...that you may know Him better: CCU

The CCU- Coronary Care Unit, or the Cardiac ICU. Call it what you will- this is where you see REAL heart attacks. What I mean is, we get LOTS of admissions for chest pain. Just about anybody who mentions "chest pain" in the ER has to be "ruled out" for an MI (myocardial infarction- aka heart attack). Even though a cast majority of these "chest pains" are NOT from the heart, there are always the rare exceptions which ARE from the heart, and it's a major problem if you miss it. So when you work "the floors" (the regular inpatient part of the hospital) you get lots of chest pain admissions to "rule out MI." What does that mean? In essense, you "cycle the trops" and get a repeat ekg in the morning, sometimes with a stress test, then tell them it's acid reflux and send them home. ("Cycle the trops" means checking a troponin level every 8 hours three times. Troponin is an enzyme found in heart muscle, so if heart cells die, it's released and the amount in the blood increases. As long as the troponin doesn't go up over 24 hrs, there's probably no heart damage- no MI.) Ok, sometimes it's NOT acid reflux. But that's usually our best guess. In either case, these admissions are plentiful and pretty much... boring. Because the REAL heart attacks are usually obvious from the start, and never come to us on the floor. They go directly to... the CCU. Finally, I'm seeing the REAL heart patients. It's pretty overhwelming at first. "They" (I'm not sure who "they" are) never let us get close to these patients on the floor, so it's like entering a whole new world. Here the EKG's are actually abnormal, the troponin levels actually rise, and we don't send patients for stress tests- we send them for "angios" and "caths" (where you stick a wire into the artery in the groin and guide it all the way into the arteries of the heart and if you're lucky, clear the blockage, thus avoiding surgery) and sometimes for open-heart surgery (the infamous "CABG"- or by-pass.) It's a very unique little world, the CCU. The best way to explain it is to demonstrate it with a few typical patients. (ALL patient identifiers have been completely re-worked so that you would never know who I'm talking about...) First is Mr Smith, a 56yo male, probably weighs about 250-300lbs, most of it around his middle. Has a couple of grown kids, and a wife who probably nags him about eating less. He came in with a STEMI (a full-blown heart attack, one severe enough to cause "ST elevation"- a specific pattern on the ekg- hence the name ST-Elevation-MI), and had a successful angio (no open-heart surgery necessary). But he still suffered some real heart damage, and was having some serious trouble keeping his blood pressure up after the procedure. At the time I met him, he was lying flat on his back in bed with COUNTLESS tubes and wires forming a meshwork all around his body. He was intubated and on the vent (a machine was breathing for him, which meant there was a nice tube sticking down his throat). He was on SIX different constantly-running IV meds (requiring 2 IV poles and 5 IV pumps and tons of IV tubing, as well as a couple of needles in his arms for IV access). He had the typical foley in place (can't go to the bathroom on your own when you're knocked out and dependent on a machine to breath for you!) And he was "special"- because of his trouble with blood pressure, he was on an IABP- intra-aortic baloon pump. Basically similar to the idea behind "angios" and caths"- only this time the wire they thread up to the heart is attached to a balloon which inflates and deflates in coordination with the beating of the heart, to help it get enough "oomph" behind each beat. The IABP means another machine, more noise, and even more wires. Oh, and I forgot all the monitors- the tele leads (sort of a continual ekg watching what his heart is doing) and the pulse ox (measuring how much O2 is in his blood) and such. To see him for the first time, you'd have to wonder if he'll ever come out of the CCU alive. I spent some time in his room, watching the monitors, listening to the machines that were helping him breath and assisting his heart... and marveling at the nurse who could so deftly work her away around countless wires and somehow know what each one was for. I wondered about his family, wondered if they'd worried about his health... wondered if HE'D worried about his health. I think most Americans are aware of the risks of heart disease. We all know (at least in general terms) what a heart attack is, and that being overweight and eating fatty fast food diets are risky. But I think it's all just words, until an actualy heart attack lands you or a loved in one a bed like Mr Smith, hooked up to all kinds of tubes, wires, and machines, and everyone around wondering "Is he going to live?" Working in the CCU this last week, I've had to rethink heart disease. An "MI" isn't just a common problem that we talk a lot about in medicine. It's a pretty dramatic often very serious disruption to the lives of unsuspecting vicitims and their families. I'm pretty sure that the average middle-aged American male who is content to be overweight and enjoy his food would consider changing a few things if he had to face a Mr Smith. I don't imagine Mr Smith expected to be in that bed, and I like to think he would've tried to avoid it had he known, at least for his family's sake. Now on to another patient- Mr Jones. (You HAVE to use classic, all-American names like Smith and Jones when talking about a classically AMERICAN disease like heart attacks, right?!?) Mr Jones is a 51yo who has been pretty healthy, basically not taking any meds at home (he had high blood pressure once but it hasn't really been an issue...) He works in construction- doing things