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A Piece of My Mind
September 27, 2000

Twenty Lessons From the Heart of Medicine

Author Affiliations
 

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.

JAMA. 2000;284(12):1486-1487. doi:10.1001/jama.284.12.1486

I am a medical geneticist. Both of my grandfathers died in their early 50s of apparent myocardial infarctions. Numerous other relatives have had heart disease. On September 20, 1999, I stopped worrying about my family history and started living it.

Although in the previous two days I had run 30 miles training for a marathon, I felt so good that I ran eight more before going to bed. An hour later my sitting up and coughing awakened my wife, Brigid. I mumbled, even more incoherently than usual, and collapsed back to horizontal. Then I was silent. Profoundly silent. Like any spouse, Brigid was initially angry for being awakened. But the silence concerned her. To deal with both her anger and her concern, she yanked the bedclothes off me. When that failed to elicit my normal squawking, she switched on the light and observed that I was motionless, breathless, and pulseless, with eyes open and fixed. Brigid, an experienced volunteer EMT, having determined unresponsiveness, cool-headedly proceeded to the next CPR step, activating the emergency response system. She called 911, while attempting to rouse me with a mixture of reprimands ("Where do you think you're going?!"), invocations of saints, and physical assault. She was about to throw me to the floor to administer chest compressions when, after being out 90 seconds, I came around. Lesson 1: Never sleep with anyone who doesn't know CPR.

I'll skip interesting times in the ambulance, ED, CT, etc (I can't remember them anyway), and move ahead eight hours. I had ruled in for MI, and while the CCU team debated whether this warranted catheterization, a nurse gave me magnesium, since a low-normal magnesium level was my only treatable feature yet uncovered. Lesson 2: It's true: Magnesium burns, ooh! To prove that I had quickly absorbed this lesson, if not the magnesium, I went into V-tach and passed out. I awoke to the nurse apologizing for "kissing me"—that is, giving me mouth-to-mouth and some chest thumps. I figured no apology necessary.

At least this arrhythmia earned me an immediate trip to the cath lab. After an alternatively boring and eventful time there, where several vessels with up to 75% narrowing were ballooned, stented, and otherwise mucked with, the team stopped my lidocaine drip.

Jack, a close friend from residency, arrived to be of support. A good host matches entertainment to visitors' interests. Knowing Jack was a cardiologist, I reverted to V-tach. To avoid recurrent CPR, I somehow self-corrected. Jack now looked even paler, if more entertained, than I, preferring to gaze at my monitor rather than me. Soon, to really entertain him, I went into V-fib. Jack, who in residency performed resuscitations with me, now tried one on me—unsuccessfully. Lesson 3: If a friend fails at resuscitation, better with you than on you.

With their home-field advantage, however, the CCU team possessed resources denied Jack, and arrived to bring me back yet again. This time I awakened to a resident asking if I had chest pain—the 20th time in 18 hours that someone asked that. Whether during my MI or in the cath lab, where the mucking around caused ST changes sufficient to give the staff angina, I had not a whit of chest pain. The others—Brigid, Jack, attendings, house staff, nurses, students, housekeepers—were doing their part, but I was neglecting mine by feeling no chest pain. I worried that others thought I wasn't really trying. Lesson 4: Although neither may know it, patients are actually more motivated than their caregivers. I felt guilty for being pain-free. Lesson 5: Patients feel guilty if they don't meet caregivers' expectations.

When I regained consciousness to this 20th query about chest pain, I proudly proclaimed, "Yes, I have chest pain. . . . Funny, it's on my right side." The resident deadpanned, "That's where we defibrillated you."

Electricity revives the heart. It also focuses the mind; although I had no memory of defibrillation, with electrification I learned several lessons. Lesson 6: Both unconsciousness and amnesia can be good (why do they have such bad reputations?) Lesson 7: While not as bad as I imagined, 250 joules is better to give than to receive. Brigid pointed that out. Her doing so exemplified Lesson 8: The sicker you are, the more helpful a sense of humor, in you and in loved ones.

Following electrification, team members approached with new respect. As one cardiology fellow enthused, "We learn that within 48 hours of an MI, severe arrhythmias can occur. But now that we treat MIs aggressively, we never see this. You are the first patient to do this in a long, long time. It is very interesting." Lesson 9: Patients do not fully share physicians' excitement in "interesting" cases.

