CW: A hand surgeon’s view of non-adherent patients…

May 2, 2012

in Atrial fibrillation,Cycling Wed,Healthy Living,Reflection

Tonight, in the true spirit of cycling blogs, I will tell you a story. (We definitely need to lighten things up a bit.)

Considered yourself warned.

It is a saga of a cat-like mountain biker, who is also a heart specialist and perhaps a less than ideal patient.

But first, you may be wondering why I am using the funny word ‘non-adherent.’ It’s because the older word, ‘non-compliant,’ has fallen out of favor. Doctors used to say patients that did not follow a prescribed plan were not compliant. But this kind of harsh language implies a paternalistic condescending attitude towards the patient. Saying that a patient does not adhere indicates that doctor and patient are partners on equal terms. That sounds funny, doesn’t it?

Don’t worry, the story gets better. (Is it normal to laugh as you type?)

Being as we heart doctors are mindful and nurturing souls, we often describe patients that refuse to exercise, stop eating potato chips or fail to take medicines as directed as non-adherent. We don’t take non-adherence personally, rather, we press on with upbeat positive reinforcement. “Keep fighting; you can do it; it’s ok; I know it’s really hard, and, of course you don’t eat very much,” are all things we say.

It turns out that not all doctors employ the cardiology approach to ‘challenging’ non-adherent patients.

Take my hand surgeon as an example…

Wait, what did you say, “your hand surgeon?”

Yes, it’s true. The ulnar collateral ligament and extensor pollicis longus tendon do not have infinite stretching properties. A brief side note: It was a nothing thing. A rock garden that I have ridden a thousand times. Sure it was a little wet. The front wheel turned on a wet rock. No problem; it wasn’t at high-speed. But those rocks were so jagged, so uneven, so hard. I felt the tear. Dang it. My thumb was as we ‘like to say’ in KY, severely caddywompus.

The shared decision-making went well. For me, surgery was the easy part. I just laid there and the doctors did the work. I read my own op note: “In essence, it was torn open like a book.” Ouch.

Back to non-adherence, and that story I promised.

After the repair, the surgeon put my hand in a hard splint and sent me home. The splint looked perfect; it was nicely wrapped, white and comfy. For the record, nowhere did it say I couldn’t ride. I mean, who doesn’t ride the trainer the nanosecond anesthesia wears off?

One thing easily taken for granted in non-casted, non-sutured folk is how easy it is to deal with sweat. You get in the shower and change the sweaty clothes. To me, and I’m sure to you, a partial splint implies that it’s okay to change dressings and re-wrap. Come on, if you can ablate AF, surely you can change a splint.

Another mistake; don’t just ‘stop by’ the surgeon’s office and ask the nurse to help re-wrap a splint that wasn’t meant to be unwrapped.

“You took it off?” the nurse asks.

“Yes.” Not said, just thought…“I’m a heart specialist, and a bike racer!”

“Why did you take it off”? she asks.

“It got and hot and sweaty.” Again, not said, just thought…“Don’t y’all have moisture-wicking technical wrap?”

She did not call me non-compliant, but I knew she thought it. I got a new bandage and all seemed well. As I left, I planned my next trainer session. I’ll do repeat 5’s. That’s what you would do on post-op day 3, right?

As I was seeing patients in the office the next day my iPhone buzzed an unfamiliar number. I answered–you never know, it might be the newspaper wanting an interview on medial blogging. “Dr. (hand surgeon) wants you to come over to the office,” said the friendly but serious voice.

“My incision check appointment isn’t for a week,” I answered. “Wait, crap, I missed another appointment.”

Ever serious, the voice says, “No, the doctor wants to see you this morning.”

Gulp.

“Okay. I’m coming over.”

Sure I had patients. But my patients are used to waiting. Many of my cycling/AF patients have a blog to write anyways; they don’t mind the peace and quiet of the exam room, as long as the Wi-Fi is working.

“It’s me, DrJohnM,” I said as I entered the office. Just kidding, I don’t call myself that. Well only when I whisper sweetly to my wife. (I’m laughing again.)

There was a chill in the office when I arrived. It was as if their faces could talk. He’s here; you know, the guy who took his splint off. Wait, let me see what he looks like. OMG. That’s the guy. He was here yesterday. You should have seen it. The splint was a mess—sweaty and all. The wrap was so bad. He said he’s a doctor, but geez, don’t heart doctors know anything?

It’s funny how guilt messes with your imagination.

Now, I’ve never been in the presence of a hand surgeon before this week. I had only heard rumors. Supposedly they consider themselves apex-predator doctors too.

“Trying to heal thyself; I see,” the surgeon says as he looks down at my disheveled splint.

Before I could counter with a something witty, he shakes his head and walks out. Counting to ten, I suppose.

A shy office staff person then directs me to a large cast room. There were two toddlers with casts. They kept talking while I tried to read a review article in the Journal of the American College of Cardiology. It was hard to concentrate. My thumb throbbed. I waited. I read. I listened to the toddlers. My medical assistant texted me, “ETA?.. the two cyclist/AF patients have finished their posts for today.”

