Alpha Docs (18 page)

So far I haven't cathed with him, and I won't today because it's 5:30 p.m. Time to clean up, change my shirt, and make sure there are no coffee stains on my tie. This is a big night.

Tonight is Johns Hopkins Medical School graduation. Not only are degrees conferred, but awards are given to students and faculty, one of which is voted on by the graduating class. Across all specialties—surgery, medicine, pediatrics—the students select the resident who has contributed the most to their education. In February, during my consult month, I'd been notified it was me. I'm very flattered.

In contrast to my own graduation, instead of sitting with the 130 people about to walk across the stage, I'm one of the people on the stage, one row back from the CEO of Hopkins Medicine and right behind the commencement speaker, Dr. Denton Cooley, one of the deities of cardiac surgery. My parents insisted on coming for my ten seconds in the spotlight—unfortunately for them, sandwiched into the middle of the three-hour ceremony.

It was worth the entire evening to hear Dr. Cooley. “It feels like just yesterday that I was in your seats, graduating a mere sixty-five years ago.” The crowd laughed but got the message. He might be almost ninety, but he's as sharp as ever. His speech was fatherly and wise. Work earnestly and ignore the naysayers. He exhorts young doctors to do what they're passionate about, not just what's lucrative or the newest flavor. What makes the speech powerful is his passion, the passion he's maintained for over half a century. He leaves the graduates feeling that if they choose an easy path, he'll be personally disappointed. And you don't want to disappoint this legend who performed the first successful human heart transplant in the United States, and the first implantation of an artificial heart in the world, whose teams have performed more than one hundred thousand cardiac procedures (hence, the title of his memoir:
100,000 Hearts
), who has won every imaginable award, including the Presidential Medal of Freedom; and, not coincidentally, he graduated from the Johns Hopkins School of Medicine.

An hour into the evening, it was time for my award. The CEO of Hopkins Medicine made the announcement and shook my hand; the vice president handed me a framed certificate; and my parents were proud.

But the effect of Dr. Cooley's speech, on the night I received the award, was profound. This medical icon put it in perspective. You got a nice honor tonight. Keep at it and someday you might truly accomplish something. This award says that I do what I do pretty well. Dr. Cooley said, in effect, that it's just a start.

Back to cath for the home stretch—the final two weeks. Put simply, more caths, more practice, more hits, a few misses, more learning, more subtleties. As it turns out, I never had to cath with Dr. Rutherford. Maybe he didn't want to cath with me either.

Cath is over. All in all, I like it. Again, I have to say, I don't know if this is the one thing I want to do every day, forever. It scares me sometimes to think maybe that one thing doesn't exist. Maybe it won't have to be “one thing.” Maybe things I like, such as cath, can be in the mix. I don't have to check that box yet. But I will….

On weekends, you push the rotation “pause” button from Friday until Monday. Then, you either have two days off or you have “coverage,” meaning duty at one of the hospitals in the system, in one particular department.

In the middle of the cath rotation, I cover the Bayview CICU one weekend, and the experience turns out to be the equivalent of an entire rotation in forty-eight hours. Sometimes you can take in as much in two days as you do in two months.

Friday afternoon, I go to the Bayview CICU and get a sign-out—the list of seven patients and their conditions—from the Fellow heading out for the weekend. My job is to make sure those seven, plus whoever comes in the door, get through the next two days. Monday morning, I'll pass the baton to whichever Fellow is on.

The better part of that Saturday is routine, rounding with the residents in the morning, putting plans in place for the patients in the afternoon, and fielding new patients as they come in. Technically, I can leave at any time the pace allows, as long as I'm prepared to come back. This weekend, I end up never leaving.

For the first several hours, I stay just to get to know a new group of patients, and because the resident on that evening is the competent-but-nervous type, which concerns me. At about 9:30 p.m., I decide I can leave in another fifteen minutes. At 9:45 p.m., the resident gets a call about a patient that the ER wants to send up to the cardiac ICU. She gets off the phone and says, “It might be helpful if you came with me,” which means: “Don't leave.” On the way downstairs, she tells me about the patient: a sixty-six-year-old woman in the ER critical care bay who has a heart rate of thirty…barely life-sustaining. They had applied a temporary transcutaneous pacemaker to her chest to try to pace her heart faster, to get her blood pressure up. (When your heart rate is low, unless you've been training for cross-country, your blood pressure will also be low.) There are several reasons a sixty-six-year-old's heart rate could be thirty, but they are all bad.

Downstairs in the ER, lying in a bed, we see Bunny, a classic, hard-living, beer-drinking, beehived “Hon”—what the locals call certain other locals, born and bred in Baltimore, often with big hair and a heavy accent. Next to her is her identical twin sister—same hair, same accent. Bunny is pale as a ghost, awake but confused, disoriented, and irritated—and, she says, exhausted.

