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A Piece of My Mind Section Editor: Roxanne
K. Young, Associate Editor.
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?"
"Awfully young! Height and weight?"
"You must wish you didn't smoke."
"Your cholesterol must be sky high."
"Last that I knew a year ago, it was 150."
"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
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
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
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
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).
Guttmacher AE. Twenty Lessons From the Heart of Medicine. JAMA. 2000;284(12):1486–1487. doi:10.1001/jama.284.12.1486
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