Fred Dickey's Island of Human Drama
Matters of the heart for Dr. Tommie Ahern
Matters of the heart for Dr. Tommie Ahern
By Fred Dickey Nov. 5, 2016
Teenage Tommie Ahern got a summer job mopping floors in a nursing home in his hometown of Bethlehem, Pa. All went well until he noticed some patients’ bathroom calls were being slowly heeded. He dropped his mop and helped the infirm hobble or wheel down the corridor.
Wrong move. Moppers were supposed to mop — only. The director made the “May I see you for a moment?” call to Tommie and fired him.
But, hold on. There’s a happy ending here: Then she grinned and hired him back as a nurse’s aide.
From that experience emerged a physician.
Dr. Tom Ahern, 59, is not a kid anymore. He is a cardiologist for Scripps Clinic at the Prebys Cardiovascular Institute in La Jolla and Encinitas.
He is also my cardiologist. He and his wife, Susan, live in Coronado and have raised four children. He’s got just a touch of the leprechaun in his personality. (That’s PC-approved: He’s Irish.)
I do believe that even today, if a patient had to “go” and no one else was around, Ahern would once again walk them down the corridor.
Ahern’s full appointment calendar attests to his popularity. That’s a flattering fact, because not everyone rushes to have their heart examined, though many should be in a really big hurry.
The heart in your chest is as mysterious as the heart on your sleeve. The one thing we all know is that it will one day stop beating. Ahern’s job is to push that day back until it happens in “the fullness of time.” (I think that’s Biblical; sounds like it.)
I start with a question that goes right to the heart (pardon me) of the matter: What sort of patient leaves you depressed? … You're shaking your head. … The question itself must depress you.
He smiles, just a little. “Patients who make me sad are the ones who, despite being told the truth, still just want to deny their condition and are unwilling to treat it. Men more than women.”
Why is that?
Another wry smile. “I don't know. Men are knuckleheads sometimes. They can be stubborn in taking advice. They hate taking pills. They think being macho will help them overcome things: ‘You just don't know me. I was an athlete when I was a kid 60 years ago.’
“We think we're unbeatable. Things can't touch us. We just can't think it's us. It's someone else. Whereas women, perhaps, are a little bit more in tune with themselves.
“I also think men can be misled by their sense of responsibility: ‘If I have a heart problem, I can't provide for my children and my spouse. So I'm not going to have heart disease.’”
Ahern says that in a certain sense, the person most safe from a heart attack is the person who has known heart disease. What he means is that if you’ve been diagnosed and treated for a heart problem, that problem is not likely to sneak up and put you on the grocery store floor with a flustered crowd gathered around.
The person most likely to end up on a gurney is the one of whom people would say, “I was shocked that he, of all people, would have a heart attack.”
What sort of heart problems do you least enjoy? … Uh, how should I phrase that? … That you most like to not see?
“For me, it's not so much the condition but the patient. I love working with someone who's engaged and willing to work together. I have some people who come in and want me to cure them. But I'm not going to be able to help them if they don't take care of themselves.
“What I've said to patients is, ‘You know, if you don't want to make good choices, there's not much more that I can do.’ I saw a patient today who's overweight and probably depressed. His wife really wants him to take care of himself. Every time I see him, we have this same conversation.
“Some people say, ‘Well, I haven't made a choice yet.’ What I tell them is that the absence of making a choice is a choice.”
In general, what are the chances of surviving a heart attack?
“I would say very high. Now, it depends on which vessel is blocked, how big a heart attack it is and how soon you get to the hospital. If a person comes in with a heart attack, we want to open the vessel within 30 to 60 minutes. Time is money. Time is heart muscle.”
Don't be 50 miles offshore in a sailboat.
“Not a good idea.”
They say about strokes that if you get treatment within an hour, your chances are much better.
“Correct. As with a heart attack, you're depriving tissue of oxygen. In the case of a heart attack, you're depriving a heart muscle of oxygen. In the case of a stroke, you're depriving part of the brain. If you deprive any tissue of oxygen very long, it will die.”
The venerable EKG test has come under attack, hasn't it?
“Many people think the EKG tells us much more than it does. (When a person is) at rest, the EKG probably offers no insight on blockages unless the patient had a prior heart attack or is actively having chest pain.
“An EKG performed during stress offers greater information. But even people with blocked arteries that do a maximal stress test will only find evidence of blockage two-thirds of the time. That's why we often add a different imaging method — stress echo or stress nuclear to raise the diagnostic yield.”
Do you have patients who get tired of hearing you always give the same warnings and advice and just stop coming?
“I'm sure. I get tired of hearing myself say the same thing every time. Sometimes, people want a different answer.”