Behind a curtain in the bay, I coax a coherent story out of her with some help from her sister. In the past two days, she's gone from feeling like her old self to feeling as if she were carrying the weight of the world, and nothing relieves it. On her Saturday errands, she can normally walk the two blocks to the grocery store, carrying her bags or pushing them in a cart. But today she couldn't even get herself down the stairs to the door. Realizing something is wrong, she calls an ambulance, and when they arrive, with her heart rate of thirty, conscious but woozy, she offers the patient go-to description, “I feel crappy.”

Now we have to find out what's going on and why. Is it a heart attack? Is it from medicine she's taking, perhaps in excess? Is it more mysterious? In a purely academic sense, this is a beautiful medical case (as in the art of solving a medical mystery). There are four challenges ahead of us. First, get Bunny out of the emergency room. Nothing good happens in the ER after thirty minutes. ER doctors are conditioned to be at their best right now—fight the fire, defuse the bomb, jerk the shoulder back into the socket, pound the chest, pull the tongue out of the throat, in the moment, but that moment rarely lasts more than thirty minutes. After that, unless the patient is threatening to die, the ER docs move to the next disaster. The second challenge is to make sure Bunny is stabilized. She has various devices attached: EKG leads on her chest, as well as pacing pads, one on the front, one on her back, all of which are keeping her heart rate steady. She isn't getting big shocks from a defibrillator but rather minijolts every second to get her heart rate to sixty instead of thirty. She's paced; that is, she has blood pressure…for now. The third challenge is to make sure Bunny has the attention of doctors, in a monitored setting, because she is clearly sick for reasons we don't yet understand.

That leaves the big challenge, figuring out the “why.” I have never faced this exact type of case before, but I have now had an almost yearlong crash course in seeing people who have something wrong with their hearts and unraveling the mystery. You develop a detective's instinct and methodology—a deductive process to go through the algorithms and arrive at initial conclusions, remain calm, and avoid panic. That's the difference between July of last year and April of this year—the difference between a resident and a Fellow.

We transport Bunny upstairs to the cardiac ICU and continue to deal with the challenge of stabilization. Being paced through the chest is not a good long-term plan—usually, a transcutaneous pacemaker is used only for short periods of time as a bridge to another step—because the device can stop working and because it's uncomfortable for the patient. The more definitive way is to place a transvenous pacing wire, which is done by inserting a large IV into the patient's neck and floating a temporary pacing wire down the vein in her neck into the right atrium of her heart, crossing the tricuspid valve into the right ventricle, where the wire sits in the muscle and can pace the heart directly. It sounds invasive, but once the wire is in place, it's considerably more comfortable for the patient, because the amount of electricity required to pace the heart from within the heart is far lower than the amount needed to travel from an exterior pad through the chest.

This procedure—inserting the transvenous pacing wire—is not done frequently. And I've never done it. I have to make the decision—there's no attending present to make the call for me—and I have to decide fast. I weigh the data. In the ER, they drew blood and sent it for analysis. Now, forty-five minutes later, the test results come in and might suggest an explanation. Bunny's blood counts are normal, including the white blood count, meaning it's probably not a raging infection. However, her electrolyte panel shows substantial indications of acute renal failure. Her kidneys, though not functioning at zero, are much worse than when she last visited the clinic. The red flag is the level of potassium (K) in her blood. The heart relies on normal levels of potassium—not too much or too little—to conduct and function properly. Normal K level is between 3.5 and 5.0 (lab measurement units). The 5.0 to 6.0 range will get the attention of the clinic doctor; above 6.0, you need to be in the hospital. Over 6.5 and you're flirting with danger. Bunny's is 7.2—trouble. There'd been a delay from the lab on her K number because it had to be double-checked, and whenever there's a double check, you can bet the number isn't going to be normal. Okay, her 7.2 makes some sense; her slow rhythms are almost certainly from potassium overload. Probable conclusion: Fix the K; don't put in the wire.

Before I rule out the wire option, though, I want to talk to the attending. My instinct says that Bunny is being paced through the skin and she's not terribly uncomfortable. On the other hand, putting in a pacing wire is a central line procedure, meaning floating a wire down into somebody's heart, and that can lead to complications, puncturing the wall, maybe causing an arrhythmia. But I need to vet my conclusion, because my
N
(numerical sample size of experience) is currently zero. I call my attending at home and say, “Sorry to wake you, but here's the situation….” I walk him through the case and my conclusion, and he says, “I concur completely.” More important, he doesn't say, “Two hours from now, check in and let me know what happens.” He trusts my take. (I could have made the decision without his blessing, but I wanted to run it by him that night to vet it, and I want to teach the resident the right way to do things.)

It's now 12:45 a.m. We have to get the potassium level down. There are only a couple of basic ways for the body to physiologically get rid of things: urinate or defecate. There's also vomit, but it's not preferred by patient or doctor. One route, despite Bunny's sick kidneys, is a large dose—eighty milligrams—of the IV diuretic Lasix. The other route is a nasty-tasting medicine called Kayexalate, which gets the bowels to eliminate potassium from the GI tract. Given the severity of Bunny's condition, she gets both. The Kayexalate takes a while, but with the IV Lasix, we hope to see a response fast. And even with her renal function at 15 percent of normal, within forty-five minutes, she is urinating into a Foley catheter, about five hundred cubic centimeters, or half a liter. We send off another blood test for potassium.

