Alpha Docs (5 page)

Dr. Franklin recognizes the challenge of getting through to Mr. Gardner. Before laying out the plan for prevention, Dr. Franklin takes an interesting tack. “Mr. Gardner, you're an active, successful guy. That's great. But I worry, not about how you feel now, but about the risk of a heart attack or a stroke. And I want to do everything we can to avoid either of those two scenarios. It's in our power to do so, but only if you acknowledge the importance of prevention and the serious consequences of failing to engage in it. A heart attack would sideline you from many of the things you enjoy doing. Your family history suggests you're at risk. We can't control your genes, so let's focus on the things we
can
control.”

Mr. Gardner is, for the first time, quiet and appears to be listening.

Dr. Franklin then lays out a plan: diet, exercise, medication, and regular monitoring. This is serious treatment for a serious problem. For a moment, it looks as if the patient gets it. But then he jokes, “I should pass this advice on to my brother and bill him for it.” Mr. Gardner knows what to do, and he has the means and the support system to do it. But will he start the regimen to change his life? Or will he put it off “until it's really a problem,” when he's on a gurney with EMTs hovering over him? This is my biggest issue with preventive medicine: Because it aims to be routinely proactive, it is far too easy for patients from all walks of life to ignore.

No matter how often he repeats the same conversations, it's clear that Dr. Franklin isn't bored by this routine. Preventive cardiology is the most important thing in the world to him, and after spending two weeks by his side, I find that some of his enthusiasm has rubbed off on me. Though it delivers essentially the same lessons to twenty different people a day, preventive is all about the ripple effect. If more doctors help more patients change their behavior, then little by little, these incremental changes can accomplish a lot. Twenty patients a day, year in and year out, and all for the hope that one day, you will read that the average person is living to be eighty-five instead of eighty-two. This is Dr. Franklin's purpose in life. It's why he writes books and makes speeches, raises money, wants to win over Fellows, and tries to get every patient to make at least some progress. But is it for me?

Dr. Franklin helps people every single day, and he is both a compassionate cardiologist and a practitioner of such skill that he makes it look effortless. But gross tracking of populations, trends, and life expectancy means that it is hard to ascribe success to any single treatment or factor. And he's battling not a disease, but risk: an unpredictable, resilient enemy that constantly fights back, and will surge forward in one area even when he defeats it in another. In an instant, it can attack and sabotage years of good effort. By definition, you can only reduce risk but not fully eliminate it. You can't win. Have you then failed? Have you lost a life? Or is success simply holding off the inevitable for as long as possible?

In medicine, heroic procedures that defy death for the moment gain more attention than steady, behavior-changing routines. A clinical cardiologist tests for and diagnoses heart disease in order to prescribe medication that will relieve debilitating symptoms. In the process, she may slow the disease and save a life. An interventional cardiologist puts in a stent and opens an artery, thereby perhaps staving off a coronary incident. Again, he may save a life. Practicing preventive medicine is the opposite of the dramatic interventions that you see on television. Instead, the goal is to keep these scenes from ever happening and stall death for years, even decades. But how do preventive cardiologists know when they've made a difference?

I've finished my third rotation, but I am still unsure whether preventive is for me. Could I see the same case with a different name over and over again without getting bored? Would I get frustrated wondering whether each patient was hearing my exhortations but choosing to ignore them? Would the big-picture successes be enough reward for the daily battles against beer and nachos?

Heart failure and heart transplantation. The title alone sounds like the stuff of action movies. The hero's heart stops. He's put on life support. A clock ticks as the camera cuts to hotshot doctors ducking under the blades of a helicopter, racing to the gory accident scene. A beating heart is harvested from a clinically dead donor, put “on ice” in an Igloo cooler, and handed off to surgeons who place the heart in the patient. The music swells as the surgeons disconnect the hero from life support, and…the heart beats! Fade to black.

That scenario does happen, but not quite like that. While it is true that the harvesting process must be done quickly to keep the donor heart healthy, the reality is more tedious and bureaucratic. There must be documented donor approval for removal, plus lab tests to verify the condition of the heart and the blood type. Nor is it done by cardiovascular disease Fellows such as me. Heart transplants are performed by cardiovascular surgeons, and the procedures are almost always meticulously planned, carefully executed, with no Hollywood special effects or music.

As cardiologists, not cardiac surgeons, we deal with the patient's heart failure while he or she waits for a transplant. It is our job to keep the patient as healthy as we can, essentially acting as a pit crew for the body. If the transplant is a success, we manage the patient after surgery, keeping him or her alive and well. Our part can be exhilarating—definitely life or death—but no one makes movies about us.

For me, this four-week rotation is a 180-degree transition from trying to head off heart disease in preventive cardiology to trying to reverse heart disease that is already running rampant. Heart failure is not the same as a heart attack. It is a physical state of disease in which the heart muscle is literally failing or dying. Heart failure can be caused by reduced blood supply to the heart muscle, a buildup of blockages in blood flow through the arteries, high blood pressure, deterioration of one or more of the heart valves, or failure of the heart muscle itself. It can be treated with medication and lifestyle changes, and sometimes with surgical intervention such as stent implantation and advanced heart-pump placement. When all else fails, it can mean a heart transplant. In essence, the rotation boils down to one thing: The patients' hearts are unable to keep their bodies adequately perfused with the nutrients they need to stay alive.