What do you mean?
“Say a patient has a weak heart that we can't make better. We have them on the best drugs, and that's all we can do. But they want someone who can cure them. They go online. They try to find a new vitamin or a new supplement, something they read about somewhere, hoping it'd be the answer.
“I tell them there are things in life we can fix, and there are some things we can't fix. For those people, I recommend getting a second or third opinion.
“A lot of it is the choices we make in our daily life. The person who chooses to not exercise is making a choice. Also, obesity and snoring and diabetes. You can modify those risk factors by losing weight, by being active.”
How is snoring bad for the heart?
“When you're snoring, you're basically choking. You're obstructing your airway. Your heart rate surges during that. Your blood pressure surges. It's like all night long, you're releasing adrenaline surges. That creates higher chance of blocked carotid arteries. That can create a higher risk of heart attack, a higher risk of atrial fibrillation. Yet when people lose weight, often their sleep apnea gets better.”
Has cholesterol been overrated as a threat to heart health?
“Many people who have heart attacks do not have high cholesterol, so we look at family history. We look at cholesterol. We look at hypertension. We look at cigarette smoking. We look at all the risk factors.
“Now, the second part of that story is that in the late ’80s, when the first statin drugs became available to lower cholesterol, we were only using them in individuals who had high cholesterol and who had had a heart attack.
“More and more data is showing that cholesterol medicines have a value above and beyond cholesterol lowering. For example, they can reduce inflammation in the vascular lining.
“These statin drugs can have negative side effects. So if patients you're providing the drug to are not going to derive any benefit, then why expose them to any risk? I would not put patients on a statin who don’t have heart disease or who don't have high cholesterol.
“There are new medicines that can be used with statins to lower cholesterol, or be an alternative for those intolerant of statins. These can be injected once or twice a month, and can lower cholesterol an additional 50 percent above statins.”
Ahern says technology is coming that he believes will allow the substitution of a CAT-scan angiogram for the traditional method of inserting a catheter through an artery to image the heart. The effect will be to eliminate the slight risk of the catheter breaking off a piece of plaque and conceivably causing a stroke or heart attack.
He says that recent years have seen a great advance in the replacement of the aortic valve. Until five years or so ago, that required opening up the chest. Now, it’s done through a catheter. The same technology is in development for replacing the mitral valve.
Medicine is so heavy on hard science, we sometimes overlook the soft science of common sense and plain talk. Doctoring wouldn’t be half as much fun without stories to take home to tell the spouse.
“I remember one patient who came in after a heart attack and wanted to be able to use Viagra. The wife was worried that he'd be using it with someone else. I kind of stepped out of the office.
“I had one man in his ’60s or early ’70s who had bad heart disease, but his wife believed in natural healing. After they put the stents in, she didn't want him to get any pills that would treat post-heart attack patients. She wanted to go to a naturalist and use herbs.
“I am intrigued by patients who will readily adopt the use of untested treatment because a friend or someone they met at the vitamin store suggested it. But when their physician offers an opinion, they don’t accept it.”
Do you always avoid arguing with them?
“I don't think I've argued with a patient but maybe once in 30 years. Years ago, I had a man yell at me about not helping his wife's breathlessness. He kind of laid into me and made it almost personal. I turned and said, ‘Now that you've told me what you think, I'll tell you what I think. Your wife has had one lung removed from lung cancer. She has a bad remaining lung and you still buy her cigarettes even though she’s on oxygen. You're the problem here. If you were man enough, you'd tell your wife, ‘No more cigarettes’ and you wouldn't buy them for her.”
Ahern is a cardiologist in demand because underneath the lab coat and beyond the “ology” words, he comes across as an approachable guy who likes people. Traces of young Tommie are still apparent.
“Asking my patients to exercise is often met with a blank look, so I challenge them. I want my older patients to practice healthy, vigorous lifestyles so they can continue living independently and in their own homes. I don’t want them in assisted living and being wheeled into my office.”
Ahern spends a lot of time watching patients as they swim toward the edge of the waterfall. He tries to throw them a line. Sometimes they grab it, sometimes they ignore it. Sometimes, the line is not long enough.
There’s an old joke that goes: If I’d known I’d live this long, I’d have taken better care of myself.
Ain’t no joke, folks.
Next Monday: The death panels cometh?
Next Monday: The death panels cometh?
This cardiologist looks at more than a patient's heart “Seniors and the disabled will have to stand in front of Obama's ‘death panel' so his bureaucrats can decide … whether they are worthy of health care.” — Sarah Palin, 2009
Palin was ridiculed for the heavy-handed way she presented the topic, a la Sarah, but she brought attention to an important and disquieting question that wasn’t swept away by pundits’ scorn.
