Alpha Docs

by DANIEL MUÑOZ

  Every doctor learns the Hippocratic oath in med school, and its implicit maxim, “First, do no harm.” It’s an unusual vow. Rather than a promise to heal or do good, it’s an admonition not to hurt anyone in the name of helping. I decide that sending a robust, symptom-free, firefighting father of three for a cath fails my clinical litmus gauge. I opt to do no harm—or, more accurately, to do the least harm.

  But now we come to the crux of the issue: Do we do nothing more? What if that EKG is a clue to something? And what if we send Mr. Hawkins home and he dies of a heart attack that might have been prevented? It can be as challenging to care for the seemingly healthy patient as for the obviously sick because the healthy patient has further to fall. So I take a hybrid approach: I do not order a nuclear stress test, because I don’t think it will tell us anything definitive, but I do order an echocardiogram and stress test with ultrasound pictures. The stress echo test isn’t perfect. It can produce a false positive or false negative. But it can also provide a measure of diagnostic reassurance without difficult-to-justify risks for a healthy patient. This is one of the greatest challenges of clinical medicine. Since every decision carries risk, it’s sometimes unclear which path offers the least harm.

  Unlike patients I see during rotations and never see again, I am now involved in treating Mr. Hawkins. When he goes in for the stress echo, as I happen to be in the hospital, I witness the test itself, and not just the written results in his chart. This time Mr. Hawkins is on the treadmill for over seventeen minutes, which borders on the absurd since we rarely expect anyone to go more than ten minutes. And this time, the technician speeds up the track and raises the incline up to a thirty-degree angle. Mr. Hawkins still runs six miles an hour, and even says to the tech, “What else do you want me to do?” Most patients are panting and can’t wait to get off, but he’s chatting.

  The value of pushing somebody is that you can compare the ultrasound pictures taken immediately after exertion to the ones you’ve taken when the patient was at rest. The longer the patient goes, the more reassured you are by normal-appearing pictures. And it looks as if Mr. Hawkins is fine. He’s sweating, but that’s normal. And his echo pictures are fine—his heart is functioning perfectly, and every portion of his heart muscle seems to be adequately perfused. We can’t see the blood flow, but the normal muscle motion indicates it is adequate. Even though his EKG shows the same quirky wave, in some ways this is actually good, since it indicates that the abnormality isn’t a sign of trouble, but is as much a part of him as his bushy eyebrows and oversized feet. In my medical opinion, Mr. Hawkins has had a false-positive EKG.

  During Mr. Hawkins’s follow-up appointment at the clinic, it’s clear that he’s doing fine but he’s not happy at having been away from his volunteer firefighter’s job; it’s his way of carrying on the family heritage. If he’s okay, he wants to go back right away. That requires an official doctor’s letter to give him clearance. And that’s a first for me, dictating a formal medical opinion in which I state, for the record, on Hopkins letterhead, that as a member of his medical team, after performing the appropriate tests on Mr. Hawkins, he has a clean bill of health to go back to running into burning buildings. And I, Dr. Daniel Muñoz, MD, have to sign it. Though I imagine this sort of ritual will become routine/commonplace as I progress into my career, right now it feels like a momentous act. I’m officially official.

  Sometime later, I wonder how Mr. Hawkins is doing and decide to call his home to check on him. His wife answers the phone: “Doctor, you missed him by five minutes. The firehouse siren always seems to sound when we’re sitting down for dinner.” That’s my answer. All should be well with Mr. Hawkins—at least until the next time the county requires an EKG. Hopefully, the next cardiologist will know that, in Mr. Hawkins’s particular case, a restrained approach might very well be the best way to “do no harm.” Mr. Hawkins is a case study in the Hippocratic oath, and an important reminder to gather the facts and then trust one’s own clinical judgment rather than adhere to a strict algorithmic protocol of testing. Mostly, it’s a reminder—again—that we’re treating people, not data.

  On my last day of nuclear, I’m working with Dr. Ulysses again. We cruise through the reports, and by 7:00 p.m., we’re finished. I say, “See you tomorrow.” Dr. Ulysses reminds me, “The clinics are closed. Merry Christmas.” My two-week rotation on nuclear stress tests was only one week and a day.

