In college, I learned about the Frank-Starling law of the heart. It is fascinating and demonstrates just one of the bewildering number of human physiologic responses needed to adapt to the demands we place upon our bodies every day. In brief, the Frank-Starling law states that a healthy, normally functioning heart will respond to increases in demand for blood supply and oxygen by increasing the strength of cardiac contractility. This occurs in response to an increased volume of blood returned to the heart. For example, when we exercise, the large musculature in our lower extremities compresses the veins in our legs, forcing blood through the femoral veins to the inferior vena cava, the right atrium, and ultimately to the right ventricle. This increased volume in the right ventricle causes stretching of the myocardium leading to an increased release of calcium from the cells’ sarcoplasmic reticulum. This results in more forceful contraction and an increased ejection fraction needed to support exercise. At the molecular level, the overlapping chains of actin and myosin exist in a state of suboptimal overlap while a person is at rest. During times of increasing demand, such as exercise, the increased volume of blood in the right ventricle causes the stretching of the actin and myosin chains to the optimal level of overlap, which, in the presence of increased intracellular calcium leads to increased inotropy, or force of cardiac muscle contraction.
Understanding the Frank-Starling law of the heart is critical to understanding what happens when this mechanism fails – this is why we study physiology in medical school before we delve into pathophysiology – the study of what happens when normal physiologic function is impaired. This disruption in normal physiology is what we in medicine call illness, and in order to heal those inflicted by illness requires that we have a strong understanding of both disciplines. With respect to the heart, the pathophysiologic process we see and treat most often in the emergency department is heart failure. Heart failure occurs when the overlying chains of actin and myosin are stretched beyond the optimal point of overlap, meaning that the heart cannot increase the force of contraction in response to an increased volume of blood returned to the heart. When both the right and left ventricles are in this pathophysiologic state, the left ventricle, which normally receives freshly oxygenated blood from the lungs and pumps it out to the body, is unable to completely empty due to reduced contractility. This leads to the classic medical condition we call congestive heart failure where the blood begins to back up in the lungs leading to cough and shortness of breath, and if left untreated, death.
The heart of the American health care system is composed of physicians who work in hospitals and clinics throughout the nation. For years these physicians have, much like the human heart while exercising, been operating at peak capacity. We see this in countless stories of burnout and moral injury, which is the result of overwhelming caseloads, productivity measures, skyrocketing amounts of administrative burden, and the expectation that we are responsible for fixing all of the ills of modern American society. We were already at the breaking point – then came the coronavirus pandemic.
The SARS-CoV-2 virus, which causes the clinical syndrome we now know as COVID-19, has pushed the American health care system, and thus American physicians past the point of peak performance and into a state of proverbial heart failure. Already stretched to our limits, we are unable to optimally respond without timely and appropriate interventions due to a failure of leadership at the highest levels of government during this once in a generation humanitarian crisis. I see it in the eyes of the physicians working tirelessly to do what they can to help those afflicted by the deadly virus. I hear it in the voices of my colleagues across the country as they tell stories of the lack of needed equipment to protect themselves and save the lives of those needing to be placed on non-existent ventilators. But most importantly, I see it in my patients – the level of fear and uncertainty that has driven everyone indoors, not knowing if or when they will be struck with COVID-19, has created a level of unease that makes an otherwise calm and collected physician like myself fearful and anxious.
As the pandemic continues to accelerate exponentially, killing our fellow citizens in a seemingly indiscriminate manner, we will continue to see body bags piled into the back of refrigerated shipping containers and onto empty ice rinks. We will see our friends, neighbors, and relatives disappear from our lives in a matter of weeks, and we will see physicians continue to break down in tears knowing that this was all preventable. This is a time of reckoning. A time when all Americans will see what physicians have been witnessing for years, that the American health care system is not, in fact, a system of beneficence but rather a system of maleficence. One that has been exploiting doctor’s empathy, work ethic, and desire to do what is right even when the system makes it nearly impossible to do so. Physicians are the heart of America’s health care system, and like the human heart experiences the pathophysiologic state of failure, we are now being pushed into that same state. I can only hope that those who are empowered to make the decisions to support us as we work to support others choose to do so in a timely and appropriate manner, but I do not see that happening. All I see is a future where more and more of our fellow citizens are piled up like so many heaps of garbage, and the heart of the American health care system stretches further and further beyond its limit to the point of total cardiovascular collapse.
Nick Sawyer is an emergency physician and can be reached @NickSawyerMD.
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