like roofing and plumbing, so he feels he's in pretty good shape. He's had a few episodes of chest-type pain but they always went away and he doesn't really like doctors so he's been content to ignore them... until one day the pain started and got worse and worse... he was struggling to breathe, and then his left arm went numb, and even looked pale. Now he began to get worried, and called for the ambulance... While in the ER, they did an ekg, and instead of coming over to talk to him, the doctor huddled over the paper with several other doctors. When they had spent several minutes mulling over his ekg without anyone coming over to him, he said that's when he knew something was wrong. They told him they were concerned about his heart, and that they needed to send him to a bigger, univeristy hospital with more experience in acute heart disease. No one really told him if he was having an MI or what was going on. At the larger hospital, he was taking straight to the cath lab (remember- wire through the groin to the heart, find the blockage, attempt to clean it out...?) They found the blockage alright- 4 different blockages, 2 of them blocking 99% of the area the blood has to flow through. Because of the number and location, this was NOT a "successful cath"- he was going to need surgery- an "emergent CABG." He went from the cath lab to the CCU, and was told he would need a bypass in the morning. (To give you a sense of time, his pain started ~5pm; he was in the OR by 8am the next morning.) In the CCU, he has multiple nurses and doctors connecting him to the inevitable tubes and wires, asking him questions, filling out paperwork... he asks questions, mostly about the upcoming surgery. "Is it the only way? What are my chances- 50/50? Should I be calling a priest or something? I didn't know what was happening. When my arm went numb, it sort of scared me. I guess it was a good thing I called 9-1-1?..." I spent a good deal of time talking with him, explaing what all those doctors had been examining on his ekg, talked about what they found during the cath, and why they decided he needed surgery. I answered as best I could his questions about the surgery itself (how long is the recovery?) I printed some information about MI's and CABG's for him to read and share with his family. He was very candid about his feelings- that morning he'd believed he was a pretty healthy guy, now he was scheduled for open heart surgery in the morning. This sure took him by surprise (as I'm realizing heart disease often does...) He was understandably anxious, appreciated having someone to talk to... The next morning, before surgery, his heart surgeon came to talk to him about the surgery, answer all his questions. I listened, so I'd be better prepared to answer the questions of the next Mr Jones I'd meet. The surgeon assured him the surgery WAS necessary, but his chances were GOOD, and the recovery would be slow (3 months before he'd be doing any more roofing!) but in the end he'd feel better than he had before (the symptoms of heart disease had been there- gradually losing ability to perform physically-demanding work, increased shortness of breath when climbing a hill or lifting something heavy, a general decrease in energy that was slow and subtle, not easily noticed...) The most enlightening part of the discussion came early on. After asking the patient for a brief description of "what happened" to land him in the hospital, the wise surgeon asked "so, did you have a heart attack?" And the patient said "No one's really told me for sure." What? I'd talked all about MI's with him the night before. I'd even printed information for him about MI's. I'd explained how we diagnose them using the ekg and lab tests. But, I suppose I didn't actually say "YOU had a heart attack. That's what this was." But surely the ER doctor at the other hospital had... or the doctor who did the cath, and told him he needed surgery? No, all of us had talked about and around it, but none of us actually wanted to say "sir, you have just had a heart attack." As much as we all squirm on the inside at the thought of giving bad news, this man really needed to know. He's already lost control of his plans for the day and for his forseeable future; he doesn't need to deal with any more uncertainty than necessary. He really needed someone to tell him kindly, but in straight-forward way- yes, this was a heart attack. So I learned something from that surgeon- next time I have a patient with a "bad" diagnosis, instead of assuming someone has told him, I'm going to ask "do you have ?????" So, two patients whose lives (and families' lives) were turned upside-down by unexpected, serious heart conditions, taught me a few things about communicating with patients, and hopefully can teach you something about your health. Heart attacks are real, they can be devastating, and are worth taking seriously- at least, seriously trying to prevent them. Go take a walk! Drive past that McDonalds. Don't open that bag of chips- go dance with your little girl instead, and remind yourself that being there for your family matters ever so much more... By the way, Mr Smith is now sitting up in a chair, visiting with his family. No more tubes, no more wires. Probably leaving the CCU soon. He made it- but you might not be so lucky. And Mr Jones? He's 3 days post-op, still having some pain but feeling better, working with his family to move forward and face the future with a slightly new perspective. I feel I must end with a Point of Grace song- the lyrics capture the message well. "Turn up the music, turn it up loud. Take a few chances, let it all out. You won't regret it, looking back from where you have been... 'cause it's not who you knew, and it's not what you did- it's how you live."