  —

  Unlike the nuclear testing itself, whose results can be vague (but lucrative), my conclusions about it are clear. The technology behind the tests is impressive; so are some of the practitioners; but the disconnection from patients and the subjectivity of reading outcomes make me question their value, and, as a field, it clearly isn’t for me. On the other hand, my midrotation clinic work further reinforces my affinity for direct patient interaction and longitudinal involvement. In fact, by the Sunday after Christmas, my mind shifts to my next immersion. In twelve hours, I’ll be back at Hopkins’s cardiac intensive care unit. Real patients who are truly sick, and who need constant medical care. I think I’m beginning to know what I like doing.

  11

  ROTATION: CARDIAC INTENSIVE CARE UNIT, PART II

  There’s No Such Thing as “Routine”

  It’s the Monday after Christmas, and I am starting my second rotation of cardiac intensive care, this time at Johns Hopkins Hospital downtown. I will be working through New Year’s, which is best described as a hospital’s “wacky time,” when all the people who somehow staved off every kind of malady to get through Christmas can hold back no more and the onslaught descends. The CICU is packed.

  Day one and this rotation is a sharp contrast to the last one. Every bed in the unit is full; every patient is critically ill; several are in heart failure or shock, requiring high-powered IV medications to support their blood pressure. Some patients are contradictions—too young to be so fragile but barely clinging to life, while others are aging miracles, still breathing despite all odds. I’ve gone from dark rooms filled with computers into the full glare of intensive patient care.

  The CICU at Johns Hopkins is a “horseshoe” of glass-walled rooms around the nurses’ station, so that the staff can see all the patients at all times. Just like the CICU at Bayview, every one of these cases is presurgical or nonsurgical, ranging from heart attacks, decompensated heart failure, cardiogenic shock (when the heart’s pump inefficiency has deteriorated to pump failure), and a variety of dangerous or malignant arrhythmias. Some patients can get out of bed and walk their attachments—a combination of IVs, tubes, wires, monitors, and encumbrances—to the bathroom, or sit up, read the paper, and talk on the phone or to visitors. Other patients lie fully sedated, attached to a mechanical ventilator that breathes for them, while their IVs provide a steady, wide-ranging stream of medications to support their blood pressure. We can monitor all of these patients from the pod in the middle of the horseshoe, on flat screens displaying EKGs, patient names, heart rates, and other vital signs. Audio alarms sound when any patient’s readings deviate from the norm (due to anything from an EKG lead that falls off to actual cardiac arrest). All this information is gleaned without stepping into a patient’s room, all without human interaction…for better or worse.

  As with every rotation, there’s virtually no orientation or introduction. We get there and do it. My team assembles first thing that morning—the attending, Dr. Chester, a senior professor of cardiology; the Fellow (me); and a team of residents, usually three first-year interns and three junior or senior residents. Together, we’ll round on the CICU patients and take care of them day and night for the next two weeks. From 8:00 a.m. until midday, the team moves like a herd down the hall, stands outside each room, and reviews each patient’s history and status. There is a highly structured format for presenting a patient anywhere in the hospital—in the ICU, on the general medicine floor, or in obstetrics or pediatrics. It starts with an HPI (history of present illness), one or two rambling, paragraph-long sentenc
es, encompassing all that is meaningful about the patient right now—not all illnesses ever, tangential incidents, or unrelated symptoms…and no conclusions yet.

  We’re here to learn, to teach, and to treat, which takes longer than just treating. The priority is always the patient, not the students or the teachers, but the residents need the chance to learn on their own. Rounding has to strike a delicate balance between the academic side of medicine and proper patient care.

  What attendings and Fellows look for are “crisp” presentations, which can be surprisingly hard to define. There are no clear-cut criteria, but a presentation should be short and pithy without omitting anything critical. You can do a good job in ten minutes or a bad job in thirty. An excellent presentation is not unlike what U.S. Supreme Court Justice Potter Stewart said about pornography: You know it when you see it.

