Asclepius’ second chance

Vol 53:  december • décembre 2007  Canadian Family Physician•Le Médecin de famille canadien

2163

Reflections

Asclepius’ second chance ^*

Cathy Risdon

I

The  man  sitting  across  from  me  wasn’t  convinced. 

After all, it was his wife’s idea that he come and speak to  someone about his fainting spell. In fact, he was so reluc- tant to see an MD that we arranged for this meeting with  me  to  occur  in  a  non-clinical  room.  The  practitioner  he  trusted most—our nurse practitioner—sat with us. 

The  3  of  us  gathered  around  a  battered  table.  Paul  McDonald^† sat with a sceptical frown, his tall, lean body  folded  uncomfortably  into  an  old  chair.  It  was  easy  to  imagine  him  as  a  runner.  Recently  retired  from  teach- ing,  he  now  had  an  abundance 

of  time,  which  he  filled  with  his  passions  for  art,  writing,  hiking,  bird watching—and running. For  the  past  40  years  he  had  been  a  runner—long  distance,  run- ning races, lapping up the miles  for  the  sheer  love  of  it.  And,  if  pressed,  he  would  probably  admit  that  running,  in  his  mind,  provided a kind of life insurance. 

Although 55 years old, he had the stamina and resources  of a man 15 years younger. 

The nurse practitioner and I did our best to convince  Paul to follow through with an electrocardiogram (ECG)  and 24-hour Holter monitoring. He was almost offended  by  our  suggestion  that  something  could  possible  be  wrong with him but agreed to go. 

His  ECG  showed  the  characteristic  bradycardia  of  an  elite  athlete.  I  stared  at  the  tracings,  imagining  the  powerful left ventricle that only needed to pump half as  often  as  mine  to  nourish  his  body.  The  longer  I  stared,  the more puzzled I felt. There wasn’t the slightest whiff  of  ischemia  or  arrhythmia  on  this  ECG,  but  something  didn’t quite fit. I made a referral to a cardiologist. 

Normal  test  results  began  to  pile  up  in  Paul’s  chart. 

Exercise  stress  test,  24-hour  Holter,  repeat  ECGs—all  passed with flying colours. The final line of the note back  from the cardiologist echoed the first conversation Paul  and  I  had  had:  “I  really  am  not  convinced  that  there  is 

anything  to  be  concerned  about  for  Mr  McDonald,  but   for the sake of completeness, I will arrange for an echo.”

In retrospect, that was the turning point.

Paul’s  chart  began  to  rapidly  thicken.  I  could  barely  penetrate  the  5  pages  of  single-spaced  type  from  the  nuclear  cardiologist—“dyskinesia,  dilated  cardiomyopa- thy, 34% ejection fraction”—but the bottom line was clear  enough: Paul had serious cardiac disease. Countless tests  and waiting rooms later, the source of Paul’s problem was  traced to a faulty conducting system. Despite the whistle- clean  arteries  seen  on  an  angiogram,  his  heart  had  suf- fered a great deal of damage. Even worse, the increasing  disease  in  his  conducting  sys- tem posed the threat of a malig- nant, lethal arrhythmia.

I had not seen Paul since that  first  visit.  I  followed  the  twists  and  turns  in  his  story  through  the  trail  of  consultants’  reports  and  test  results.  Each  new  rev- elation  was  greeted  by  a  grow- ing  sense  of  astonishment  at  the  severity  of  his  disease  and  a chill when I inevitably thought “what if” at how close  I  had  been  to  sending  him  home  after  his  first  fainting  spell. I didn’t, however, know Paul well at the time—as  I read the reports I thought more of my own “near miss” 

than whatever experience Paul was having. 

My  empathy  deepened  somewhat  when  I  read  the  report  from  the  electrophysiologic  studies  lab: 

“Cardiomyopathy  with  inducible  monomorphic  ventricu- lar tachycardia with sinuatrial and atrioventricular node  dysfunction  …  requires  dual-chamber  implantable  car- dioverter  defibrillator.”  Subspecialist  electrophysiologic  studies  cardiologists  completed  their  job  by  sewing  the  device just below Paul’s left clavicle. 

I  had  never  met  or  spoken  with  anyone  with  an  implantable  cardioverter  defibrillator,  but  they  have  always  struck  me  as  a  lousy  alternative  to  a  worse  dis- ease.  Cardioversion  is  one  of  the  most  dramatic  treat- ments  in  medicine.  I  found  it  hard  to  imagine  what  it  would  be  like  to  live  with  a  figurative  set  of  “paddles” 

wired directly to my heart.