Throughout my hospitalization I was struck that few caregivers pondered deeply what I found quite the important question: Why was I having these cardiac problems? Lesson 10: Always wonder, "Why doesthis person have this disease?" A fascinating question that moves the spotlight from illness to patient and emphasizes the uniqueness of each person. Electrification did seem to increase interest in this question. Earnest interviewers sought to determine what I had done to visit these calamities upon myself:

"How old are you?"

"49."

"Awfully young! Height and weight?"

"6-2, 170."

"You must wish you didn't smoke."

"Don't."

"Your cholesterol must be sky high."

"Last that I knew a year ago, it was 150."

"Blood pressure?"

"115/75."

"You could exercise more."

"True. I run only 50 miles a week."

The interviewers now appeared uneasy; seemingly not from dissatisfaction at finding no rigorous explanation for my plight, but from inability to pin something on me. Lesson 11: Illness may not be the patient's fault. Particularly something that would distinguish the interviewer from the sick, maybe dying patient. Lesson 12: All physicians become patients.

I sadly noted that not all interviewers asked about my major risk factor. Lesson 13: Always ask about family history, particularly if the patient is a geneticist.

I was proving habitually arrhythmic and a generally bad boy. The team suggested recathing to find reasons for this boorish behavior, or at least more vessels to prop open. When informed of their plan, I happily adopted a passive role—whatever they wanted was fine. Lesson 14: Even for a physician, it is easy to be passive as a patient, especially when scared.

And I was truly scared, scared that I would die soon. My heart had stopped three times and I didn't know how many times it could restart.

However, to summarize several days, I exhibited increased cardiac correctness. I limited myself to frequent PVCs and only rare, short, self-correcting runs of V-tach. I swore off resuscitation altogether. Feeling better, and more likely to live than die, allowed me to notice my medical care more keenly. For instance, I noted that ICU monitors, cath lab monitors, and ECGs each requires different leads. Lesson 15: To prepare for Olympic swimming or a heart attack, shave your entire body.

One 2 AM experience epitomized my life as patient. My nurse came to proffer a saline bolus with a several-liter chaser. Having survived this routine the previous night, I knew what was up and why. However, to pass the time of night I politely inquired, "Why the saline?" She told me it was ordered for bradycardia and hypotension. Since an automated blood pressure cuff awakened me every 15 minutes to gather such data, I was aware of these, but thought my numbers normal for me, someone who runs 50 miles a week. I understood why the intern ordered the saline; in her shoes, I would too. However, I was in my bed, not her shoes, and from there it wasn't a great idea. Where the resident saw only upside, I saw mostly down. Tubes, lines, and wires already trapped me like Gulliver in Lilliput. The saline would pin down my last free limb, immobilizing me on my aching back in a sweltering room, rather than able to shift position enough to sleep (at least until the next medication, temp check, or trash-can emptying). Lesson 16: Too seldom inquired about, the patient's view of therapy often differs from the physician's, and is valid.

Later, I pointed out to the intern that if we were to have a nightly normal saline ritual, as appeared the local custom, it might make sense to take me off the no-salt diet the team reflexively had me on. A light bulb snapped on over her head. She changed my diet. Of course, a post-MI patient on a full salt diet proved so novel that it took three days to implement the change.

During morning rounds, I asked about medications planned for me on discharge. The attending noted need for a statin, to drive cholesterol under 160 and LDL under 90. I appreciated his aggressiveness, but suggested checking chemistries before reflexively ordering the medication, mentioning that values from the ED might be in my chart nearby. By the next morning those values were uncovered. The attending conceded that since, without meds, my cholesterol was 130 and LDL 72, statins might be unnecessary after all.

The saline and cholesterol incidents highlighted Lesson 17: In medicine, one size does not fit all. Treat the patient, not the disease.

To finish the case presentation, I went home a week post-MI with an intracardiac defibrillator/pacemaker (which at least lets me, and Brigid, sleep more easily). Nine weeks post-MI, I celebrated my 50th birthday by running a half-marathon.

Ironically, meeting Death was my most life-enhancing experience. Of the many other lessons that it taught me, I'll end with three.

Lesson 18: You can't overvalue family or friends.

Lesson 19: Illness is an intense part of the human experience. While always unwanted, it is often literally "invigorating."

Most of all, Lesson 20: Every day is a gift. Be well. Do well for our patients.

Previous Presentation: This essay is based on the commencement address delivered at the University of Vermont College of Medicine, May 21, 2000. The full text of the talk was published in Hall A: The Magazine of the University of Vermont College of Medicine (summer 2000).

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