Life-Saving Measures

A few weeks ago my young daughter and I were shopping when we ran into a patient of mine.  After chatting with me for a bit, the elderly gentleman turned to my daughter and said “you should be really proud of your dad—he saved my life.”  My daughter nodded politely but seemed unimpressed.  Later she told me that she already knows that I save lots of lives; in fact, she told me, she’s perfectly aware that I save lives every day I go to work and every night I get called into the hospital.

I hated to disabuse a child of the lofty opinion she holds of her father, but I felt I had to come clean with her.  I don’t really save lives too often, I told her.  In fact it’s pretty rare that patients who would’ve died are alive because of me.

The patient I described above, for example, came to me for evaluation of shortness of breath.  My assessment of him ultimately led to a heart catheterization and a stent to one of his coronary arteries.  His breathing improved over the next few weeks as he completed the exercise regimen in cardiac rehabilitation.

About a year later he started having episodes of abrupt lightheadedness and was diagnosed with periodic slowing of the heart.  I solved this problem quite easily by inserting a cardiac pacemaker that kept his pulse rate at a comfortable tempo.  Again he felt better in short order.

At no point did he ever roll into the emergency room with a life-threatening condition that only a quick-witted cardiologist could cure.  He never suffered a mysterious malady, elusive to all other clinicians, leading him to the brink of death until I arrived at the scene to shine the light of my knowledge on the diagnosis and initiate a curative course of therapy.

No, I can’t say that I’ve ever done any of those things.  In his case in particular, neither of the problems we treated were actually life-threatening.  A solitary blockage in a coronary branch can often cause symptoms, but we know from countless research studies that opening the narrowing with a stent—while providing symptomatic benefit—doesn’t really decrease the risk that the patient will succumb to a heart attack.  Similarly, the placement of a cardiac pacemaker rarely means the difference between life and death.  Rather, it serves mainly to improve the quality of life in an individual whose slow heart rate is vexing them with fatigue or lightheadedness.

So, while there are a lot of patients out there whose lives have been impacted by procedures we cardiologists perform, I would argue that the majority of these people would have still been alive without our fancy pacemakers, balloon catheters and stents.

There are obviously a lot of exceptions to this theory.  A patient who comes into the emergency room with a heart attack and who is rapidly brought into the catheterization lab has a much better chance of living if his vessel is opened quickly with a stent.  But even in this situation it’s not clear that we cardiologists represent the difference between life and death.  It may surprise you to learn that the death rate among patients who suffer a heart attack and survive long enough to reach the emergency room is not all that high even without aggressive therapy.  If you were to clutch your chest in pain and be rushed to the ER with the diagnosis of heart attack, and if we were to do nothing more for you than to sit at your bedside and pat your hand, your chance of dying would be no higher than 30%.  In other words, more than two-thirds of patients will survive their heart attacks even if we do no more than let them sit around and watch soap operas on their hospital televisions.  Years ago (before the age of thrombolytics, stents, and coronary care units) this is how we used to handle heart attack victims, and most of them survived despite our best (or worst) efforts.

So, you see, for most of these people we’re not the lifesavers they think we are.  To be fair, early revascularization provides considerable benefit even in those patients who would have survived their heart attack anyway—down the road they suffer less congestive heart failure and arrhythmia symptoms if we can get the blocked vessel open early in the course of the heart attack.

So now I’ve got a daughter who thinks her father rushes into the hospital at nights to do a lot of palliation.  With that kind of record I don’t see her begging me to come to her school on career day anytime soon, standing next to a fireman and a policeman as my daughter proudly proclaims “my dad doesn’t really save anyone—he just stabilizes the heart rate of patients with bradycardia.”

But here’s a thing that’s even harder to explain to an 8-year-old: I really do save lives—lots of them—just in ways you wouldn’t think.  In the world of cardiology it’s not the balloons and stents and pacers that prevent death, it’s the drugs and lifestyle changes and early detection.  The entire country has seen a drop in the rate of death for coronary disease mainly because of the wider application of statin and blood pressure medications.  For every 10 patients I talk into being compliant with their medications, diet and exercise, a handful are surviving simply by not having the heart attack or stroke they were destined to suffer.  Perhaps I did save the old man’s life after all: I started him on the right medications, referred him to exercise therapy, and instilled in him a need to better recognize the importance of caring for his cardiovascular system.

Still, it’s just not really all that cool for an 8-year-old to hear that kind of praise coming from a stranger: “You should be really proud of your dad—he brought my cholesterol and blood pressure under control, got me off cigarettes, and started me in an exercise program.  My risk of heart attack, stroke, cardiac arrest, and congestive heart failure has been cut by a substantial degree and my quality of life has improved markedly.”

No, I don’t think that sort of thing will get me an invitation to career day.