Alpha Docs (15 page)

Right now the prognosis for Richie, or someone in Richie's situation, is “good” with an asterisk. He'll see his clinical cardiologist frequently at first, then four times a year, then twice a year. He'll live on immunosuppressant medications for the rest of his life. He'll invariably have bouts of jeopardy as Cliff had. The asterisk is how we measure “good.” Unfortunately, compared to normal male life expectancy, the rest of Richie's life is an actuarial estimate. About 85 to 88 percent of transplant patients live a year or more; 76 to 79 percent live at least three years; 67 to 72 percent live at least five years. And the longevity is improving. Male transplants tend to live longer than females. According to the numbers, Richie has a reasonable chance of long-term survival. As of this writing, the longest-surviving transplant patients include: Tony Huesman (over thirty years, ultimately dying of cancer), John McCarthy (thirty-one years), and Lizzy Craze (thirty-plus years). Kelly Perkins, who survived nineteen years, climbed Mount Kilimanjaro six years after her transplant. Dwight Kroening, a twenty-two-year survivor, finished the Ironman competition. (Dwight's luck also held as he ran the 2013 Boston Marathon but a leg injury kept him from the finish line to miss the bombing.) These patients have all come a long way since Dr. Christiaan Barnard performed the first transplant, in 1967. His patient lived eighteen days, a miracle at the time. Richie's prognosis is good, with an asterisk, but the footnote is changing in his favor.

Two weeks and a day after arriving at Johns Hopkins Hospital, Richie and his new heart were sent home. Richie's case—one of heart failure's “yes” cases—was a medical rarity. It was a learning experience for me, and one I was lucky enough to see all the way through. But for every uplifting case, there are always a few that foment cynicism.

Around the time we're all crossing our fingers for Richie, in walks Zelda. “Zel” is sixty-three and has a long history of cardiac issues. She has smoked for most of her life, and has poorly controlled high blood pressure plus high cholesterol: the full spectrum of coronary risk factors. No surprise, she's had several heart attacks, each one damaging a little more heart muscle, leaving her with a severe case of congestive heart failure due to coronary artery disease. Even though Zel had a bypass, as well as stents, her heart continued its progressive decline, even with an oxygen tank and lots of meds to keep her going. But Zel managed to quit smoking a few years ago, because she needed a transplant, and not smoking is a cardinal rule: Smokers don't get new hearts, just as drinkers don't get new livers.

Over the next six to nine months, Zel was monitored closely by her cardiologist, referred to Hopkins for a formal transplant evaluation, and put on the transplant list. Like Richie, Zel had a favorable blood type, so the wait wasn't excessive. After she received a new heart, her story appeared to have a happy ending. A patient with bad coronary artery disease and multiple heart attacks, largely due to a self-abusive lifestyle, finds cardiac religion and gets a lifesaving operation.

Not quite.

A lot can go wrong with a transplant, even with a patient who has made significant life changes. The body can reject the heart, develop infection, or die. That's why getting on the list is so selective and so specific. But human nature still throws this process for a loop: We cannot factor in the idea that, with some people, things can go
too
well. If the transplant is a success, the patient feels much better. The symptoms of heart failure—shortness of breath, edema, swelling, abdominal girth, nausea, overall fatigue, inability to lie flat, inability to walk across a room—all tend to go away. And when people feel healthy, they start to think there's nothing wrong with them. They think they're “all better.” But they're not. As one of the other Fellows said, “Give some people a new heart and it affects their brain. They get ‘cardiac amnesia.' ”

And according to what I glean from Zel's chart and computer records, she has developed a very serious case of cardiac amnesia. Bit by bit, she reverted to her old bad behavior. She missed appointments with the transplant team and didn't reschedule them. She was lax about taking her immunosuppressant medication. Amazingly, she even started smoking again. A new heart, with a new set of coronary arteries, tends to develop disease faster than the arteries in the original heart. And that's without smoking. When you throw in a pack of Marlboros a day, coronary artery disease is off and running. And nothing the doctors say seems to deter Zel.

I call Dr. Dwight and say, “We have this lady who's a mess, a transplant six years ago, congestive heart failure, off her meds, no recent biopsies….”

He sighs. “Yeah, I know her.”

