Ms. Smith (name changed) is 82-years-old, but currently looks about a hundred. I met her, intubated, in the ICU two weeks ago. She lived alone, hadn’t told family she wasn’t feeling well, but had called 911.
In the emergency department, she was struggling to breath, and was intubated, having gone into respiratory failure. She was found to have a severe pneumonia affecting the majority of both her lungs. She also went into heart failure, causing her to retain fluids in her lungs. Then she went into kidney failure, making it much harder to use diuretic medications to get rid of that fluid, which would help the lungs heal from her pneumonia. Then, she was found to have — or was having, more precisely — a rather sizable heart attack that ultimately damaged her heart’s ability to pump. That’s when I got called.
The question I was asked was this — did the heart attack come first, just before she called 911, causing her to go into heart failure, retain fluid, and then develop a subsequent pneumonia and kidney failure? Or did the pneumonia come first, putting such a strain on her heart and kidneys that she suffered heart failure, a heart attack, and kidney failure?
It’s the classic chicken-and-the-egg story in the medical setting. Most people this age, who are this sick, have multiple things happening virtually at once. We end up treating them all hoping something will help make them better.
But in this case the question wasn’t entirely academic. If the heart attack came first, then we could potentially go do something — intervene — on the process by going to the cardiac cath lab, giving her lots and lots of really high-powered blood thinners, and attempting to put in a cardiac stent into her clogged coronary arteries.
If the infection, the pneumonia came first, then giving her lots and lots of high-powered blood thinners could be extremely dangerous, making a bad situation potentially even worse by causing diffuse bleeding associated with a dysfunction of her blood system, a condition called DIC, which can happen when people have multi-organ failure from an infection. Not to mention that she was so sick, and old, and frail, that the very act of moving her to the cath lab from the ICU and performing the procedure carried sufficient risk as to potentially cause as much or more harm than not doing the procedure at all.
So, “tag,” I was it. It was my job to decide which of these two approaches to treating — or managing to use a better term — her heart failure and heart attack was the best option. Knowing of course that if I was wrong, I could harm her, and that she was sick enough that any little extra bit of harm could prove fatal.
When you go see your doctor, you are paying for a service. Not many people understand what that service is. We often think of the service as the act of doing: prescribing the medication, ordering the test, doing the procedure or surgery. But the real service isn’t the act of doing: the act of doing in medicine can and often is relegated to individuals with less training and experience than your physician. The prescription can be filled out and the test often run by a technician; the procedure often times almost completely done by an assistant.
The true service your doctor is providing is thinking. Should I order the test? Is there enough data, or do I have enough experience, to think that doing this procedure or using this medicine will help, or at least not harm? In procedural-based specialties like cardiology, one of the truisms we teach young doctors-in-training (also called residents and fellows) is that just because you can do something or order a test, doesn’t always mean you should.
This is the art of medical decision making, and this is the part of being a physician which can’t be delegated to a computer algorithm, or nurse assistant, or robot. As much as your insurance company, or some credentialing organization, or medicare guidelines want to try, the thinking part of medicine — what goes on between your doctor’s ears when you are together with him or her in the exam room — is the most vital aspect of modern medicine and the most important skill your physician can hone. It makes the difference between good docs and bad ones. It is hard to measure, and almost impossible to quantify using claims or medical records data, because it does not fit nicely into a check box to be scanned by the millions into computer databases for future analysis.
Physician’s know that this skill is what sets apart the really good clinicians, the people we refer our family members to, and the one’s we seek out for our own care. This skill is also what is sorely lacking in modern training programs, where the residents and fellows have such stringent work-hour limitations that they have only limited opportunities to face these types of situations and to get the experience to guide their future decisions.
So, Ms. Smith and I sat with each other. I talked to her family, reviewed her tests, read her chart, did a physical exam, analyzed the findings. And I made a decision. No one else made that decision. It was my call, my responsibility, my job. There was no protocol or guideline to follow, no data in a peer-reviewed journal, no randomized, double-blind placebo-controlled trial of 82-year-olds with multi-organ failure critically ill having a heart attack and wondering which came first, the chicken or the egg, and what to do about it. There was no manual. I made a medical decision based on my experience and training in doing so.
Today, nearly two weeks after she arrived at our hospital, Ms. Smith and I had a nice conversation. She is off life-support, breathing and eating on her own, lungs healing, kidney’s responding, and heart pumping better than it was when I first saw her. It was her second day off the breathing machine, and her first day awake and alert enough to talk with me. She was transferring out of the ICU to the step-down unit, and the physical therapists had been by to start working with her to regain her strength and independence. She was very pleasant, and her family sat nearby and beamed, knowing how sick she had been, and how close she was to not surviving the last two weeks.
At the end of our brief conversation, we shook hands, and she said she was glad to meet me.
I smiled and told her I was glad to finally meet her, too.
J. Russell Strader is chief, cardiovascular services, the Medical Center of Plano. He blogs at The Musings of Heart Doc.
