The Patient Was…

The patient was a world-famous musician, whose fingers and hands produced magical tones from the instrument he played. He was a towering figure in musical circles, who concertized around the globe, and commanded respect and admiration wherever he performed. He was a powerful personality, as well, who did not shy away from voicing his opinions on a variety of subjects.

It is known that there are profound, positive relationships between music, intellect and emotional intelligence. While studies have shown that both playing and listening to music activate multiple areas of the brain, it is playing a musical instrument, in particular, that is said to facilitate deeper emotional expression and connectivity with others.

Of course, there are also critically important physical aspects to playing an instrument. Think of the breath control required of a wind instrument musician. Consider the manual dexterity needed for string and percussion instruments. It was his hands and fingers that underlay this patient’s extraordinary musical proficiency.

Imagine the care and concern of star athletes about their hands. How about neurosurgeons whose dexterity is at risk from injury to their hands. And yes, think of the musician whose production of beautiful sounds is crucially dependent on fingers and hands and a finely tuned instrument.

One day, in his late-middle-age, the patient experienced typical symptoms of a heart attack: chest pain, sweating, weakness, a bit of nausea. An ambulance brought him to the hospital where he was admitted into the CCU (Coronary Care Unit, an intensive care unit devoted solely to cardiac patients).

The CCU had an established routine for new patients, a protocol that was followed faithfully unless the patient was clinically unstable and required emergency action. That was not the case for this patient who, despite his symptoms, did not require deviation from the routine procedures that had two purposes.

The first purpose was to establish a warm, friendly, relaxed atmosphere insofar as possible, to counteract the usual anxiety that accompanies admission to an intensive care setting. Anxiety itself can worsen the condition of the heart, especially in the setting of an acute heart attack, and lead to serious complications. The second goal was to establish access to the circulatory system for administration of necessary medications; this meant inserting a needle or catheter into one of the patient’s veins.

Veins are blood vessels that carry blood from the peripheral parts of the body toward the heart. Any time a needle is introduced into a vein, the puncture produces a slight injury to the blood vessel. Sometimes the vessel is injured more than slightly, and the flow of blood through that region of the vein is impaired or even blocked. So, blood is prevented from flowing from beyond the area of injury toward the heart and the rest of the circulatory system. It’s like the backup of fluid in a pipe that is blocked. As a consequence, we almost always try to use the veins furthest from the heart, so if they are injured by a needle puncture the rest of the vein, nearer the heart, is still useful.

When the patient was rolled into the CCU on a gurney (a wheeled stretcher used to transport patients), he was quickly approached by a nurse whose job, according to the protocol, was to create the warm, relaxed atmosphere for him. The nurse was young, had only recently moved to New York, and was completely unaware of who this patient was.

As the protocol demanded, she introduced herself by name, and asked, ”And who are you?”  (For purposes of de-identification, we will call the patient Mr. XXX YYY).

The patient looked at her in surprise and anger. He was not used to going unrecognized and didn’t like it. “I am XXX YYY,” he bellowed.

“And what do you do, Mr. YYY?” she said.

He was furious. “I play music,” he yelled.

“I mean for a living,” the nurse said.

XXX YYY was apoplectic. A senior nurse rushed over, pulled the younger nurse away, and took her place. She tried, with some success, to placate the patient. And then, just as things were beginning to calm down, a resident physician assigned to the CCU approached the gurney. He had a needle attached to a plastic tubing in one hand, and with his other he grabbed one of the patient’s hands rather roughly.

“What are you doing?” said the patient angrily, pulling his hand away from the doctor.

“I’m going to start an IV (intravenous) for fluids and medications,” said the doctor.

“Do you know what these hands are?” said the patient, almost shaking with fury. “These hands produce magic. These hands are priceless. I want the Chief of Cardiology to start my IV. Nobody else touches me!”

Now, how do you tell such a patient that the Chief of the Cardiology Department probably hadn’t started an IV in twenty years? Starting IVs are routinely done by young doctors in their training, or nurses in some instances. Starting an IV is often considered scutwork in the hospital. In some hospitals there are now IV teams which may be called if there is particular difficulty in starting an IV in a given patient. But the Chief of Cardiology? Never!

Well, our Chief of Cardiology was wise, indeed. He had come to the CCU when he heard that Mr. XXX YYY was being admitted. He conferred briefly with the young doctor assigned to start the IV and then approached the patient on the gurney and introduced himself. Moving the patient’s arm away from his body, he stepped into the “V” space created and moved close to the patient. The patient was flat on the gurney, and with the Chief of Cardiology blocking the view of his arm, he couldn’t really see what was happening. Meanwhile, the young physician, standing just behind the Chief of the Department deftly inserted the needle into a vein, attached it to the plastic tubing, and started the intravenous fluid flowing.

The rest of the patient’s stay in the CCU was uneventful. The Chief of Cardiology fussed over him, giving him the attention the patient felt he deserved. As for the initial procedure, it was a slick handoff in a “hands off” situation.