“What tactics have you tried? What do you think would be helpful?” I ask.

His voice is resigned. “We've tried everything. This is what she does.”

Ten years after being diagnosed with heart disease, Zel has gone from a textbook success to a case study in regression. She's still alive six years after her transplant. On paper, her case looks like a testament to Hopkins's quality of care, an outcome that boosts our reputation. But along the way, she has probably consumed millions of dollars in healthcare resources, far beyond what her insurance covers. And worst of all, she has taken someone else's healthy heart, and, whether she sees it this way or not, has flagrantly mistreated it.

To be fair, Zel isn't a mean person. She's tough but sweet, loves her pickup truck, and cracks crude jokes. But it's hard to find her attitude—“What heart condition?”—funny or charming. She treats the hospitals and the doctors like her personal pit crew. When she breaks down, she rolls in and the experts check her vitals, stick tubes in her, take the tubes out, then put her back on the road, so she can do damage to herself all over again. Meanwhile, someone such as Cliff has a heart attack at thirty-nine, takes his meds, exercises, shows up early for his appointments, and may not live as long as Zel due to the inevitable complications that can arise from being chronically immunosuppressed on antirejection medications.

We put Zel on a regular cardiac floor. I examine her. When I listen to her lungs, I hear a crackly sound in the lower lung fields. That's fluid, or pulmonary edema. If you have fluid overload, when you lie flat, it can be uncomfortable and cause a labored breathing noise. Fluid that collects in the body takes the paths of least resistance—to the legs, the soft tissue, the lungs, the belly, wherever it can reside. Zel has it in three or four places. I also look at the veins in her neck. They are visibly bulging, a sign of increased pressure, which means that her congested heart is working too hard. And to make the situation even worse, Zel ran out of her medications two weeks ago—medications designed to keep the fluid abated and her heart from overworking—but she hadn't bothered to refill her prescriptions.

I probe: “How did you run out of medications?” (It's not hard to count. There are only so many days' worth in a bottle.) She shrugs. “I just did.” I persist: “When you were running low, how come you didn't get a refill?” Another shrug. “I just didn't think about it.”

With the medicines we have in the hospital, it's relatively easy to get the excess fluid out. We put an IV in and pump her full of diuretics. Right away, Zel starts to feel better because she's dumping liters of excess fluid each day, by urinating it out. It's exiting her legs, her belly, and her lungs. She's not as achy, she's carrying less weight, and she can breathe more fully. She feels better, which is double-edged. For the twentieth or fiftieth or hundredth time, she thinks she's all better. Which means she can go do the things that will send her back here. Of course, she swears this time she gets it. This time she's going to take care of herself. This time…

On her last day at Hopkins, I give her a version of the “Life or Death” speech. Though it's likely an exercise in futility, I make my last-ditch effort. Despite all Zel's self-destructive behavior, I want to believe that I can get through to her. “What you're doing to yourself is going to kill you. It's not a matter of if, it's just when,” I tell her. “And you have to stop smoking. If you want to live, you'll quit. It's up to you.”

Dr. Dwight is less impassioned and more realistic than I am. Patients such as Zel are one of the reasons doctors such as him don't get starry-eyed about transplants. He's seen the good ones and the bad ones. He even empathizes with her: It's human to want to believe you're fixed. It's human to deny reality. Dr. Dwight doesn't condone her attitude. But, as a realist, he knows that this can happen. He, and now I, have witnessed the injustice in the Ms. Zels who seem to have nine, unearned lives while there are people such as Cliff and Richie who cling to theirs.

Dr. Dwight's tempered demeanor befits the field of heart transplantation. And, I realize, maybe mine does not. Transplantation offers hope. But it does not do the impossible. Even when it can overcome human physical flaws, it cannot overcome human nature. For me, I know it would be hard to keep making an emotional investment in people who don't want to invest in themselves. The fear of dying, the chance at a new organ, the screening process itself, may motivate patients to change their bad behavior. But all the fear, all the promise, and all the screening panels and teams of multidisciplinary experts cannot predict when the change is temporary, when the patient will miss appointments, fail to take medication, and take a new heart and a new life for granted. But it's hardly black-and-white; for every Zel who flouts the rules, there's a Cliff who does everything he can to save his own life. My goal is to help people who want help. Maybe I am asking too much.

