Editorial: A view from the other side

By Stuart E. Mirvis, MD, FACR
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Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

It is great to be a physician and help the sick return to health. Many of us constantly deal with ill patients, sometimes seriously ill. We fight illness; it's our sworn enemy and certainly something to be avoided. It's also great to be on the right side of the line between healthy and ill. Maybe physicians are often so good at denying their own illnesses so they can avoid being on the wrong side of the line. Physicians tend not to be comfortable giving up control, becoming dependent, and putting our fate in the hands of others, even briefly. We are not alone in this; it is a powerful tendency.

I speak from experience. I spent at least a year ignoring dyspnea on minimal exertion. I assumed I was just out of shape (I am) or just getting older (I am). I couldn't actually be sick. As long as I could do what I needed to, why worry? I just walked slower, took elevators, asked my wife to take out the trash, etc. Then my internist noted a louder systolic murmur than previously and told my wife in absolute terms,"Stuart needs to see a cardiologist soon." I was caught. Fortunately, one of my best friends is a great cardiologist. I'd planned to make it a social call. I was, however, in for a bit more. He wanted a cardiac cath and left-sided chamber pressures, as I had some left-ventricular hypertrophy. I resisted, first opting for a cardiac CTA (since I could do it in my department with familiar techs and radiologist colleagues). The cardiac CTA did not look so good, so on to coronary angiography.

The cath was easy, really nice drugs, friendly staff, and a skilled interventional cardiologist. On the down side, it seemed like Grand Central Station on a Friday afternoon in the cath suite when I was being shaved "down there." I expected a bus load of tourists with cameras to meander through any second.

The catheter went in almost painlessly. I could even see the fluoroscopy screen. My coronaries looked pretty good as they injected contrast. I'm just getting old after all. Then they did the pressure measurements. The pressure wire went into the left ventricle, the run of ectopicbeats ensued, and the wire was slowly pulled back. The catheter was withdrawn and the artery sealed with a plug. That was easy-what was I worried about?

But the cardiologist stopped by the head of the bed to say, "Stu, you don't have much coronary artery disease, but you have a gradient of 100 mm Hg below the aortic valve. You just need open heart surgery."

I must have misunderstood him due to all those drugs. Did they forget to zero the pressure monitor? Sadly, there was no mistake.

To make a long story shortish, I had hypertrophic obstructive cardiomyopathy (what I learned in medical school as idiopathic hypertrophicsubaortic stenosis). This is an autosomal dominant genetic defect that is found in roughly 1 in 500 people. It causes the cardiac muscle bundles to overlap like strands of spaghetti instead of layers of lasagna (food analogies work well in describing most physical maladies), and there is often a bump of myocardium that sticks out from the superior septum into the aortic outflow tract like a big butt. Fortunately, my kids had no suggestion of the problem. I paid many visits to an excellent cardiologist specializing in my condition. In the consultation letter, I was described as a "friendly, unfortunate gentleman." You never want to be the unfortunate gentleman. I had a trial of medical treatment with some less than fun drugs, but it did not lessen the gradient enough. After an agonizing 4 days in which my wife and I read the entire medical literature on the subject (including the Czech literature), I opted for the surgery that the consulting and my cardiologist recommended, rather than catheter-targeted septal alcohol ablation. It's a complex debate, so I give you a reference if you are curious. 1 If it had been gin that I could drink,I would have gone the ablation route.

I found the most highly recommended surgeon (insurance) money could buy. I met him to make sure he did not have shaky hands and that I could deal with him. I guess he needed to check me out too. He was a completely sensational, kind, confident, clear, experienced, honest, and to-the-point physician, and my anxiety was largely relieved. My surgery date was 6 weeks later. But, the evening before surgery, my surgeon called to explain that the OR would be backed up with emergencies. Was I willing to wait a day? I could have the surgery late the next day with a very tired, hungry surgical team if I wanted. That's a no-brainer. That day was really long. I felt like a resident waiting in Louisville a day before the oral boards.