I picture what I'll face: patients far sicker than any I saw as a med student or resident, patients whose congestive heart failure no longer responds to medication and who are now flirting with death. Either they are suffering from an acute issue that we're trying to fix without recourse to a heart transplant, they're vying or waiting for a transplant, or they've already had a transplant but have developed a complication.

Given the gravity of what we're about to do, I was prepared for a structured indoctrination: “Today you are about to embark on the most perilous endeavor in your cardiovascular education….” But there is no indoctrination. Instead, I walk into the hospital at 7:30 a.m., just like every other day in fellowship. Still, I want my own take on who's who and what they have before making rounds with the attending. I head up to the CICU (cardiac intensive care unit) and meet patient after patient: “Good morning, Mrs. Carson, I'm Dr. Muñoz. No, Dr. Smith [the last Fellow] is no longer on this rotation. You've been in the CICU since [check date] with severe breathing problems and [check notes for details]…” I don't have to do this, and I'm not doing it to earn points. I am doing it because it's my nature to be neurotic and detail-oriented—and often, the extra time spent turns out to be justified.

Another reason for this extra preparation is that this rotation is a crash course in what, until now, we have studied only in an academic setting—the effects of chronic immunosuppression. The immune system is supposed to keep you alive by detecting anything alien in your body—pollen, smog, bacteria, viruses, infection, disease, parasites, poison, or an organ that doesn't belong to you—and rejecting it. If we can suppress the immune system with medication, we can fool the body into accepting an alien liver, kidney, or heart, but, in the process, we leave the body vulnerable to every other kind of attack. Without the normal defenses, something as minor as a sniffle in an elevator or germs from a grandchild can turn into a cold. That cold can become a lung infection, which creates respiratory failure, which builds up fluid that strains the new heart and puts the patient in imminent danger. And it happens every day in hospitals across the country. Pneumonia, flu, diarrhea, or that sniffle can ultimately kill a person whose immune system is down. And hospitals are full of sick people. So even when immunosuppressed patients are shielded from the outside world, their proximity to other patients can endanger them.

Fortunately, there's a cadre of talented doctors who have devoted their lives to studying how to dial the immune system up or down for the maximum effect, to trick the body while putting the patient at minimum risk. After the transplanted organ gets past the new host body's initial resistance, and if it is fully accepted into the body, the immunosuppressants are gradually, but never totally, dialed down, which allows the patient's body to build up resistance to infection and disease. In the meantime, the patient is kept in as safe an environment as possible. But reality rarely plays by the book. The dialing up and down of the immune system seems as much guesswork as science. As a result, chronic immunosuppression is a constant, precarious balancing act between organ rejection and disease invasion.

The attending is Dr. James, whose list of degrees, credentials, and papers makes him a heavy hitter even by Hopkins's standards. Once a West Coast surfer type, he is a longtime Hopkins veteran, with rimless glasses, longish gray hair, and no tie. Above all, he is unflappable. As we make rounds, it becomes clear that Dr. James can get a little bored with the simple cases and often gravitates toward the more exotic. If a patient's heart failure is a result of not taking prescribed medications, Dr. James gives a one-line summary and moves on. But if the case is more challenging, he becomes more thoughtful, takes a longer look at the chart, asks more questions, and turns to me for my thoughts. His training approach is executive style: I trust you. Give me the details that matter. What do you think we should do?

The patients in the CICU range from the very sick but not in imminent danger, to the very sick and in danger but temporarily fixable, to the gravely sick who need a heart soon, to those too sick to get a heart, plus several who change overnight from one category to another. This means constantly weighing two possible conclusions: Is the patient progressing enough to eventually go home, or, if not, could he or she be a candidate for more advanced therapies, such as a transplant? The reality is that it's rare for a patient to check in to the CICU, immediately get placed on a transplant list, and then get whisked away to the OR (operating room). This happens only when the patient's decline is so precipitous that he or she cannot go home but still meets the criteria for a transplant, if a compatible heart can be found fast. More often, patients are put on the transplant list and then go home to wait…and hope they live long enough for the call: “Come in. Your new heart is here.” A patient could spend months, even years, on the list, with deteriorating odds; a good candidate at the beginning can sometimes become a weak candidate later.

A transplant is not just another operation. It means mobilizing vast resources, people, talents, rooms, equipment, commitments, and finances. The hospital wants all operations to be equally successful, but some operations—transplants—are more equal than others. Though there are approximately three thousand patients on the national heart transplant wait list each year, only about two thousand hearts become available annually, most often from victims of injuries that have left the heart unscathed. As a result, the wait time on the list varies greatly, from fifty days to well over five hundred. It's brutal but simple math. Hundreds of candidates each year never receive a heart.