  The art of rounds lies in the interruptions and the critiques the attendings and Fellows make. A good interruption prompts the resident to expand on a point because it’s a salient issue, while cutting in on a presentation and saying “Whoa! You’re jumping to conclusions pretty fast” is not only bad form, but incredibly discouraging for a resident. I first learned this on the receiving end, noting that while some Fellows and attendings could deftly interrupt a presentation, others would let the resident wander off course before finally flashing the “T” time-out sign and guiding the resident back to the issue at hand. Hopefully, these experiences will come in handy now that I’m the one doing the interrupting.

  The first patient we see is Ms. Jentzen, a sixty-seven-year-old woman who came in two days ago with an ST segment elevation myocardial infarction (MI)—a serious form of heart attack. She had a stent put in, but still needs IV dopamine to maintain her blood pressure. The resident presents the relevant questions of the case: Why is this happening? How long should we continue this course? What’s the long-term outlook? It’s a good presentation, fifteen minutes, relevant data, and a clear treatment plan, a routine case for the unit. I listen and critique. The attending listens and critiques my critique.

  The next patient, a Mr. Orlando, requires a full presentation because he was admitted in the last twenty-four hours. A typical rundown goes through the patient’s symptoms, tests, history, other illnesses and conditions, previous visits, medications, family patterns, in order to provide a total physical assessment of the patient. Mr. Orlando also came in with a heart attack, but he is currently sicker than Ms. Jentzen, and thus his case is more complicated.

  Dr. Chester, Starbucks grande in her hand, is on one side of the nervous resident who is reviewing the chart. I’m on the other side, peeking at the resident’s notes, while two other residents cluster in to learn how to, or how not to, give a presentation. The resident begins, “This is Mr. Orlando, who came in last night with a myocardial infarction because he smokes heavily and is diabetic, has high blood pressure, and was experiencing chest pain.” As he goes on, “…but he’s doing better now. We started him on a beta-blocker…,” I know his presentation is heading down a rathole.

  I’ve observed enough of these presentations to know that the most dangerous thing you can do is draw conclusions too fast. If you’re a venerated teacher or practitioner, you can do your own version of the format, but if you’re a resident, you stick to the book. Or the attending or Fellow will cut you off at the knees. And this resident is doing the unforgivable: He’s presuming an accurate diagnosis before getting through the objective data, a critical error. Like a game-show host, the attending, Dr. Chester, zaps him, but her version is a withering scowl: “Doctor, we would prefer to have the facts first and make our assessments afterward.”

  Then it’s my turn. While the attending is a teacher for the entire team, my role is to be a teacher for the residents, and right now, my job is to help the resident without undermining or contradicting the attending. I nudge the resident: “Please review the EKG, the echo, and the enzyme results.”

  The resident rifles through his papers, which, given the silence, seems to take an eternity. The other residents are collectively holding their breath. Finally, the resident delivers the sequenced facts as he should have—the symptoms, the EKG, the blood work, and so forth—and the attending lets him off the hook, though not without a parting shot of sarcasm: “Thank you. We cannot assume a patient arrived in the ER with a sign over him announcing that he’s had a heart attack and that his diabetes and smoking were to blame. The information you’ve now provided gives us a clearer picture of the situation.”

  What should have been a ten-minute presentation became a forty-minute case study. But the presenting resident (and the other residents) absorbed the lesson of presenting a spectrum of facts, not presumptions. Truth is the analysis you arrive at…if the facts are right.

  The conclusion, as expected, is that the patient had a mild heart attack. He’s scheduled for a cardiac catheterization to see if further interventions, such as a stent implant or bypass surgery, are warranted. His blood levels are checked to monitor effects his diabetes might have had. In the meantime, he’s put on additional heart meds, and his vital signs and blood work will be watched carefully. These conclusions are not dissimilar to those of the resident, but the means by which they are reached are as important as the end.

  Afterward, I walk the presenting resident down the hall to commiserate. “We’ve all been there. Don’t worry about it. Nobody died.” He nods and thanks me, but I can tell he feels awful.