I responded, “dunno, I think they are mad here…not sure they know what electrophysiology is.”

I get up and looked around.

Then it happened.

“What do you need?” asks the very mom-like woman. Flash-back to junior student OB-GYN rotation. A run of atrial tachycardia thumps my chest.

In cardiology mode, I say, “Well, should I tell my patients that are waiting for me to go home?”

“You need to sit down and let him put a cast on your arm.”

Vagal surge. Dizzy. Hot flash.

Ah…

Well…

“He won’t tell you that, but I will.”

I thought, “How many joules was that shock?”

An amazing thing happened. I sat down, shut up and waited. When he came over and started with the casting, I managed to eek out something about getting another (removable) splint.

“Don’t take this the wrong way, but I am going to idiot-proof this situation. I am going to protect you from yourself.”

You ever see a dog with those collars over their noses? They keep shaking their head about and scratching at the thing with their paws. That’s me with this damn cast. I keep wanting to shake it off. Not only can’t I ride, or sweat; the worst part is not being able to hit the space bar. I am back to pecking out blogs.

The take home:

Of course the greater message here is more than a dumb doctor’s non-compliance adherence.

What poofs in my mind is the fact that hand surgeons use casts to protect people from themselves.

Imagine if heart doctors could do that for heart disease. Or, are we already trying?

JMM

Two more issues on the treatment of Sudden Death in the young person…

May 1, 2012

in Athletic heart,Doctoring,General Medicine

There was a flurry of words written today about preventing the rare but tragic occurrence of sudden cardiac death in a young person. At the heart of the debate lies the issue of how best to protect the young from dying.

I think it’s worth making two more points on this issue.

Treating Sudden Death:

SCD due to VF in a patient wearing a 24 ECG monitor

Sudden cardiac death almost always results from ventricular fibrillation–rapid and disorganized activation of the ventricles. The best way to stop VF is to shock the heart. The shock resets the heart and restores regular rhythm. It’s important to get this done as soon as possible because organ damage starts within minutes of the VF episode. (The patient pictured on the right died on the golf course.)

AED

The automatic external defibrillator (AED) deserves mention here. My colleague, Dr Jay Schloss (@EJSMD) correctly writes–in this insightful comment today–that AEDs can mean the difference between life and death. Jay tells us of the tragic reality surrounding the death of star athlete, Wes Leonard. First, Mr. Leonard’s loss of consciousness was wrongly attributed to benign causes; then, when a nurse recognized the cardiac arrest, an AED was not easily accessible or charged. It’s an awful story; one which highlights the urgent need to have easily accessible AEDs. Sportsmen unlucky enough to have VF don’t need policies and procedures; they need shocks. What’s more, that same AED might also save the life of a fan. Unlike screening ECGs, AEDs offer definitive therapy of VF with few downsides.

(A good reference source on sudden cardiac arrest and AEDs can be viewed at the Heart Rhythm Society’s website.)

The ‘heart’ of a sportsman:

In the effort to inoculate young people against all that can fell them, an often forgotten casualty is the removal of what makes life fun–the competition and risk-taking that comes with being young. In writing this must-read essay, ‘The Dark Side of EKG Screening in Athletes‘, my friend and colleague, Dr Wes Fisher, poignantly captures the essence of how costly it can be to label a young person with heart disease. Wes tells me, “of all the things that medical bloggers can offer, bringing readers into the exam room is among the most powerful.” His provocative story of star-athlete, ‘John,’ his tearful mother, meditative father and gloomy cardiologist, ‘Dr Kiljoy’, shines a bright light on one of medicine’s greatest tragedies: making a well person sick.

Fortunately, sudden cardiac arrest rarely kills young people. But even so, no one wants a young person to die. Much work remains. We must find the means to save the lives of the few unlucky souls who suffer sudden death. But also, we must do this without excising that which makes the young so beautiful–their good health.

JMM

The NY Times gets it wrong on ECG screening of young athletes

May 1, 2012

in Athletic heart,Exercise,General Medicine

When a news source as powerful as The NY Times publishes an article about sudden cardiac death in young people, one expects accurate information. It’s far too important a topic to write about imprecisely. This piece, entitled Should Young Athletes Be Screened for Heart Risk, included numerous inaccuracies and failed to tell important facts about the complexities of widespread screening of athletes. It was a really bad post.

I’d like to help clarify things.

Let’s state the obvious first. Few events in medicine–and life–pull at your heart more than the sudden death of a young person. As a Dad, it hurts just thinking about it. I accept that the tragic nature of the problem can cloud thinking on the matter.

As a heart rhythm doctor, I am tasked with diagnosing and treating conditions that could cause life-threatening arrhythmias. This is a tough problem. One reason is the rarity with which sudden death occurs in the young and outwardly healthy. Another is that sudden death rarely gives second chances. Its finality, therefore, motivates medical people to strive for 100% effective treatment. Again the obvious: whenever one strives for 100% efficacy, over-diagnosis and over-treatment become more likely. Never missing anything has steep costs.