It never occurred to me to pick up the phone to talk  to Paul and find out how he was doing through all this. 

His  story—complete  with  compelling  medicine  and  a  vivid  reminder  of  our  mortality—was  one  I  followed  from a distance.

*According to Greek mythology, Asclepius, the god of   healing, was killed by Zeus who mistrusted Asclepius’ 

powers to bring humans back from death.  Zeus used a  thunderbolt as a weapon.   

†The patient’s name has been changed. 

I thought more of my own “near miss” than whatever experience

Paul was having

2164

Reflections

Paul  was  the  last  person  on  my  mind  when  my  sec- retary  alerted  me  to  a  waiting  call:  “They  sound  very  upset.” It was Paul’s wife; he was crying and afraid to let  her leave the room. She was at her wits’ end and didn’t  know what to do. I agreed to see him immediately. 

The  man  before  me  was  a  shell  of  his  former  self.  

Although  struggling  to  maintain  an  air  of  matter-of- fact  self-control,  I  could  see  Paul  was  deeply  shaken,  on  the  verge  of  tears,  trembling.  With  quiet,  coura- geous  resolve,  he  began  to  tell  me  what  it  had  been  like  to  come  face-to-face  with  his  new  status  as  a 

“cardiac patient.”

“Sure, I was deeply shocked when they told me I had  a heart problem. But they said I could die if I didn’t have  this  put  in  me.  Now  I  wonder  if  I  made  the  right  deci- sion …” 

His voice trailed off into silence.

I sat in silent respect as I tried to imagine what he had  been through. Several days after his surgery, having been  declared “fully fit” by the doctors who had implanted his  device,  Paul  decided  to  seek  refuge  at  his  cabin  several  hours away. He went alone to read, write in his journal,  and  reflect  on  the  sudden  change  in  his  health  status. 

There  was  no  sign  anything  was  amiss  as  Paul  headed  out on a sunny April morning for a long walk. 

WHAM!  Like  a  thunderbolt,  he  hit  the  ground.  As  he  tried  to  get  up  and  regain  his  bearings,  another  jolt  knocked  him  to  the  ground.  He  realized  his  defibrillator  was firing. Again! Once more! Desperately, he fumbled for  his cell phone, not knowing how long he had to live before  his heart would stop responding to these horrendous jolts. 

It  seemed  like  forever  before  the  local  ambulance  found  him on the side of the road. His defibrillator had gone off 7  times in the 15 minutes it took for medical help to arrive.

Beads  of  sweat  dripped  off  his  forehead  as  he  described  the  physical  pain  and  emotional  anguish  of  those 15 minutes. His grudging acceptance of medicine  and his trust in doctors had been destroyed in that time. 

Even worse was the reaction of his subspecialist: “What  are you complaining about? Don’t you know you would  have  died  without  this?  It  just  needs  a  bit  more  tuning. 

You’re one of the lucky ones.”

That  was  4  months  ago.  Paul  and  I  have  gradually  worked  away  at  the  layers  of  terror,  flashback,  mis- trust,  betrayal,  grief,  loss,  and  pain  that  have  charac- terized  the  past  year.  As  we  slowly  narrowed  the  gulf  between  us,  I  became  aware  of  how  self-centred  I  had  been—worried  first  about  the  proximity  and  poten- tial  risk  of  my  near  miss  (as  if  anything  about  this  was 

“mine”)  and  then  finding  myself  immersed  in  the  medi- cal  and  technological  drama,  as  revealed  through  the  matter-of-fact  notes  from  the  subspecialists.  As  much  as  I  prided  myself  on  empathy  and  relationships,  Paul  had  never  been  the  object  of  my  attention.  His  suffer- ing  illuminated  for  me  how  much  he  could  have  used  a  medical  ally  over  the  preceding  months.  He  has  also  taught  me  so  much  about  courage,  the  role  medicine  plays  in  creating  illness,  and  the  central  importance  of  paying  attention  to  suffering  and  not  merely  disease.  I  think  both  of  us  are  showing  signs  of  improvement. 

Dr Risdon holds the David Braley and Nancy Gordon Chair in Family Medicine and is an Associate Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.

competing interests None declared

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