Out of Harm’s Way
Illustration by Sherrill Cooper
||IT CAN BE JUST AS CHALLENGING TO CARE FOR HEALTHY PATIENTS AS IT IS TO CARE FOR THE SICKEST OF THE SICK. A HEALTHIER PATIENT HAS FURTHER TO FALL.
It is perhaps the most widely recognized concept from the Hippocratic oath: “First, do no harm.” The challenge of clinical medicine is that it is often unclear which path offers the least harm. Every decision carries inherent risk. Case in point: Dale Hawkins.
On Mr. Hawkins’ first visit to the cardiology clinic, I was struck immediately by his attire. He wore a gray suit impeccably tailored to his linebacker-like frame, rimless glasses, silver cufflinks, and a confident glare. His message: “I mean business. Do you?”
As we sat in my office and discussed his history, a profile emerged. At age 22, he joined the Navy. By his early 30s, he was in a command position and in exceptional cardiovascular shape, regularly running three miles in 18 minutes. Retiring from the military at age 35, he put himself through law school and eventually settled on his current career(s): financial planning, with a weekend gig as a volunteer firefighter. Eight years and 40 pounds after retiring from the Navy, he sat in my clinic.
In many ways, he was not a typical cardiac patient. No prior heart disease. No prior hypertension, diabetes, high cholesterol, or tobacco use. No family history of heart disease. And perhaps most interestingly, he denied having any symptoms. He could chase his three kids around, jog a few miles, or carry 50 pounds of firefighter’s gear into a burning building without any noticeable limitations. He felt great. So why on earth was he here? In short: county regulations.
To stay a volunteer firefighter, he had undergone routine stress testing at the county health office a few days earlier. Attached to EKG leads, he exercised on a treadmill until he could go no further. He lasted an impressive length of time, 50 percent longer than the average 43-year-old male, and reported no symptoms whatsoever. There was one problem: During peak exercise, his EKG waveforms changed in a manner potentially indicative of ischemia, a condition whereby arterial blockages deny adequate blood supply to the myocardium during periods of heightened physiologic demand. The question posed to me by his superiors, the county lawyers, and Mr. Hawkins was: Now what?
As I asked Mr. Hawkins to recite the details of his medical history, I acted like I was listening. In reality, I knew these details already, having studied his chart. I removed my glasses, dropped my pen on the desk, and assumed a look of confident attention. In fact, I was stalling. I contemplated a decision, a decision aimed principally at steering Mr. Hawkins onto the path of least harm.
The waveforms detected in his EKG were undeniably abnormal. I had clinical grounds for ordering advanced testing to better define the architecture of his coronary arteries. I could send him for a cardiac catheterization, perhaps the most informative snapshot in our diagnostic arsenal. It is also the most invasive and risky. Anyone undergoing a “cath” is at risk of bleeding, stroke, heart attack, arrhythmia, and even death. Thus, ordering one is never a casual decision. The way I think about it is, if my patient suffers the worst complication from a test I order, can I still look back and say it was the right thing to have done? If the answer is no, I have no business ordering that test. The thought of sending this robust, symptom-free, firefighting father of three to cath failed my clinical litmus test.
Should we call it a day? This was a healthy man with a funny-looking EKG during exercise. He otherwise looks and feels just fine. There’s one problem: What if his EKG was the sole clue? What if I sent him away and he died of a heart attack that might have been prevented by opening a hidden blockage?
This dilemma drives home an often overlooked point. It can be just as challenging to care for healthy patients as it is to care for the sickest of the sick. A healthier patient has further to fall. And we as doctors, while trying to do no harm, can actually precipitate that fall through both the test we conservatively fail to order and the test we over-aggressively order.
I chose an intermediate (albeit imperfect) approach that would yield more information, while minimizing the testing risk. I put Mr. Hawkins through a more advanced stress test, accompanied by non-invasive CT coronary imaging. Neither test is perfect. Each can produce both false-positive and false-negative results. Nevertheless, in a diagnostic search for reassurance, we found some measure of it. Both the stress and CT were negative: There were no obvious indications of significant coronary blockage.
Last Friday evening, I called to check on him. His wife answered. “Oh, hi Dr. Munoz. You missed Dale by five minutes. The firehouse siren always seems to sound when we’re sitting for dinner. He still feels great!”
A good sign, I hope.
Daniel Munoz, M.D., is a first-year fellow in the Division of Cardiology.