Dr John M

cardiac electrophysiologist, cyclist, learner

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Introducing Dr. Staci Mandrola — @DrStaciM

February 24, 2015 By Dr John

It took me four years to convince my wife, Dr. Staci Mandrola, to join Twitter. Like many (previously) analog docs, Staci was resistant. “I don’t need another distraction,” went one of the arguments.

Yet I knew if she tried Twitter, she would love the medium. If you care about a topic, if you are curious, and if you are comfortable in your own skin, Twitter works. This is why I predict Staci will do well in the digital realm.

The one bad thing about @DrStaciM being online is that one of my secrets is out. All these years, I have had an advantage–sort of like cheating. How does a cardiologist know these things? Well, I have Staci.

In a post for the popular Hospice and Palliative care blog Pallimed, Staci explained why she became a public physician.

Two other things:

Staci is at the national HPM meeting in Philadelphia. I know many of you are interested in these topics. She plans to Tweet updates from the meeting. If you aren’t yet on Twitter, now would be a good time. Dr. Atul Gawande will be the keynote speaker. The hastag for the meeting is #HPM15.

Screen Shot 2015-02-24 at 6.23.14 PMSecond, I have tried to get Staci to change her Twitter avatar. I took that pic minutes after she woke from hip replacement–which she wrote about here: 10 observations from a 49 year-old falls risk.

Social media experts advise authenticity. That picture takes it to the extreme.

Here are two other images of Staci.

Staci the shredder.

Screen Shot 2015-02-24 at 6.34.13 PM

Staci the G-ma.

Screen Shot 2015-02-24 at 6.37.50 PM

JMM

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Filed Under: Reflection, Social Media/Writing/Blogging Tagged With: Hospice

My ICD presentation to a Hospice and Palliative Care Group

April 5, 2012 By Dr John

Last night I gave a twenty-minute presentation on ICDs to a group of hospice and palliative care professionals.

It was a real honor to speak to such an enlightened and dedicated group of caregivers. These are people who really get it.

I wasn’t restricted in what to say about ICDs. They kindly gave me plenty of leeway. That’s scary.

These days, the notion of ‘parallax’ keeps popping up in my mind. That is, the idea that a therapy can look so very different depending on the vantage point of the observer. You can bet a hospice doctor sees ICDs differently than does a heart doctor.

That was my approach for the talk. I tried to show how a cardiac device can be beautiful and life-saving, but also, if not applied smartly in a well-educated patient, these imperfect machines may be associated with substantial risk, fear and no benefit. I tried to show how similarly smart people interpret the same randomized controlled NEJM ICD trials differently. Perhaps it’s because they look at these trials through a different viewfinder–their experiences and feelings about death.

The last few slides summarized my top-five take-home messages from the  2010 HRS Consensus Statement on Management of Cardiac Devices in Patients Nearing the End of Life. Hospice folks know these basic tenets of ethics well, but they were eye-openers for an installer and ablator.

Here are my slides: ICD Parallax-2012

JMM

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Filed Under: ICD/Pacemaker Tagged With: Hospice, MADIT 2, Palliative Care, SCD-HeFT

Going gently…

February 25, 2012 By Dr John

…is how doctors die.

Few essays written by doctors are more relevant to today’s crisis in end of life care than Dr Ken Murray’s now famous, Why Doctors Die Differently.  It made it to the WSJ today, thank goodness. It’s available for free in its original (and longer) form at Zocala Public Square.

We discussed two cases this week in a review committee. Both patients were elderly and had multiple organs failing, but both underwent aggressive procedures that failed to prevent death. The debate centered on why the bad outcomes had occurred. I suggested that maybe the procedures should not have been done in the first place. Blank faces appeared. One person muttered, “they would have died.” But they died anyways, with a lot of tubes, bright lights and pain.

Dr Murray has it right…

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits.

Knowing our limits. That’s a tough one. My greatest challenge as a doctor in 2012 is not moving catheters, or sliding leads through s-shaped veins; these are easy, compared to honing the skills needed to help patients decide whether they should, or should not have such fury done onto them.

JMM

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Filed Under: Doctoring, Reflection Tagged With: End of lfe care, Hospice, Palliative Care

When will Palliative Care and Hospice discussions be considered normal?