But the following day there was no escape. The squad of medical staff came to lead me to my fate. I was wheeled directly into the OR room, and I greeted the surgical team. The anesthesiologist "immediately" injected my IV. No time even to offer a joke. Now the scene fades to nonexistence.

I awoke in the ICU feeling a tad less than perfect. My first memory was of asking, by thrashing around like a newly landed fish, for the endotracheal tube to be removed. After agreeing to hold still, that annoyance was taken out. All the other invasive tubes and lines you never want in your body made their presence known as I tried to move. "Do you really need all this stuff?" The nurse was great and did everything to try to make me more comfortable. Early the next morning, my wife was very upbeat because I didn't look quite as bad as she expected. Iwas already going to a floor bed. They made me walk 10 feet to the transfer chair with my chest barely closed, dragging those tubes and lines. I never knew I could feel so exhausted.

On the cardiac floor, you are still very dependent for everything. I learned some things in my early convalescence. It's OK to be dependent. Just pretend you have control of the situation and you actually want everything that's being done to (or for) you, because you know how necessary it is. Any hospital staffer who walks into your room is either going to give you something or take something away. It's fineto ask for more pain relief-you are not the Terminator or Bruce Willis. The nurses really do not want you to be in pain-it makes YOU a pain. The button you push to get a nurse is not the same as the button for self-administered IV analgesic. Try to remember which is which. Either you will feel better but never see a nurse, or you will have an angry nurse and a lot of pain. Try not to interfere with your care. It's fine to ask what's going on, but don't get into a pissing contest with your caregivers. Do not watch your vital signs monitor as if your life depended on it.

Whatever TV show comes on will be amazingly boring and you'll watch the vital signs monitor anyway. You will be tempted to throw a full urinal at the TV, but it's hard to be on target just after a median sternotomy, so spare the cleaning staff. Speaking of urine . . . never get your bladder catheter removed before you get IV diuretics. Your bladder will be highly insulted after the presence of the catheter and refuseto work for a while. Quickly your bladder capacity will max out, your eyes will bulge, and your navel "inny" will go "outty."

No matter how lousy you feel, always look your best when medical professionals come by, especially the nurses. You should smile, wave, and kid with them. You might get discharged sooner. Show respect to everyone involved in your care. They will respect you either way, but it is a lot more pleasant for them to take care of you (remember being on the healthy side). The people who took care of me were fabulous, enough said. If you are not on a strict diet, have a loved one bring in meals and snacks on the second postoperative day. I find Chinese food the most therapeutic. You are definitely not in a 4-star restaurant. Adding hospital cuisine to a poor appetite will not get you enough calories. I had a hamburger for lunch that made a hockey puck seem like cotton. Bring ear plugs or headphones to try to actually get some rest (not).

Don't try to take on the world once you can walk to the bathroom. After a big operation, you have a long period of physiologic derangement. Let yourself be pampered at home. Just don't get too used to it. After a few weeks as a relative invalid, taking out the trash will be a wonderful diversion and going back to work will be pure nirvana (it's a fleeting feeling). Hopefully, good friends and family will throw gifts, cards, support, and love in your direction. It is the most attention you may ever get, excluding winning a Noble prize or taking the first step on Mars, so cherish it. Try not to look too healthy, since visitors expect someone who appears sickly. At least use the incentive spirometer during visits since you won't use it otherwise.

I am fortunate. I had a good operative result (or so the surgeon tells me), few complications, except perhaps a little less frontal lobe activity now (ie, lower inhibitions than before [just kidding]), and a smooth recuperation. Having major surgery is a really lousy way to get time off work.

It was uncomfortable being on the other side, but it is valuable to know first-hand what being a sick, scared, and vulnerable patient feels like. Such an experience may help you deal with your patients from less distance. I hope most of you can avoid a similar experience, but try to make the most of it if you do get pushed over the line.

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Editorial: A view from the other side.  Appl Radiol. 

February 12, 2009

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