Alpha Docs

Alpha Docs
is a work of nonfiction. Some names and identifying details have been changed.

Copyright © 2014 by Daniel Muñoz and James M. Dale

All rights reserved.

Published in the United States by Random House, an imprint and division of Penguin Random House LLC, New York.

R
ANDOM
H
OUSE
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OUSE
colophon are registered trademarks of Penguin Random House LLC.

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Muñoz, Daniel, author.

Alpha docs : the making of a cardiologist / Daniel Muñoz, M.D., and James M. Dale.

p. ; cm.

ISBN 978-1-4000-6887-6 (alk. paper) — ISBN 978-1-58836-953-6 (eBook)

I. Dale, James M., author. II. Title.

[DNLM: 1. Muñoz, Daniel. 2. Johns Hopkins Cardiovascular Fellows Training Program. 3. Cardiology—education—Maryland—Personal Narratives. 4. Fellowships and Scholarships—Maryland—Personal Narratives. 5. Internship and Residency—Maryland—Personal Narratives. WG 18]

RC682

616.1'20023—dc23

2014043542

eBook ISBN 9781588369536

www.atrandom.com

Book design by Christopher M. Zucker, adapted for eBook

Cover design: Rachel Ake

Cover photograph: © Tetra Images/Offset.com

v4.1

ep

The stories depicted in this book are based on, or derived from, real-world medical situations. In order to protect the privacy of patients and families, names, personal and medical details, and other identifying characteristics have been changed. The names of attending doctors have been changed to the first or middle names of U.S. presidents. Other medical personnel names and details have also been changed.

East Baltimore in July, and the temperature and humidity are an identical, unbearable ninety-eight. It wasn't raining, but walking one block left you soaked. I walked three. That was my route within the invisible Johns Hopkins safety zone, the world's biomed fortress, surrounded by lead-painted welfare housing and occasional crack dens. By the time I stepped into the outpatient entrance, my shirt was like a second skin. A blast of AC turns the perspiration to a chill as I enter the underground tunnel that leads to the main hospital, content to be out of the heat for the next thirty hours. Nothing about this night seems different from any of the others I've spent as the internal medicine resident on the cardiac intensive care unit (CICU) rotation—but then, life-changing moments rarely come with advance warning.

In the CICU, the attending doctor leads the team—a cardiology Fellow and a small squad of residents that includes me—through rounds, patient by patient, checking charts and meds. The attending fires questions like the lightning round of a game show; we spit back answers and then move on to the next bed. When we finish, the attending glances outside, through a window steamed with sweat, and casually says, “This is the kind of weather that can kill people.”

He's right. Not far from the hospital, at 6:00 p.m., a man named Randy is walking through Patterson Park in East Baltimore. In the daytime, Patterson is still just a park, full of kids on bicycles, joggers, and softball teams. But a few hours later, darkness transforms it into an open-air drug market, where people such as Randy can buy a small packet of coke, their little nightly jolt. Out of a job and with nowhere else to be, Randy lights a cigarette and waits for night to fall.

Randy is thirty-nine, but an overweight, dissipated thirty-nine. Even the short walk from the southeast corner of the park to the crisscross at its center has exhausted him. He sits down on a splintered green bench and waits for the fatigue to go away, but it doesn't. His chest feels strangely heavy, as if something were sitting on his rib cage. Even when Randy stretches out on the bench, the unfamiliar pressure refuses to let up.

An old woman walks by, a park regular who pushes a stroller filled with empty bottles and cans, but no baby. Seeing Randy, she stops and asks, “You okay?” He doesn't answer. “You need help?” He tries to shake his head, but it won't move. The woman starts to walk away, then turns back. “Want me to call an ambulance?” Hearing Randy's faintly whispered “Yeah,” the elderly lady fishes a flip phone out of her collection of bottles and cans, and dials 911.

When the EMTs find Randy on the bench, they ask him his age, name, and pain level; check his vital signs; then roll him onto a gurney and into the ambulance. After putting an oxygen mask on Randy and hooking him up to an IV, the medics phone ahead to Johns Hopkins with the data: time, 6:47 p.m.; thirty-nine-year-old male with substernal chest pain; 10 out of 10 on pain scale; nauseous; likely MI (myocardial infarction) according to the electrocardiogram (EKG) in the ambulance, eight to ten minutes from the emergency room (ER).

The call from ambulance to hospital is a trigger, alerting each of the appropriate hospital care units to be ready. Even though Randy is a heavy-smoking, obese, habitual drug user without a job, having a life-threatening emergency in the locale of East Baltimore means one thing: He is headed to Johns Hopkins, one of the top-ranked hospitals in the United States. Unlucky Randy has lucked out on this one thing.

