Asclepius’ second chance

I‘m sure it’s probably nothing—but you deserve a thorough check to make sure.”

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 reluctant 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 teaching, 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, running 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 cardiomyopathy, 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 suffered a great deal of damage. Even worse, the increasing disease in his conducting system posed the threat of a malignant, 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 revelation was greeted by a growing 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 ventricular tachycardia with sinuatrial and atrioventricular node dysfunction … requires dual-chamber implantable cardioverter 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 disease. Cardioversion is one of the most dramatic treatments 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.

Paul was the last person on my mind when my secretary 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, courageous 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 decision …”

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, mistrust, betrayal, grief, loss, and pain that have characterized 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 potential risk of my near miss (as if anything about this was “mine”) and then finding myself immersed in the medical 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 suffering 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.

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