Man, Medicine, and Mike

My last patient of the day was an 85-year-old with HFpEF. 

HFpEF (or Heart Failure with a preserved Ejection Fraction) is a condition where the patient’s heart looks normal on the echocardiogram, but they have heart failure anyway. It is very common. It accounts for about 50% of the heart failure that we treat. But it also can be very frustrating. Things can look normal. But the patients get short of breath. Sometimes they can be very short of breath. Often they end up in the hospital.  We do not have good treatments for it. It is one of the big gaps that we have in medicine. 

She was 85. Her chart indicated a history of hospitalization for severe depression, frailty and some other medical problems.  Really? My last patient of the day? 85 years old. Sick. And likely with something that I can’t make better.

Sigh. 

Let’s go back to a few other stories first.

We had a close family friend who was in his 80s. His speech had slowed down. His mind had not. If you would be patient enough to listen to him, it would become abundantly clear that he was very much still “in there.” He was very intelligent with a great wit. There were riches within if you would be patient and wise enough to wait for them.

He was admitted to the hospital. My wife went to visit him and was frustrated at how some of the staff could buzz in and out of his room and not acknowledge him. If he were younger, or faster of his speech, they would never have done this. They would of course greet him, explain what they were doing and ask him if it was ok. But he was slow of speech, and slow to object, and old and quiet. They would just buzz in, do what they needed to do, and buzz out of the room. They wouldn’t truly acknowledge him for the intelligent man that he was. They wouldn’t wait for his permission to do things or to find out what things he needed. They would be gone before he could speak. He would get frustrated by it. But over time he had started to come to expect it.

Is this what it means to live life when you get old?

I was rounding in the hospital. It was a busy day. I had a long list of patients to see. I too “buzzed” into a patient’s room. I had to see him, do a brief exam and confirm what the APP (physician’s assistant or nurse practitioner) had told me about him and his care. When I looked at him, I was reminded of our family friend. That acknowledgement stopped me. I slowed down. I grabbed a chair. I sat down. I asked him how he was doing. I waited. His words came slowly. Much to my surprise however I found that he was very much “in there.” I got a lot more information from that visit than I had suspected. I also got a lot more out of the visit than I had expected. I got to interact with a kind, intelligent, and wise man. There was so much more to him that I wouldn’t have known if I hadn’t made myself slow down. I walked out of the room more satisfied and enjoying my job more than I had when I walked into the room.

People look different when they are in the hospital. They often lose their identity. The certainly lose a lot of control. The activity in the hospital can come and go and buzz in and out and leave little time to let them catch up with what is happening. This is much worse when they are elderly. They become tasks. They lose their humanity. We lose our humanity.

It was another day several years ago. I was going to see a patient in the “ACE” or “Acute Care of the Elderly” unit. I marched into the room where there was an elderly man asleep. His sheet had fallen to one side of him exposing his private parts. His hospital gown was askew. My goals became to get in and out of the room as quickly as feasible. 

And then I looked at his name. He was one of my patients from years before. He was not only one of my patients, but he was a retired physician. He was a brilliant man. In his day he was visionary. He brought new ideas and new techniques to our city. He was loved by hundreds or more likely thousands of patients. 

Once again I was stopped in my tracks. My interaction with him slowed down. I covered him up and straightened his gown before I woke him to talk with him. He was an important man and deserved to be treated with dignity. (Aren’t they all important people deserving of dignity?) Age had pulled at his intellect. He was not all that he used to be. But to me, he was still very much “in there.” I reminded him who I was and how I had been his doctor years before. I reminded him of who he was and how much I valued the things that he had done in the past. He didn’t remember all of it. But I could, and I was going to remember it all for him. 

I was in the office on another day. It was another very elderly man with shortness of breath. His family spoke a lot for him. He was quiet. I stopped in the middle of the visit and directly asked him what his career had been. He started to describe his work. In the process I discovered that he had a PhD in chemistry. He was a brilliant man. His face lit up as he was able to describe where he went to school. We went to the same college. We talked about shared college experiences (even though they were separated by a generation of years.) He was very much “in there.” Suddenly he was a part of the office visit rather than the subject (or victim) of it.

My last patient in clinic was an 85 year old woman with HFpEF. 

I went into the room and saw a frail elderly woman accompanied by her son. It is always so easy to just talk to the son. He of course is younger and has more rapid speech. 

But I forced myself to address her and talk primarily to her. When I did she astounded me with her eloquence. She had a quiet dignity buried within her withered frame. I could imagine what she had been like in her younger years.

She told me how the staff at her assisted living were forcing her to do physical therapy. She told me how every time they tried to stand her it would create great distress for her. She eloquently described her shortness of breath and chest pressure better than I have ever heard it. “When they stand me up, I get the idea that I am going to die.” “My chest fills with pressure. I have to sit back down. I have to wait to let the ‘air go out of the overinflated tires’.”