The Hopkins ER—a contradiction of rusty steam pipes and chirping digital monitors—has a bed slot ready. By the time the ambulance team bashes the swinging doors open with the gurney, another team is waiting for the handoff. An ER nurse hooks Randy up to the twelve leads (sensors) for the EKG, which will measure the rhythm and strength of his heartbeat. Another nurse draws blood to check whether elevated enzyme and protein levels are leaking into Randy's bloodstream. Definitive lab results will take ninety minutes—minutes that Randy doesn't have. The nurses give Randy aspirin, slip a nitroglycerin tablet under his tongue, and connect his IV to a cocktail of morphine and heparin, to help the pain and thin his blood. Meanwhile, Randy pants. He can't seem to catch his breath. The weight on his chest is relentless.

The attending emergency room doctor and his resident read the jagged lines on Randy's EKG, looking for “STEMI,” an elevation in the ST segment of the EKG that indicates MI. Although Randy's EKG is ambiguous, it is abnormal enough to kick off a series of rehearsed responses: The STEMI code is sent to the pagers carried by both the cardiac catheterization team and the cardiac intensive care unit doctors, and the EKG printout is faxed up to my team in the CICU on the fifth floor. My CICU Fellow and I each see the EKG and draw the likely conclusion: This heart tissue may be dying. This is a significant moment for me: Perhaps for the first time, I think I know what this is. And I know what to do. With no time to waste on extra conversation, he says, “Let's make sure,” and nods toward the portable echocardiogram—the ultrasound machine. As I roll it into the elevator, I barely have time to register the significance of my personal moment of clarity.

After navigating a service elevator and three hallways, we arrive at Randy's bedside, to find his breathing even more labored. The pressure on his chest has increased from a box of bricks to a small elephant. Randy is in visible distress, and he is scared: “Doc, am I having a heart attack?” I look over at the CICU Fellow, who is so intent on the echo images that he doesn't seem to hear Randy. For now, all I can do is give Randy safe but impossible-to-follow advice: “Try to relax.”

The evidence from the echocardiogram is undeniable. The anterior wall of his heart is barely moving, indicating that it is not getting enough blood. And if his heart wall is dying, then Randy might be next. Already his color is gone, his breathing shallower. We have, at most, two minutes to make our assessment. It takes seconds: One look and two nods, and the CICU Fellow gives the order: “Get him to the cath lab.”

The head ER nurse asks Randy whom to notify of his condition. He mumbles, “Nobody.” They put hospital forms in front of him, and he signs. That small act of signing his name was exhausting. “Am I gonna be all right?” he asks as his bed is wheeled onto the elevator to the catheterization lab.

The cath lab looks like “the future” in a science fiction movie: a blindingly bright, antiseptic, totally silent chamber. The CICU Fellow and I watch from a control room, shielded from the radiation that the fluoroscopic imaging generates. The cath team preps Randy and begins to snake a catheter into his femoral artery. The lab is kept at a constant sixty-eight degrees, but we can see that Randy, terrified and in pain, is soaked in perspiration.

Randy, covered in sterile drapes and monitoring equipment, is awake throughout, as the catheter travels into the femoral artery, against the tide of blood flow, into the iliac artery, up the aorta, past the aortic arch, to the juncture at the aortic valve where the arteries branch off the aorta to feed the heart. The team then injects a dye into the catheter to locate the occlusion. A camera registers the strong flow of the dye until it hits a blockage in Randy's left anterior descending artery (LAD). The width of the flow goes from a drinking straw to a strand of thread. This miniature dam, less than a centimeter in length, is why Randy is here.

The team snakes in the angioplasty line, a second catheter that remains small and flat until it reaches the critical spot, at which point it is inflated like a balloon to stretch open the blocked artery. After inflating the angioplasty line, the cath team injects more dye, this time to see if blood can flow through the opened section. For a moment, everyone holds their breath. Then the dye rushes through, followed by essential blood, nutrients, and oxygen. Seconds later, Randy relaxes and lets out a sigh of relief so immense that it seems to hover in the air. The elephant has rolled off his chest.

What Randy does not know is that the balloon is a temporary fix. He isn't out of the woods yet. A third catheter containing a stent (a small hollow cage, collapsed for transport) must be inserted and maneuvered to the spot opened by the balloon, then deployed to keep the artery open. The CICU Fellow and I track the video fluoroscopy as the dye is reshot through the catheter in what seems like slow motion, waiting to see if the stent worked, if the dye and the blood can now flow through. Practice and statistics say they will, but problems—misplacement, misreading, a tear, the unknown—can still arise. Two seconds. Randy could still re-occlude his LAD. He could still end up with severe heart damage. Three seconds. He could still die. Four seconds…

At last, the dye flows through. There is a moment when the cath team, the CICU Fellow, and I all collectively exhale. No one, no matter how experienced, treats this as routine.

