymptomatically with first-degree heart block. Second-degree heart block is the fuzzy area, a slightly more abnormal conduction pattern, between the relatively benign first and highly threatening third degrees. Third-degree, or complete, heart block, is when the top chambers and the bottom chambers aren't coordinating activity. A patient in complete heart block will usually end up in the CICU, a wire placed through a catheter in the neck, floated down into the heart, to send electrical impulses to control the heart rate until a permanent pacemaker can be safely implanted.

It appears that Mr. Blue belongs to one of the subsets of second-degree heart block. Since he had a normal EKG at Hopkins a year prior, this situation is new and not good. And this is why the internal medicine team has asked for a consult on whether Mr. Blue needs a pacemaker.

Before I see Mr. Blue, I do a “chart biopsy,” which is an objective look inside the patient based on his or her total records—what's happened, what's been done, patient history, as well as the computer data on lab work and tests. I do it as a matter of practicality, a pattern I got into during cardiology consults. Walking in uninformed and asking the patient to tell me about himself would result in a conversation that could last for hours and never reveal what I need to know. The reality is that my task is not to hear a life journey, but instead to focus on developing an understanding of the patient's heart rhythm. Based on Mr. Blue's records, his bedside chart, and EKGs, I confirm that it looks to be a subset of second-degree heart block. At the nurses' station, I scan the monitors on all the patients, and see that, thanks mostly to the passage of time, Mr. Blue's heart rate is now forty, at least up from thirty-five.

When I walk in, Mr. Blue is lying in bed, a happy, smiling guy who has no idea why so many doctors are interested in him. I start off by introducing myself and asking some basic questions. “What brought you to the hospital?” He says, “Well, I felt a little funny at home, but now I feel better, and to tell you the truth, I don't know why I'm here.” I ask, “Is anything bothering you?” He answers almost before I finish. “Yup! I'm hungry.” In the med school course informally titled Figuring Out Fast Whether the Patient Is Sick, if the chief complaint is hunger, it's usually a good sign.

Then I start to ask more focused questions. Instead of asking “How long have you had health issues?” or “Has a doctor ever told you before that you have second-degree heart block?” I ask whether Mr. Blue has ever passed out before, and whether he often feels dizzy or light-headed. I ask direct questions about chest pain, shortness of breath, as symptom-based as possible. His answers are generally in the negative. He's independent and functional, able to walk a few blocks every day without the assistance of a walker or a cane. He's a content retired guy. But he does acknowledge that in the last two weeks, he's had a couple of episodes where, during mild exertion, walking upstairs or getting out of bed, he felt light-headed. The most pronounced episode was yesterday, the day he came in.

Coupling this with his heart rhythm, I begin to wonder if Mr. Blue has deteriorated to second-degree heart block in just the last three weeks. If that were the case, he might need a pacemaker, which would assure his heart rate wouldn't fall below a critical threshold (fifty beats per minute, for example), and he wouldn't get symptomatic again. But it's my first EP consult, in my first week of EP rotation, so I'm wary.

To qualify for a pacemaker, a patient must be diagnosed with a heart rhythm issue that is causing his or her symptoms and that has no underlying cause that we might be able to correct or reverse. In Mr. Blue's case, he has a heart rhythm issue, which is causing his symptoms and which doesn't seem to be something that we can quickly correct. I know that because I looked for other culprits—specifically, his medications. Mr. Blue is taking beta-blockers, which are prescribed to slow the heart rate and control the blood pressure. Too much beta-blocker and the heart can slow excessively. But this man has been on the same dosage of a beta-blocker for high blood pressure and coronary disease for years. The effects of a wrong dose would have declared themselves long ago. I check his liver and kidney function, because sometimes abnormal liver or kidney function can impact how the body metabolizes a beta-blocker, causing it to build up in the system and act like a higher dose than it is. But Mr. Blue's liver and kidney function are both fine.

Nonetheless, while he's in the hospital, we stop his beta-blocker in order to prevent his heart rate from slowing even further. I don't expect that decision will correct his heart rhythm and obviate the need for a pacemaker, but this is my first consult and I err on the side of exploring options before electing to implant the device.

That evening, I meet with the week's EP attending, Dr. Harry, and summarize the consult: “My sense is this is symptomatic bradycardia with second-degree heart block in the absence of a clearly reversible cause of that bradycardia. Because he is symptomatic, it's an indication for a pacemaker.” He nods, so I go on: “In the interim, we've held back his beta-blocker because his heart rate's thirty-five to forty.” Dr. Harry talks to the patient himself, then concludes, “I agree with your assessment, but let's give him a day or two more off his beta-blocker and see what happens.”

The next day when I walk in, Mr. Blue's heart rate is up to fifty, which is still low but considerably better. He remains hungry but otherwise has no complaints. The nurse takes him for a walk around the unit with a monitor on—no panting or wheezing, no pain—and he gets his heart rate up to the low seventies, which is very close to normal. When he lies down and is at rest, it dips back to the high forties to fifty, but still trending in the right direction. This puzzles me: Our only intervention so far has been stopping Mr. Blue's beta-blocker. Why is he getting better when we withhold a medication he's been taking for years? And if he
is
getting better, is he no longer a candidate for a pacemaker? It's good news, but it doesn't make physiologic sense, at least not to me.

My instincts say, do some medical detective work. It turns out the patient's neighbor, a nursing student, helps with his medications. I get her on the phone and tell her that one of Mr. Blue's medications may have caused a problem but we can't figure out why. Before I can get another sentence out, she says, “I'm glad you called, because I've been concerned about his medicines for a long time. I try to lay them out, keep them in order, but now he's less able to distinguish between the pills. I worry he gets confused, taking not enough of one, too much of another.” If her instincts are right, there's a real possibility that Mr. Blue's low heart rhythm was a response to accidentally taking too much of the beta-blocker.