July 26, 2011 By Dr John

The patient greeted me with a smile that belied his horrible luck. He was my age, but looked far older.

It was a slowly progressive neurological disorder that left his mind intact while his body stopped working. He was now imprisoned in a bed. Various family members fed him, changed his diaper, and freshened the skin bandages on his legs—“road rash” that recurred after repeated falls. He refused to stop trying to get OOB—out of bed. He had his pride.

The immobility caused problems with his urinary tract. Kidney stones kept getting infected by bacteria, which traveled up and around that permanent rubber tube in his bladder. Surgery to remove the stones was recommended.

But that dang ECG was a problem. It showed a high heart rate; 160 beats per minute was high enough to excite most of the medical people on his case. Though he reported no heart-related symptoms, he did indeed have a common, benign, non-life-threatening heart rhythm condition called PSVT, or paroxysmal supra-ventricular tachycardia. It occurs because of an extra electrical highway that one is born with. The two pathways conspire to cause the heart to spontaneously race. It too, occurs because of bad luck and in this case was unrelated to the neurological condition.

I was called in to consider fixing the racing heart. On paper, a catheter ablation for PSVT is straightforward. However, this case was a problem. His chronic illness conferred a higher than normal risk:

  • Pneumonia as a complication from sedation;
  • Blood clots in the legs from immobility after the procedure;
  • Contracted arms across his chest made X-ray visualization of his heart a challenge.

Now these were not insurmountable problems. A catheter ablation could be done, and likely with success. Sure, the master-of-the-obvious EP-lab nurses might heave looked askance because I was ablating a patient in diapers, but I could have offered them a lame excuse, like, referring-doctor X was making me do it; it’s not my idea, or the patient had to have it before kidney surgery.

The larger issue at hand, however, was that the patient needed something else. He needed someone to tell him the truth, to mention the large elephant in the room: that he had a diaper, bed-sores and a progressive neurological condition. When your lifespan is measured in weeks, or months, elective ablation for a non-symptomatic, benign heart condition makes little sense.

When I discussed his heart with another sub-specialist on the case, I voiced my opinion that doing an ablation was not indicated. I added that his medical problems and lack of any significant functional capacity warranted consideration of hospice.

“Yes, I get that, but what was I to do: Tell him…Nice to meet you sir… I have only known you for ten minutes, but really, you only have weeks to months to live. We should have hospice come to see you.”

That’s the thing. Just mentioning hospice is a like holding a hot potato. For instance, when I suggested a hospice consultation to one of the younger health professionals involved with this patient’s care, she looked at me sideways, as if to say, people don’t really die. We can prevent death here in this ICU. We have protocols, and respirators, and pressors. Geez.

And consider this fact: as our health care is increasingly fragmented, between out- and in-patient services, the problem of bringing up hospice and palliative care intensifies. In general, sub-specialists called to see a patient for problems of their specific organs are not going to start the palliative care discussion. We don’t know how. We are not trained to consider death as inevitable. More than a few heart doctors I know consider death to be a failure of therapy. A mistake. If only, we had titrated the drugs more skillfully, implanted an ICD, or squished the blockage sooner.

The health care profession needs a culture change. We need hospice and palliative care to be a normal option, not one that is given ten minutes before death. The control of symptoms, rather than the prolongation of life, at all costs, should be mentioned without stigma. I’d even go so far as to make the “goals of care” discussion part of a checklist. Just make the conversation as “normal” as taking a statin, ACE-inhibitor or calling a time out. Make it normal for patients to hear that relief of symptoms is as viable a choice as eking out the maximum number of days with toxic drugs or painful procedures.

I found it heartening to read this Washington Post story on how some Emergency rooms are benefiting from having palliative care teams available. That’s a step in the right direction. But there’s a lot of work left to be done in the real-world.

In this heart-wrenching case, I spoke with the patient, the nurse, the family (multiple times), and the two other doctors on the case. In total, I spent two-three times longer than it would have taken for me to ablate the heart problem, and was paid many fold less for the emotionally draining work.

This is a problem…

That I hope to see corrected soon.

JMM

P.S. This case occurred many months ago, when I worked at many different hospitals. I have changed the details to maintain privacy.