But sizing up patients for transplants is about more than just the obvious factors, such as blood type. Having someone else's heart placed inside of you is a major undertaking for both your body and your mind. The heart, unlike almost any other organ, carries symbolic overtones that are impossible to ignore: Your heart is your essence, your emotional center. Even the smallest details, both objective and subjective—patient history, illnesses, genetics, habits, foibles, fears—may affect the fate of a transplant. How will you react to having someone else's essence in you? Will you think or act differently? Are you not only physically but psychologically prepared for a second chance, a new life? On a very practical level, will you take the immunosuppressant medications that will fend off organ rejection and thus keep you alive? The surgery is physically brutal and exhausting; the recovery, long and draining. If the mind cannot help the body, the ordeal will be all but impossible. It's up to the mind not only to make the emotional adjustment but to then be the conscience that ensures the body takes its anti-rejection medicines and shows up at appointments and doesn't play Russian roulette with its new organ. Even after a patient receives a transplant, it is still our responsibility to do the post-transplant biopsies to make sure that the heart tissue remains healthy. This means spending time in the cath lab, looking for evidence of rejection on a cellular level. The resounding lesson of heart failure and heart transplantation is that every single detail, from the patients' mood to their cell tissue, matters.

Still, the extraordinary becomes the ordinary fast. What scares the hell out of you on Monday is a day's work by Wednesday. It's not that we take things for granted; we just become less intimidated and more conditioned about what to expect. Patient after patient comes in with congestive heart failure, and we do temporary fixes—diet adjustments such as salt reduction, diuretics to get rid of fluid buildup, blood pressure medications, ACE inhibitors (which lower arteriolar, or small artery, resistance), beta-blockers to relax the heart and fend off arrhythmias.

We see a youngish grandfather who has come in for his routine “oil change”: His fluid retention needs to be flushed out with IV medication. His blood pressure is up; he's short of breath and needs rest. We decide to monitor him until he's out of the danger zone, and with luck, we'll be able to send him home. Another patient has been referred to us by a semirural hospital in the northern suburbs. The doctors there saw a weak heart and some kidney failure—beyond what they felt they could handle—and sent him to us. Is he a candidate for a transplant? We'll see.

Deciding whether a patient is a candidate for a heart transplant is a very human decision on one level, but a very cold and calculated one on another. If the key metrics—age, weight, organ function, test scores, levels, and readings—don't make sense, you cannot responsibly go forward. There just aren't enough donor hearts, and adding someone to the list when the key metrics aren't auspicious means that another candidate might never get the transplant that he or she needs, and possibly deserves, more. One example of this is Mrs. Rabinovich, an overweight, mildly diabetic fifty-six-year-old. She is a former weekend jock and a breast cancer survivor, but she has also had numerous myocardial infarctions and is now in severe congestive heart failure. Is she a candidate? As a cancer survivor, she is resilient and there is a chance that she would be able to survive, and thrive, with a new heart. Although she is stable for the moment, the reality is she's still facing a limited, sedentary life, breathing hard just walking across the room. On the other hand, neither her diabetes nor her weight (things within her control) are well-managed, perhaps signaling that she is not yet ready to take the necessary responsibility for a new organ. As often is the case, it's a judgment call.

The Friday of my first week, we see Mr. Bundy, a returning patient who is gaining weight and whose fondness for overindulgence is loading his body with salt, resulting in fluid retention. This kind of case may bore Dr. James, but since I'm new to the field, it interests me. Mr. Bundy is breathing hard, almost gasping for air when I ask him to stand up at the side of his bed. His blood pressure is unacceptably high, and he's scared. I can't help but wonder what made him think he could go beer for beer with his nephews. Did it slip his mind that he has a bad heart? Judging from his wife's glares, they've already had this conversation. He stares at the floor and says, “Can you hook me up to that IV medicine, doctor, and get this fluid out of me? Usually, eighty milligrams of IV Lasix works for me….” Our goal is to stabilize him, to see if he takes a turn for the better (unlikely) or for the worse (more likely). In the meantime, he remains a viable candidate for a heart transplant. Over the next twenty-four hours, Mr. Bundy responds to the medication and his body rallies. Three days later, we are able to send him home.

Another case is that of Ms. Francis. In her midforties, she is in excellent physical shape and seems too young, too lean, and too healthy to be in a cardiac care unit. A weekend athlete and the full-time CFO of a construction company, she's managed to achieve gender equality in a male-dominated field: an impressive testament to her will and force of character. Ms. Francis also has bad genes on both sides of her family: Her mother died young, her father has severe coronary artery disease, both sets of grandparents had heart issues, and she survived a heart attack less than a year ago. Last week she had fevers and cold symptoms. She got steadily worse, developing a case of viral myocarditis, an inflammation of the heart muscle that can result in heart muscle function deteriorating rapidly, sometimes within days, and was now at death's door in the cardiac intensive care unit. Given her deterioration, Ms. Francis undergoes an expedited evaluation. Dr. James and our team review and rereview her chart, her vitals, and most important, the human factor, Ms. Francis herself. I weigh in. Together we perform our best assessment of her outcome. Dr. James makes the call. She will be recommended to go on the heart transplant list.