Now, let’s get to the specifics of the Times’ misstatements:

On the incidence of sudden death:

As stated by author, Mr Anahad O’Connor…

“Once thought to be exceedingly rare, sudden cardiac death is far more prevalent among young athletes than previously believed, recent research has shown.”

Not exactly. The two scientific papers described as ‘recent’ were published in 2001. In fact, the lead sentence in the referenced policy statement from the American Academy of Pediatrics states, “in the [US], there is no centralized or mandatory registry for pediatric sudden cardiac arrest (SCA)…Available data generally are collected through media reports, from lay SCA advocacy groups, or from peer-reviewed publications, often from major referral medical centers.” In other words, we have no idea whether sudden cardiac death is becoming more prevalent in the young.

On who is at risk:

“While it can strike those who are sedentary, the risk is up to three times greater in competitive athletes.”

This statement makes athletics sound dangerous. Given our crisis in youth health, that seems unwise. Here’s another way of stating the known facts. The best peer-reviewed estimate available (Circulation, 2009) for sudden death incidence (US) in young people are that approximately 100 competitive athletes die suddenly per year. Considering the tens of millions participating, the actual death rate is 0.6 per 100,000 person-years. Keeping the things that threaten our youth in perspective, and even if we agreed on a three-fold increase in risk from competitive athletics, tripling the risk to 1.8 per 100,000 person-years hardly seems dangerous. The bottom line, which should have been written clearly, is that sudden death in the young is exceedingly rare—and three times rare is still rare.

At the risk of sounding unsympathetic to Ms. Varrenti, a grieving mom who started a foundation dedicated to sudden death after her teen died, I disagree strongly with her statement that…”it [sudden death] happens all the time.”

On ECG screening:

The rarity of sudden death in the young person directly impacts our ability to prevent it. Enter the debate about screening ECGs, which I have written about previously. This is where the Times gets it really wrong. First, on simple facts, they are way off on the price of an ECG. Just trust me: no one charges 1400$ for an ECG. Most often, it’s below 100$.

More importantly, the article overstates the benefits of the ECG as a screening tool. Though it is true that an expert electro-cardiographer may detect abnormalities in many of the underlying conditions (hypertrophic cardiomyopathy, Long QT syndrome and myocarditis) predisposing to sudden death, this doesn’t mean that’s what will happen in the real world. I respectfully disagree with family physician, Dr. Drezner, who stated that newer methods of ECG interpretation are better. If anything, ECG skills have worsened. The very human skill of ECG reading has gone the way of the physical exam. It’s not taught, appreciated or desired anymore. And despite what you may have read, computers cannot interpret ECGs accurately. (Not even iPhones) The under-detection of ECG abnormalities combined with the sharp rise in over-investigating normal findings will negate the rare finding of a potential abnormality.

Can we screen all athletes?

Dr. James WIllerson, the head of Texas Heart Institute, and beneficiary of a five million dollar private grant to screen 10,000 Houston-area kids, says “if we save even one life, it would be worth it.” That’s hard a statement to argue with. And it’s certainly easier to strive for such lofty goals with 5-million-dollar grants.

Here are some questions that Dr. Willerson should have been asked:

  • How would you know whether finding an ECG abnormality saved a life?
  • How do you measure the emotional costs of holding a kid out of sports?
  • Does prohibiting a kid from sanctioned athletics prevent him (or her) dying on a playground or at home?
  • Will you tell us how many extra heart tests (and complications thereof) will be done in the name of saving one life?

The Times should correct (or add too) this terribly flawed story. It’s important for the youth and parents of America to have accurate information about sports-related death.

I’m no journalist, nor a precise writer, but it’s really important that educators of the public understand what we were taught in medical school: No data is better than bad data.

JMM

P.S. I am not against the use of the ECGs in individual cases in which a doctor and patient understand the pre-test likelihood of abnormalities. Rather, these comments pertain to the widespread screening of low-risk populations.

New Trials and Fibrillations post is up:

April 29, 2012

in Doctoring,Reflection

When doctors make big salaries…

The “rich”-doctor debate is old, but surely not tired.

Lately a number of stories detailing the big salaries made by cardiologists have stirred the pot again.

How much is your doctor worth? Do we make too much? How happy are we with what we make?

Head over to the Trials and Fibrillations blog to see my comments. Hopefully you will leave one of your own.

JMM

Some writing music

April 28, 2012 Reflection

A favorite. For my Canadian friends… JMM

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CW: My Athlete’s Heart Podcast

April 25, 2012 Athletic heart

I recently had the pleasure of doing a podcast with Rob Orman, an ER doctor and fellow cyclocross racer from Oregon. As Dr. Orman says, we discuss the broad intersection of sports and Cardiology. Of course they intersect; there shall be no sport without a good heart. In the 35 minute conversation, we discussed the [...]

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