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Filed Under: Doctoring, Health Care Reform, Hospice/Palliative Care Tagged With: Hospice, Palliative Care

A simple phone call…

April 24, 2010 By Dr John

His wife said, “I couldn’t wake him from his nap.”  The coroner told her he died in his sleep without moving a muscle.  His family doctor told me that Parkinson’s had slowed him greatly in the past year.

He was 81, and the day before, he had enjoyed the usual lunch with friends. His multi-lead pacemaker was devoid of high voltage shocks.  Whether shocks would have made a difference is completely unknowable.

His wife said she was so grateful he didn’t suffer.  Me too.

I wonder how many electrophysiologists are married to a practitioner of palliative care?  How many of us installers of life-prolonging devices see, or hear of, the human suffering in those patients unlikely enough not to have sudden ventricular fibrillation?  How many cardiologists know that the locked dementia ward of a local nursing home is cruelly named, Paradise Island.

I can learn from a wife.  She practices palliative care and hospice. Some may consider this an emotionally draining field.   Indeed it is sometimes, but her stories detailing the relief of human suffering are seemingly boundless. As a younger doctor, I recall thinking hospice practice was gloomy and dark.  Like everything in life, knowledge serves to illuminate. To relieve human anguish is the opposite of gloom.

“You always call the family of the deceased…Isn’t that really hard,”  I ask.

“No, it helps a lot.”  

The common sense lessons of palliative care are applicable to all aspects of medical practice.  Like calling the family of the recently deceased, so as to express sympathy. This simple phone call is a given for some, but for an installer of life-prolonging cardiac devices, death is not easily or readily acknowledged.  It is uncomfortable, like a mistake or failure.

But I have called three times this year.  Each phone conversation has been well received.  Each is less scary than the previous.

I am learning.  This is good.

JMM

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Filed Under: Doctoring, Reflection Tagged With: Hospice, Palliative Care, Sudden Cardiac Death, Ventricular fibrillation

A Mom takes the Medical Board

October 22, 2009 By Dr John


Staci takes the Internal Medicine board exam tomorrow; in a cubicle, with a computer. No pencils. No ovals.

It has been 12 years since she last took the exam. For 10 years, she stopped doctoring and simply took care of Cat, Will and me. A mom. Moms do that stuff. They are a different species than Dads, for sure.
The last two years she has gone back to practicing medicine. She is a hospice and palliative care doctor. That means she relieves suffering, often in the 9th inning of life.
We talk medicine tons. I have learned so much from her. When Catherine first found out her Mom was tasked with the care of the dying, she commented something like: “Mom, you are too smart for dying patients, anyone can care for them. Let the dumb docs take care of the dying.”
A common response when discussing Hospice/Palliative Care is: Why would anyone want to do this? How depressing?
I say, on the contrary. If one takes as fact, we will all die someday and only a minority will be blessed with a sudden painless death, then that leaves most with a potentially difficult struggle. The few that have Staci and her team taking care of them are so lucky.
They sometimes sing to patients on rounds. Sitting on the Dock of the Bay was the last one I heard about. Imagine that on a cardiac or surgical service.
The relief of suffering is far from depressing. As Docs, it is our essence.
As a trained observer and master of the obvious, I say she breezes through the exam. My thoughts will be with her tomorrow.
JMM
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Filed Under: Doctoring, General Medicine, Reflection Tagged With: Hospice, Mom

John Mandrola, MD

Welcome, Enjoy, Interact. john-mandrola I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape

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  • Electrophysiology commentary on Medscape/Cardiology

Mandrola on Medscape

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For patients...Educational posts

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  • A new cure of AF
  • Adding a new verb to doctoring: To deprescribe is to do a lot
  • AF ablation — 2015 A Cautionary Note
  • AF Ablation in 2012–An easier journey?
  • Atrial Flutter — 15 facts you may want to know.
  • Benign PVCs: A heart rhythm doctor’s approach.
  • Caution with early Cardioversion
  • Decisions of 2 low-risk cases of PAF
  • Defining success in AF ablation in 2014
  • Four commonly asked questions on AF ablation
  • Inflammation and AF — Get off the gas
  • Ten things to expect after AF ablation
  • The medical decsion as a gamble
  • The most important verb in our health crisis
  • Wellness Requires Ownership

 

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