Pacemaker Story

I was recently wheeled from a “prep room” to a, “procedure room” by a registered nurse who reviewed how fortunate I was to be where I was: a nationally renown cardiac center. The theatre where my procedure was to take place was packed with computers, covered tables with instruments, and three very efficient looking workers in scrubs. Pulled alongside the operating table, there was a need to move over from the gurney and I questioned if it would just be easier for me to get off the one and hop on to the other.

“Just slide on over,” was the no-nonsense response. I did and found myself in a warmed cocoon of sorts. I let out a spontaneous sigh reflecting how comfortable it was. As these three “techs” worked about me (EKG leads taken off, chest re-scrubbed), I told them about my first year in private practice:

“We were young and new and were trying to show our best when we opened that practice. We did a lot of women’s health care as women having babies were our demographic of choice. One of our nurses suggested putting a heating pad in the top drawer with the KY Jelly at the end of the exam table. The first patient I used the warm KY on let out an almost sexual, “Oooohwhoah” when it was applied for her vaginal exam. I made sure to warn my future patients of our thoughtful preparation as her spontaneous exclamation was, well, awkward.”

This got an appreciative laugh and before I knew it, a mask was applied.

My experience in said procedure room found its birth four days before. The holidays and serial atmospheric rivers in both the Northwest and Southwest found me fairly sedentary over a three week period. After New Year’s the rains let up and I went for a walk with Kernie and Sloane. Returning home, I noted on an incline of about 60 yards that I was exceptionally short of breath. I checked my pulse and was surprised to find that my pulse was below 60; once more, I seemed to skip a beat after two normal beats, regularly.  I rested up, continued the walk home feeling a little tired and maybe a little more nervous as my thought process attempted to regain knowledge I took for granted a decade ago. At home, my blood pressure ran quite low for me and the pulse remained below 60 which at rest, elicited no problems I could sense. We went to bed and upon awakening, my Apple Watch informed me that my pulse had gone below 40 between 5-6:30 AM.  I had a nice breakfast and we agreed it was time to have a trained professional get eyes on this problem.

I don’t throw my MD title around liberally but in this case, I decided broadcasting this as I presented would make me credible (or not….) and would elevate the vocabulary to help us cut to the chase more quickly. It worked well. The nurses chatted using medical lingo as they put cardiac leads and “shock pads” fore and aft, “just in case.” The R2 (second year resident)  from Urgent Care bonded with us nicely while taking my history,  complimented me on providing a complete history that did not require many follow up questions. Within minutes we met a cardiologist (this was mid morning on a Friday) who was affable, interactive, and conducted the interview without taking his eyes off my heart monitor.

“Well, you clearly have a second degree block and I am worried you may occasionally have a third degree block. You will need a pacemaker. Oh, and by the way, how long have you had your left bundle branch block?”

And I thought this was going to be complicated! I remember what a bundle branch block was—a slowing of the electrical conduction communicating with the left ventricle. Once more, I could answer his question in some detail.

“I have never had a bundle branch block.”  His face provided evidence he did not trust this answer.

“How do you know?”

“Because I had an EKG run almost a month ago and it was normal.”

His eyebrows raised—“Can you show me this EKG?”  I failed this one, not taking advice I had given for years: Old people should always have an up to date EKG in their back pocket.

“Why no, but I can pull up the report!”  Within a minute, My Kaiser portal delivered the reading which he read.

He looked thoughtful. His next question was from out of left field: “Could you have been exposed to Lyme disease?”

His orientation to that question was seeking out reversible causes for an electrical heart block over a three week period. That meant we were searching for zebras (old medical school aphorism, “when you hear the sound of hoofbeats, look for horses (a common cause of hoofbeats), not zebras (an uncommon cause of hoofbeats, at least in N. America) ”). We were going to look for some unusual and exotic diseases.

OH BOY!

Of interest, before going to the ER for further testing, he reviewed the need to stay in the hospital over the weekend—no pacemakers are placed non-urgently over the weekend. He anticipated that we would resist. Despite having a new Medicare Advantage plan with higher hospital co-pays, I was on board as was Kernie (especially Kernie) and he smiled saying that saved us a quarter of an hour as he had anticipated resistance on this point from an old retired doctor.