  The attending was rough on him, but she had to be. Her responsibility is to turn residents into good doctors. She doesn’t want to send doctors into the world who cut corners or do their job wrong, because a doctor’s error can mean a patient’s death. Do you tread lightly with students out of sensitivity to feelings, or do you have tough standards that may bruise feelings? Hurt feelings will recover. Patients may not. And Dr. Chester isn’t really mean. I’ve witnessed mean. One attending, after a bad presentation, said to the resident, “Doctor, now that you’ve leapfrogged over the facts and somehow divined the diagnosis, we can assume this patient is miraculously cured, and we can move on to the next patient so you can perform your magic again….”

  But I’ve also worked with doctors who could skillfully and subtly nudge residents back on track. “So…did the patient describe what the chest pain felt like—its intensity, location, duration?” “Can you tell us how the tests did or did not support your observations?”

  During the rotation, during rounds, my conscious goal is to emulate and practice that method—“an iron fist in a velvet glove.” In addition to the second- and third-year residents, there are interns or first years, and I want to show the younger ones how it’s done so they won’t have to relearn it later. Out of empathy, I find myself erring on the side of the velvet glove. If residents say something a little off, I raise an eyebrow or try a time-out signal to get them back on script. If the resident says something just plain wrong, I stage-whisper, “Hmm, I don’t know.” If that doesn’t work: “Whoa. Slow down!” The art of interrupting—like being a good doctor—is about knowing when to listen, and when to act.

  —

  As week two begins, my interrupting skills are put to the test with three very different residents and a different attending. The attending, Dr. Herbert, has a background in economics and a fascination with technology, and he has a reputation as a fanatic for detail. Many residents, and even some Fellows, find him intimidating. During presentations, he will seize on a hint of incompetence, and he can make even outstanding residents wilt. Nothing annoys him more than lazy doctoring or disorganized thinking. He wants things done right, and he’ll grill a resident like a homicide detective if necessary. As a result, some of the residents and Fellows think the right way always means his way. I don’t agree. Dr. Herbert is obsessed with advocating for the best care, and has no tolerance for doctors he feels aren’t equally obsessed. And when a resident veers off course, Dr. Herbert will bring the process to a halt. He will deconstruct a case for an hour until he’s co
nvinced that the resident understands not just that he or she made a mistake, but why and how not to do so in the future.

  To get the full, fair picture of Dr. Herbert as a non-ogre, you only have to look at his bulletin board. There are pictures of him, his wife, four kids, and their grandmother, flanked by oversized Berts, Ernies, and Big Bird characters at Busch Gardens or elsewhere on their annual theme park trips. Despite his obsession with medical care, he is very much a human, caring person.

  The other evidence of this is that as brutal as Dr. Herbert can be, ripping a resident a new orifice one moment, he can ease a patient’s anxiety the next. He can even employ gentle humor, a rare feat in the somber CICU. He’s been known to ask, in a very bad French accent, how a patient is enjoying the hospital’s “haute cuisine” or to squint at his or her IV tube and say it’s time for an oil change. This is the same dedicated but complicated attending who strikes terror in residents, which doesn’t always make their work better, but which makes my job of training each of them challenging.

  And when it comes to training, there are two basic truths:

  1. For residents, at least one patient will get in real trouble in the middle of each night. This is a scientifically proven—albeit baffling—fact.

  2. The attending is evaluating all of us—the Fellow, the resident, and the patient. As the Fellow on call, I will be evaluated not only by how the patients fare but also by how well the residents handle them. It’s like treating two people per case.

  Every night, I am faced with my end-of-day decision: How long do I stay? Most nights I go home around 7:00 or 8:00 p.m. if I feel comfortable there’s a solid plan in place for each patient. But if my pager beeps at 2:00 a.m., I may head back in. There’s an adrenalin-like excitement to these moments—a life hangs in the balance—but since I have to return to the hospital at 8:00 a.m., the days can run into one another. Some nights, even before I leave, I know I’ll be back. It depends on many things, including the degree to which I feel I can trust the resident on call.