We're reasonably confident of the results because we'd done a short-term maneuver to, at least temporarily, move the potassium from the blood cells into tissues. We'd used an IV cocktail of calcium and insulin, plus sugar, or dextrose (so the insulin doesn't make the sugar drop and cause hypoglycemia). With that combo, Bunny's heart rate had come up right away and didn't require as much pacing…but that effect will last only until the cocktail is out of her system and the body reverts to its previous state. The temporary result was a clue that we're on the right track.

I use the blood test waiting time to think a few steps ahead, a now-ingrained behavior from fellowship. If this works, okay, but if not, then what? The most surefire way to de-K patients is to dialyze them. At midnight, I tell the resident, “Call renal to discuss the case because we may have to do an emergency dialysis session.” I could call the kidney doctors myself, but the resident needs both the experience and the middle-of-the-night pushback; it's all part of her training.

Within the hour, the renal team arrives and puts a dialysis catheter in Bunny's femoral vein. Her potassium level comes from the lab, and it's 6.5—down but still high. As quickly as we take the potassium out of her system, it seems to come back (which is a clue to what triggered it in the first place but we don't know that yet). There's still not enough progress. I speak to the kidney doctors about readying the dialysis machine.

In the meantime, we give Bunny an additional 120 milligrams of Lasix. This time she puts out about eight hundred cubic centimeters of urine, almost a full liter. We test again sixty minutes later, and her potassium is down to 5.9. The dialysis isn't needed yet. If a sick kidney is making urine, it's probably getting better. An hour later, Bunny's K level is down to 5.5. Her EKG shows she's generating her own rhythm—heart rate at sixty-five—no longer totally reliant on the pacer. We turn the pacer off, and Bunny's heart rate remains at sixty-five. Her blood pressure is coming up too. It's 3:30 in the morning.

Bunny's body is sending out cautiously optimistic signals. She was ash white; now she has a little color. She wasn't able to communicate well; now she speaks in full sentences. Her sister and her girlfriends see the difference. Medically, her potassium is coming down, and she's generating a heart rhythm on her own. What the textbooks say should happen is happening.

One last potassium check: 5.3, trend line in the right direction. At 4:00 a.m., I leave, seven hours later than I expected. Driving home, I wonder: If I hadn't stayed that extra fifteen minutes, and if the same events had transpired, would the resident have called me?

And one other question haunts me: “How did Bunny's potassium get so high?” That question is there, still unsolved, but it will wait, and can wait, until morning.

Unfortunately, morning comes just a few hours later, at 7:00 a.m. Bunny is still in her own rhythm. Her potassium is in the 4s, normal for anybody. She's essentially weaned off the blood pressure–supporting medicine. All good. Since her K is now down, the resident asks, “Did we put the dialysis catheter in unnecessarily?” I reply, “Absolutely not. We did the safe thing by being prepared to dialyze her the moment her potassium inched up rather than having to spend an hour and a half getting it in later, when she might have been truly vulnerable.”

Now we need to answer the “How did the K get so high in the first place?” question. If Bunny had suffered through her symptoms one more night at home, she likely would have arrested and died, with the death perhaps chalked up to “natural causes”—which, given what we subsequently find out, would not have been natural at all.

We search through Bunny's medical records, reconstructing events. She has a baseline history of some congestive heart failure and a propensity to retain fluid. To combat it, she was on a diuretic, oral Lasix, to keep fluids balanced and the heart appropriately unloaded. She'd seen her primary care doctor three weeks before, and her blood work showed that her kidneys were functioning at only 70 percent, which was new for her. Her doctor concluded she was getting too much diuretic, which can dehydrate, and with dehydration, the kidneys can start to shut down. The doctor then, logically, decided to substantially cut back the dose of the diuretic. But what
wasn't
addressed was the fact that, like many people on diuretics, Bunny was also on oral potassium to compensate for the potassium she was urinating. Her doctor cut the oral diuretic but didn't cut the potassium. So when Bunny continued to take her supplemental potassium, together with other medications that raise potassium levels, she accumulated it in her system until it caused a disaster. Unfortunately, this information was not in her records since her primary care doctor is not in the Hopkins system.

But Bunny actually helped us piece it together, in a way. She proved one of the two rules attributed to an apocryphal resident, way back when. Rule 1: Patients always lie, whether they mean to or not. Rule 2: When patients are too sick to lie, their families will lie for them, again purposefully or not. What the rules mean is that usually without any intention to mislead, people tend to present the facts selectively or even falsely, either because they want to look like good, conscientious patients, or because they don't want to present bad news, or because their memories are limited, or some combination of all those elements. As a result, the lore goes, you can't rely on what patients and their families say. You have to listen past the words, to what was not said.