So for the first time in my life, I was admitted to a hospital for a non-elective procedure and of more than 24 hours. I stayed at the Kaiser Hospital mid-county San Diego. I felt like I was at the Hilton despite admonitions to not get out of bed without someone on hand and to collect every drop of urine.  My TV screen was wall-to-wall and on it, I watched the Seahawks play the 49ers. One ordered food from a menu when the mood struck. The food was pretty good.  The staff, from janitor (Spanish speaking and when he heard my accent, engaged briefly but deeply in matters of the world here and beyond. He was a Jehovah) to respiratory care, lab techs, nursing, and doctors all had attended the obligatory Nordstrom Service courses because they were uniformly engaged, interesting, interested, and helpful. My night nurse the first two nights was from Kenya by way of Berlin. I had her at, “Jambo”. She developed concern with my pulse in the low 40’s but could not convince the attending to give me atropine and I salute his good judgement as well as her attention to detail. The Hospital Cardiologist was an energetic young woman with an Armenian name and she also engaged and reviewed the likely outcomes: I was to be transferred on Monday to Scripts in La Jolla for a cardiac MRI and pending the results put on the schedule for a pacemaker (with or without a defibrillator depending on the MRI) for either Monday or Tuesday.

She loved Sloane and asked if she could take her on rounds……..

This uniformly positive experience reminded me why I did not settle down in San Diego which for many, would have been an easy choice; after all, II grew up here. My grandmother lived in La Jolla.  But as a, “young lion” just out of residency, I wanted a broad scope of practice and as San Diego was over-doctored (then as now) I could never have had that practice—no hospital work, delivering babies, or urgent care work.

My friendly relationships with the hospitalist and cardiologist at the Kaiser hospital paid off in that they decided to transfer me to Scripts Hospital in La Jolla where their “Cardiac Work” was done a day early. First thing in the morning I was to have an MRI of the heart (now explain that to me—-you have to hold perfectly still for an MRI but the heart does keep moving, yes?). The exercise in the basement consisted of me selecting music (I chose “Americana” but when it proved to be new age country pop music, I switched to opera), lay very still, and then, yoga-like, inspiration, expiration, now hold your breath……. I started counting the intervals holding vs catching back up and the cycle was 15-20 seconds in each phase….until she forgot to tell me to “OK, now breath.”  I counted to 40 on that one and was about to disobey when she told me the first phase was done.

Returning to my room at Scripts, I got feedback from the nurse that I was likely to have the pacemaker placed on Tuesday (the next day) and I asked if I could eat. She asked that I wait until she was sure.  It was almost noon when I met my new cardiologist who blessed the MRI (“You know, they were looking for zebras…..you don’t have a zebra”), and told me we were a go for 2:00.

I only waited a half an hour or so as at 1:00, they were ready for me and down I went into the bowels of the very large hospital. The pre/post op area for the cardiac service reminded me of the ancient harbor of Carthage: a central raised area surrounded by an ellipse of stalls. The babble of patients and nurses was quite loud but it was a fine place for people watching. My LPN who prepped me was a squat hispanic woman named America who had a pleasant affable way as we chatted and she efficiently got EKG leads attached in record time after shaving and prepping my chest. The anesthesiologist visited and we agreed on a non intubation form of anesthesia, and lastly the RN came and got me while discussing my luck at being a world-renowned cardiac center.

My last night found dog in lap and wife on hand as a distinguished old doctor came in, dressed as I used to dress: nice slacks, button down shirt with a tie.  He introduced himself and went to the closet opposite the bed and pulled out a folding chair. He sat and proceeded. He was the hospitalist and would write orders for discharge the next day. LIke me, he wanted to gather his own data and had not looked at the chart. I related my story from the beginning and he suddenly jerked to attention and raised his hand.  “You said dyspnea on exertion a minute ago; where did you learn that expression?”

“Oh, I am sorry, I thought you knew, I am a retired physician.”  He beamed the smile of camaraderie and we traded war stories for the next half hour.  I learned that he started the hospitalist system, is 3 years older than me and still going strong, taking call even now. I felt an admiration for him and yet, felt sorry for him as well. His love of medicine kept him going but he looked like he had been ridden hard, and put away wet. I contrasted this sense to that when I asked the R2 on the first day, what he saw himself doing when he finished his residency.

“As little as possible….”  Said with a smile and a short story reflecting that at his point, he really was not sure that clinical medicine was what he wanted to do for the rest of his life.

My conclusion of this very stimulating week was that there are places where the medical system is not broken. Kaiser did manage care and provide great service. I have yet to be billed for a copay but I have confidence that will come. The care I got was top rate and I have finally gotten to bicycle once again, riding the hills of North County to the tune of 20 miles a ride. While a Scripts hospitalist on day one, a young “technical” doctor, asked what I thought of the Kaiser doctors, I thought he was speaking to competence but that was not his real question. San Diego remains over-doctored so each institution finds itself in a buyer’s market. His question related to the quality of work life at Kaiser as he had heard that their compensation was very good—better than Scripts—but that they had heavier workloads.

Perception of workload remains very subjective and influenced by one’s mission at work. That old internist and I shared that for most of our work lives.