Now that Randy is in the clear, the team snaps back into action: It's time to clean up and get out. The three catheters are removed, but the sheath in Randy's groin remains in order to prevent his thinned blood from bleeding out. Randy is smiling as he is rolled out of the cath lab, down several corridors, and into a room in the cardiac intensive care unit. A team of nurses hooks him up to monitors and checks his vital signs. I tell him to try to relax, knowing that, this time, it isn't impossible-to-follow advice.

Leaving Randy, I grab a quick cup of coffee and sit alone, taking the opportunity to gather my thoughts. It is 8:25 p.m. Everything from the EMT report through to the procedure and Randy's return to the CICU has happened in less than two hours. A thirty-nine-year-old, overweight, smoking, drug-using male had a heart attack. We had saved his life, at least for the moment. And I was part of it.

I stared at my hands, wondering what, ultimately, I would do with them. My education, my experience, my instincts, had played a critical role in saving a patient, but, at the same time, at a crucial moment, I had been an observer, behind the glass, watching others carry out the life-changing procedure. What did I want to do? Which side of the glass did I want to be on? Once again, I was faced with my recurring career multiple-choice test, starting with the serious options: (a) an internist, (b) a pulmonologist, (c) an oncologist, (d) a cardiologist. Usually, as the right answer eluded me, I would wander into the less serious: (e) a fireman, (f) a baseball player, or (g) an astronaut. But that night, as I thought back to how I'd watched the cath team at work, I could feel the answer beginning to form.

I returned to check on Randy. Now that he was in the CICU after successful emergency stenting, the challenge was to keep him healthy, hopefully for years, but critically for tonight. The heart doctors would start him on medications—a beta-blocker, blood thinners to inhibit clot-prone platelets from forming new blockages—a diet, a light exercise regimen, and a schedule of checkups.

Randy, still shaken by what had happened, promised to do exactly as we said. I asked questions about his life—parents, marriage, children. When he said he was married but it didn't work, he had a little girl but didn't see her, he had lost touch with family…it made me pause. Randy was alone, a drug user, a guy living on the fringe who had come in off the streets, and by the mere geography of where he had his heart incident, a fluke. Or was he? The more I probed, the more I realized how normal Randy was. He had traveled, done odd jobs as a cook, as a bartender, and on a fishing boat. He liked to listen to Orioles games on the radio, even though they almost never won. “They're bad. I love 'em 'cause they're bad.” Randy was just another guy, with ups and downs and experiences that made him unique but hardly extraordinary.

Randy had his quirks. So did the sheiks, CEOs, politicians, and well-heeled royalty who often checked into Johns Hopkins. Whether they had wives or husbands or children or jobs or fame or drug habits, they all had bodies and flawed organs and hearts that could stop beating. It was chance that had brought Randy to Johns Hopkins, where he was able to get the best treatment available in the world.

For Randy, the night had been life-changing. It was also life-changing for me. I knew where I wanted to be: not watching but doing, on the side of the glass where I can help shape a patient's fate. I would be a cardiologist. I wasn't thinking about where I'd train or how long or under whom. I knew I was choosing a demanding path. But I knew I wanted to be a heart doctor.

Every year in the U.S., approximately 800,000 people die of cardiovascular-related disease. 720,000 have a heart attack; 620,000 for the first time and 295,000 recurrent. All told, an astonishing one-quarter of all Americans—over 80,000,000 people—live with or die from some form of cardiovascular disease.

—American Heart Association, December 2013

Then there are the heart doctors. According to “The Match” (The National Resident Matching Program), the official body that links doctors to training programs, a little over thirty thousand doctors apply for specialty residencies—pediatrics, radiology, neurology, general surgery, or internal medicine—each year. Only twenty-four thousand are chosen to be residents. In my year, of the sixty-five hundred residents who applied for an internal medicine subspecialty fellowship—gastroenterology, clinical oncology, hematology, cardiovascular disease—roughly forty-five hundred made the cut. In cardiology, one of the most selective subspecialties, success is often 50 percent at best. And at the most elite cardiology programs—Hopkins, Harvard, Columbia, Duke, Cleveland Clinic, Mayo Clinic, UCSF, Penn, and a few others—the odds are still tougher.

The Johns Hopkins Cardiovascular Disease Training Fellowship Program receives five hundred to seven hundred impeccably credentialed, impressive applications from all parts of the world, but only nine are “ranked to match.” Only nine will receive training from some of the most brilliant, demanding cardiac practitioners and professors in the world.