Though the rotation order is random, sometimes the timing works in our favor. My previous high-adrenaline rotation is followed by the technically complex, but otherwise low-key, echocardiography. And the next two weeks lead into my vacation, coming at the end of a calendar year that has been intense. (You don't realize how draining rotations are until they're over and you still feel the impact.)

Echo is decompression. There are no minimum or prescribed requirements. How many echoes you read and how involved you are in the lab depends on you, your personal degree of interest, whether you plan to make this your career or not. You have to be present to help supervise stress tests, and to read some studies each day, but the expectations are largely self-set.

I arrive at 8:30 in the morning, get a double espresso to stay awake, and head into the echo lab. It's filled with computer screens and operates in relatively real time, meaning the studies are done by technicians at the patient's bedside, or elsewhere in the hospital, or remotely at a clinic, and the images are electronically beamed to our station. The lab is small and windowless, a distinct contrast to dealing directly with real patients in the bright white light of the CICU, or heart transplants, or the outpatient preventive clinic. Going from a bedside with sick patients—worried families, life-and-death situations—to staring at magnified images with a little pointer requires something of an adjustment. The reading is a daytime activity, with routine studies done as they come in, unless bumped by an urgent or emergency study (such as in the medical or cardiac intensive care unit or the emergency room). To me, echo resembles a slow-motion videogame: I read the echoes, then an attending reads them, and the reports become final a few hours after they come in.

Each echo is a picture, or series of pictures, of the heart created by high-frequency sound waves that bounce off solid objects but pass through liquid and soft tissue. Just as with any kind of ultrasound, gel is put on the patient's chest, and then a probe is moved over the area to give several different perspectives. The result is a moving image of the heart and the valves within. It's incredible technology and can reveal a lot: the size of the heart chambers, the thickness of the walls, whether the heart muscle is working properly. But to the uninitiated, an echo is just a series of fuzzy snapshots of pulsating body parts.

The echo attending, Dr. Millard, is a gentle woman in her midforties who reads scans all day. An expert spirited away from a renowned midwestern medical center, Dr. Millard has dedicated her life to echo. She also has what we call “a brevity aversion,” meaning that she never answers a question in less than fifteen minutes. My orientation alone takes almost an hour, far more than needed, but a testament to Dr. Millard's being so invested in making this rotation as meaningful as possible.

After the intro, Dr. Millard has me reading studies right away. I go through them one at a time, very slowly. The stakes are low and the pace is regular: We read, we interpret, we report. If I'm unsure, I hit Replay, or adjust the brightness or pixel detail, and rerun it. Whether I take five minutes per study or an hour, it doesn't seem to matter. As the Fellow in the lab, I have time. It's pretty isolating, so I have to leave the echo lab occasionally to talk to someone outside the room, on another floor, or at the coffee shop, or to visit the bathroom to get rid of the coffee, or to go anywhere but the lab to return to planet earth.

On some rotations, the Fellow takes on a good deal of the workload from the attending. Not true in echo. Whatever I read, an attending also reads. I compare what the attending saw with my reading on every study. The final report is the attending's, not mine. I learn by observing how a read by one person becomes a group consensus.

In the beginning, it takes me a full hour to complete each study—to look at all the images from every angle before I can offer a preliminary assessment. That same prelim report that takes me an hour takes an attending six or seven minutes. My first reports are essentially extra work for the attendings, who have to read, comment on, and correct my work in order to lead me to the right observations and interpretations. I try not to interrupt the attendings with too many questions, because their first priority is to plow through the studies and get timely, accurate reports out. I put what I conclude into objective data for the report, plugging it into a template that prevents you from getting too verbose. There's even a Commentary drop-down menu so you don't have to write out “Aortic valve is without stenosis.” Instead, you click the “No aortic stenosis” option. Although the automation is handy, it reinforces for me why this rotation is more like a technology app than patient care.

Toward the end of the day, Dr. Millard will usually volunteer input. The attendings on this rotation often make use of the “shit sandwich”: compliments on the outside, criticism inside. “Dan, on this echo, you got these aspects [pointing to the images] totally right. I just wanted to talk to you about this aspect [pointing to another image], which I interpret a little differently….Except for that, you did a good job interpreting the study.” When I'm wrong, Dr. Millard takes me through the images and instructs me on how to discern and measure, how to see what she sees.

