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Hands-On Experience

By Eric Van De Graaff, MD December 13, 2010 Posted in: Heart Health

I am a certified expert in the realm of cardiovascular disease (at least that’s what my framed certificate says).  For years I have studied the anatomy of the heart, the physiology of blood flow and electrical conduction, the mechanics of ventricular contraction, and the workings of the valves.  I have seen thousands of patients seeking care for the myriad of ways that the heart can fail and have followed them through their recovery or, sadly, seen them through their demise.  I am intimately familiar with the hundreds of drugs we use to alter cardiac function and am facile with numerous tests that determine the heart’s health and my patients’ outcome.  At least weekly I don my scrubs and perform some invasive procedure that purports to improve the efficiency of the heart and thereby the quality of the patient’s life.

But here’s the really interesting thing: I specialize in the diagnosis and treatment of a bodily organ that I never actually see or touch.

It occurred to me one day as I was watching a computer image of ultrasound reflections that, as a cardiologist, I am never really in contact with that part of the body about which I am supposedly an expert.  During the physical exam I feel the reflection of the heartbeat in the radial artery of the wrist and listen to the sounds of fluid turbulence and the closing of valves.  The EKG is just a snapshot of electricity passing between the electrodes on the arms and legs.  An echocardiogram sends sound waves through the tissue of the chest wall and uses their reflection to create a composite image of the heart cavities and valves.  The nuclear camera collects gamma rays to generate a mosaic of blood flow and the fluoroscope sends x-ray beams through the chest to produce a film negative of its contents.

Even in the cath lab, as we hunch over the human body and intently tinker with the heart, we never really come close to it. Cardiologists have spent decades inventing clever ways to get inside the heart from remote areas of the body: the arm, the wrist, and, most commonly, the femoral artery of the leg.  In the cath lab I hover over the groin more than over the heart—I probably spend as many hours in vasectomy territory as my urology colleagues.

Patients sometimes ask me if I need to open their heart to put a pacemaker in.  Of course not.  I start at the axillary vein, pass the wire through the subclavian vein, into the superior vena cava, and finally into the right atrium and ventricle.  Once again I avoid any immediate contract with the organ of interest.

So how much of an expert am I when I never really lay eyes or hands on the subject of my expertise?  Would you ever take your car to an auto mechanic who never opens the hood of the car?

"Yes, ma'am, we can fix the knock in your engine.  We'll just listen to the hood with a stethoscope, thread a plastic tube through the radiator while we monitor the whole situation with electrodes on the wheels and fenders, and finish off by cleaning out the fuel injector with a solvent we infuse into the exhaust pipe."

I guess we cardiologists are not too different from other professionals who study stuff they never personally experience.  Astronomers spend their lives pursuing knowledge about far-off worlds they'll never set foot on.  Paleontologists examine animals they'll never encounter and atomic physicists analyze particles too small to ever hold in their hands.

Our partners in cardiac care, the heart surgeons, don't have this problem.  Their purview is the hands-on maintenance of cardiac anatomy.  They cut through the breastbone, crack open the chest and lay their gloved hands directly on the beating heart.  After suspending the motion of the ventricle and rerouting blood through an external machine, they are free to cut, slice, manipulate, and essentially perform all kinds of arts and crafts on the organ I see only through indirect means.

When I was in cardiology fellowship I took the opportunity to scrub into a few cardiac surgery cases.  For the first time I was able to lay eyes on a live human heart, take it into my hand and feel its pulsations.  Along with the surgeon I explored the chambers and valves as he performed a rather meticulous repair on an unusual congenital defect.  I felt like Dr. Grant in the movie Jurassic Park when he first lays eyes on living versions of the animals whose fossils he'd devoted his life to studying.

These days I still take in a heart surgery every couple of years—somehow, I feel I need to.  It gives me a better perspective on all the images I normally view from a computer monitor.  Just last month I was kindly invited into a case by Dr. Dwaine Peetz, Jr., our CHI Health Clinic cardiothoracic surgeon.  I donned surgical scrubs and joined doctor Peetz in front of the open chest of our patient.

If you ever have the opportunity to watch a heart surgery (click this link for a short video from the BBC, but be warned: not for the squeamish) you'll be struck first by how clean the interior is.  Contrary to Hollywood depictions, the inside of the chest is a sparkling, ordered environment of beautifully crafted organs and vessels, moving and working in concert to push oxygenated blood to the body.  You'll also notice how the heart moves when it beats.  It doesn't really squeeze like the bellows of a pipe organ, but rather contracts and rotates like a balled-up fist that is twisting as it clenches.  The structure actually moves up and down in the chest with each beat (in the early days of the study of circulation, doctors would place the patient on a firm board that lay on top of rollers and measure the distance the body would glide, to and fro, with each beat of the heart).

Dr. Peetz made it all look easy.  Cut open the chest, isolate the coronary arteries, attach the grafts, and ablate the arrhythmia for good measure—all while the heart was still beating (so-called off-pump coronary artery bypass surgery or OPCAB).  Close it all up and the patient is as good as new in less time than it takes to watch a Harry Potter film (of course, these days, with the marathon length of those movies, you could probably get a kidney transplant before Voldemort even shows his sneering face).  As I was leaving the room Dr. Peetz invited me to join him anytime, and jokingly added: "Next time you come, you can do the operation yourself."  I don't think so—the old mantra of medical training, "see one, do one, teach one," seems a little out of place in the world of open-heart surgery.

Seeing the heart in an open chest is like looking out the window of an airplane as you fly over your home city.  As a land-dweller, you know the streets and buildings and rivers and parks because you pass through them every day, but until you are able to gaze on it all from several thousand feet you can’t really appreciate the relationships between geographical structures and get a sense of the overall layout.

Even though I can identify all the structures from pretty much any angle I'm sure I'll be back in the operating room again in the future.   It can never hurt to actually lay eyes on the thing that I spend my life analyzing, studying and treating.

Eric Van De Graaff, MD
Eric Van De Graaff, MD

Eric Van De Graaff, MD is a Heart & Vascular Specialist at CHI Health Clinic.

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