It was an amazing experience. She was very much “in there.” I learned a lot about her. I was better able to understand and take care of her. I may not have been able to solve all of her problems, but I at least heard her and tried to help her. I also walked out of the room a lot happier and more satisfied with my day. Not that we ever have favorites, but she was my favorite patient that I saw that day.

I tell myself this regularly: “Slow down. Look for the person inside. Look beyond the slow speech. Look beyond the hospital gown or disheveled clothing or uncombed hair. Look beyond the frailty. Look beyond the disease.”

You may be surprised. I suspect you will be rewarded if you do this.

You may discover a wonderful human being. You too may see that “he or she is very much in there.”

A couple of weeks ago I was rounding and needed to go see another old, frail patient with an LVAD (left ventricular assist device). He was admitted to the hospital again. This time it was for pneumonia. He is 79 years old and is getting older and older.

I hear the complaints of the staff. “What are they thinking? Why do they put LVADs in these old patients who just get sick and end up in and out of the hospital?” I find myself asking the same question sometimes. I rounded on the rest of the patients in the hospital and left seeing him for later in the day. The nurse called me. The family was questioning some of the medication orders. 

Sigh. Ok. I will go and talk with them.

And then … I was given an important lesson.

We can always learn something. No matter where we are in life or in our career, we can always learn. And sometimes the lesson comes in an unexpected way and in an unexpected time.

His wife was in the room. The patient looked better than what I thought he would. His wife had a series of questions. It turned out they were all rational and logical questions. We worked through them together. 

Then she stopped me. She looked me in the face and told me that she wanted to thank me. 

“It has been over 7 years since he had his LVAD implanted. Those have been 7 more years that I have had my husband. They have been 7 years where he has really lived his life.”

Wow. Has it really been 7 years? It has gone by so quickly.

She wasn’t finished. 

“I have got to thank you for those 7 years and for something else. You probably don’t remember. It may not have meant much to you, but it has been very important for us. You told us that the team was not going to put his LVAD in for him to just sit at home. It was being put in so that he would really live his life. I have never forgotten that.” 

“When we first got home, he was too weak to do much. But then he got better, and he started getting up and doing more and more. One day some friends asked if he wanted to go play golf. He asked me if he would be able to. I told him what you said. I reminded him that he had to try. He didn’t have the LVAD just to sit at home. He needed to try to live his life. He played golf. He enjoyed it. In fact, he has played golf again and again and again ever since.” 

“Next came bowling. One of the men on the bowling league had to have a knee replacement. The others on the league asked my husband if he could fill in. He told me he didn’t think he could do it. I reminded him again. You told us he didn’t get the LVAD to not do things. I told him he had to try. He went bowling. He did fine. He enjoyed it. And he continued to go bowling again and again and again.” 

“I have you to thank for all of that. You helped us get to the LVAD. You have given us seven more years together that we would not have had. More than that what you told us helped us so that they were seven really good years. Thank you.”

I struggled to maintain my composure. I think I pulled it off. But there were tears in my eyes after I left his room and as I walked down the hall. I slipped onto a side stairway where I could be alone and out of view. I didn’t know what to say. Wow. 

We forget. We get used to it. When we first had LVADs it seemed like such a miracle. Each and every time we saw patients that were going to die and then – they didn’t. More than that we saw them start to do things again that they hadn’t been able to do in years. It was such a heady and amazing time. One patient went back to work. Another got married and had a baby. Another did the River Bank Run.

Over time however we have gotten used to it. We know that all of our patients (all of us too) are going to die someday. Is it really worth going through the surgery and recovery and hassle of an LVAD? Or should we just let our patients have a more simple and uncomplicated death? 

We see the 79-year-old man admitted for an aspiration pneumonia and we wonder if we are doing the right thing. 

But we have forgotten. I had forgotten. I needed a nice older couple to take me back to school and teach me.

It is seven years later. It is seven good years later. He is getting older and with it is accumulating more illness. I shouldn’t be so surprised by that. But he is alive. He has really enjoyed and lived these past seven years.

His wife told me that she hoped I still give that instruction to my patients. I told her that I do. I explained the phrase that I use: “We do LVADs and transplants not to just keep people alive. We do them so that they can really live.”

What an honor to be in a position to make that sort of difference in someone else’s life. It really is a privilege to do my job. It makes me so excited to think that they heard that lesson and really lived. He learned how to “live” and not just remain to remain alive.

I suppose there is a lesson in this for all of us.  Life is not just about marking time. It is about finding purpose and meaning and going after that purpose and meaning.

That was my first weekend on call since my diagnosis with cancer, the treatment and the long recovery time that it took to get my energy back. 

When I was first diagnosed my brain was flooded with questions about how I should use my time. What should I do? What would you do if you were told you had cancer? What was important? Should I just run away from all my responsibilities and hide out on a sailboat or beach somewhere? What should I be doing with my time? Now that I was coming back on call, I wondered if this was the right thing for me.

Life is not just about marking time. It is about finding purpose and meaning and going after that purpose and meaning. Why do I do what I do? Is it worth it?

That day – in that moment – I was told with some forcefulness – yes – yes – it is. 

I am back.