In the middle of week one, I read what appears to be a straightforward result, a measurement called the “ejection fraction.” The ejection fraction reflects the efficiency of the squeeze of the left ventricle, and for a healthy heart, a 60 to 65 percent ejection fraction is normal. It can be higher in states of hypercontractility (excessive cardiac wall motion occurring, for example, in a septic or dehydrated patient), or lower in cases of heart failure or after a heart attack, as low as 5 or 10 percent. The estimate of the squeeze of the left ventricle is based on different pictures, different cross sections, and images that show the left ventricle contracting. My prelim report on this particular patient's study is 45 percent. Dr. Millard thinks it's more like 55 to 60 percent. I'm not way off, but I'm off compared to the veteran, which is a useful lesson in why my report is the preliminary one, and an incentive for me to review the images. This is a visual assessment, not done by a device that measures the percentages. There are some quantitative tricks of the trade, but no perfect measure. As long as you're in the same ballpark, it's fine.

It's a stress-free rotation, because even when you're corrected, the focus is on learning. The environment is more collegial and academic than other rotations. However, each review tends to be short, and for good reason. Attendings spend thirty seconds or so on any single clarification because they have to keep pace with sixty or seventy studies a day—a report every seven minutes—and they cannot leave any unread at the end of the day. The bean counters who keep the hospital in black ink would likely come down hard on unread studies.

The volume of studies, and the pressure to get them out quickly, are good medicine. High-quality, timely reports lead to faster, better treatment. But logic says there's an economic factor too. Echo exists primarily to serve Hopkins patients, Hopkins clinics, and Hopkins doctors. However, on certain occasions, we get studies sent from other hospitals; more volume, more pressure, but also more revenue. The number of doctors a hospital maintains to read echoes is a clear sign to referring doctors, patients, and the medical community at large that the hospital is a thriving cardiac center, with commensurate revenue streams. It's simple: Much of what we do in medicine loses money. Echoes bring in money.

But, when you're the Fellow, a rotation such as echo gives you downtime—that is, time to think. I find myself wondering about cases from past rotations. I go into the EMR (electronic medical record) and look at patients' lab reports. I seek out another Fellow, now on heart failure, and ask how Cliff is doing. I ask another if he's seen Malcolm.

Sometimes I walk over to the CICU if I have a few minutes to see which of the patients I might know. When you go into someone else's rotation territory, you're careful not to intrude, not to offer advice or input, just get an update. We don't know enough about what went on before we saw that patient, and what will come after. We try to extrapolate in snapshots backward and forward, but we don't see the whole picture. In spite of that, we try to make decisions not only about patients but about ourselves and our futures based on these limited exposures: I'm going to be a heart failure doctor because I thrive on the intensity…or, rather, the intensity I experienced for my particular four weeks. I'm not going into electrophysiology because EP is technical and detached…at least during my few weeks of it. I like continuity clinic. I don't like nuclear. I'm interested in interventional. A monthlong rotation is fellowship's maximum length of time to attempt to focus, concentrate, and minimize interruption. We do care about the patients. We get attached. We root for them. But we don't usually know what happens in the long run. We've gone on to the next rotation. Most doctors in training come to accept it. Some even opt for specialties virtually cut off from direct patient care, such as nuclear or echo, marketable skills but not patient-interactive. That works for some doctors, but not for me. I want to be good enough at these areas to know what I know and what I don't, when to bring in the wizards. I'm not sure yet exactly what I'll choose as my area, but it's clear to me that I want to be at the bedside.

By the end of the rotation, I can read ten to twelve echoes a day, and I'm starting to pick up the subtleties. My attendings are complimentary, but not over-the-top. They tell me that I'm mastering the skills, but the reality is that I'm simply less of a novice than I was two weeks ago. I say goodbye to Dr. Millard, and express my gratitude for her teaching. She says it was her pleasure, which takes a long time, but I'm not impatient. I close out the screens on my computer. Tomorrow I leave for Costa Rica—my first break from training in almost a year.