We don’t have to be actuaries to see the problem. We only need to scan the conflicting statistics between the growing numbers of aging Americans and the dwindling funds to pay for their health care.
Exacerbating those facts is the happy ability of modern medicine to constantly come up with expensive new ways to help us hang around as long as our fingernails can grip. Sometimes, maybe too long if our bodies say it’s time to go.
To live a really long time is a rosy future to look forward to, but it becomes a societal problem if too many people do it and we can’t pay for it.
Then we add the human factor: Because of tears, anger and the threat of lawsuits from patients’ relatives, doctors sometimes bow to pressure to keep deathly ill people alive, but at great expense and for a short time, and conceivably with the patients in considerable pain.
That can cause Mother Nature to complain: Didn’t you hear me? It’s time!
It’s an awkward circumstance for medicine: It’s much happier for a doctor to tell patients they can go on living happily ever after, not so much fun to gently suggest maybe it’s not such a good prognosis.
Dr. Tom Ahern is a 59-year-old cardiologist for Scripps Clinic and the Prebys Cardiovascular Institute in La Jolla and Encinitas whom I wrote about last Monday. Dealing with this touchy dilemma on a doctor-patient level is a delicate issue he doesn’t sidestep.
Ahern is a white-haired, family man who at day’s end makes the long rush-hour drive south to Coronado to grill fish for dinner.
He’s a cheery people guy who loves to talk about what he does. He’d probably chat up pacemakers if the guy next to him at a Padres game asked.
Ahern says, “About two years ago we presented a case at our Scripps Clinic cardiology division to discuss a 70-year-old male patient with severe heart disease. We had 19 cardiologists there.
“We had a lively discussion back and forth as to what the other cardiologists would recommend for this individual. Then at the end we said, ‘We misled you. This is not a 70-year-old man. It's a 93-year-old man. He lives independently, he cares for his wife. Now, what would you do?’
“There was silence in the room.
“I had a patient last month who passed away at 104. I sent her for an ablation (heart procedure) at 95. My associates kind of laughed. ‘Tom, a 95-year-old woman?’
“She was wonderful. She was going to the gym every other day at 102. She was great. I look at the health of the patient, what their quality of life is and what procedure we can offer to benefit them.
“For instance, if she's 95 and has terrible health, why do open heart surgery? Why would you even consider it? They're not going to have great quality (of life) whether you do the surgery or not do the surgery.”
If you're going to bend over backward for a woman in great health at 95, what about a shade of difference — someone who’s 95 and in doubtful health?
“If the government allows us, we as physicians should use our judgment. I'll give you an example. I had an 87-year-old patient who was admitted to one of those hospitals in town here a few years ago. She had chest pain. The inpatient team wanted to treat her with medicines only. The daughter wanted her mother to have a heart angiogram catheterization and stents.
“I was her doctor and I’d known her for years. I went to the family and said, ‘If this were my mother, I would not recommend it. I do believe she has blocked arteries. I do believe she has chest pain, but she has a critically narrowed valve. She has end-stage lung disease. Her kidneys are on their last legs. She’s getting ready for dialysis soon and she’s a diabetic. If I fix the artery, she will have no better quality of life because her lungs are limiting her. Her valves are limiting her. Her kidneys are limiting her.’
“The daughter said she was going to sue me. How dare I not offer her mother the treatment?
“I recommended the following: that she talk with her brother, talk with her mother, and I would accept their decision. The next day they came in and said they wanted to proceed. The mother had the angiogram and the stent. She left the hospital and less than a week later died at home.”
Did the daughter give you an apology?
“I'm not looking for apology. My point is that if we as physicians know a lot more about certain things, we should be able to tell patients, ‘Yes, your dad’s only 70, but he has cancer. He has end-stage liver disease. He has bad lungs. There’s only so much we can do to solve some of these things. I'm sorry.’
“Conversely, there can be someone who's 90 who is still shopping, living and driving. I had a 100-year-old man come in to see me last month. He drove to the office. He still lives alone.”
Evaluating quality of life is really part of the physician service, right?
“It should be. We have become so sub-specialized that we tend to look at patients through the filter of our specialty. A cardiologist tends to see a patient through the condition of the heart, but things like prior strokes, cancer, diabetes, kidney failure and emphysema all play a role in the overall picture to be looked at.”
If you have a patient with a history of cancer, would you call to have a discussion with the oncologist?
“Oh, yeah. If I have a patient who has heart disease and cancer, I’ll seek to know the patient's five- to 10-year risk of dying. If it’s 95 percent at one year, then doing life-extending measures is not going to have any value.
“I had a patient who last year came in to see me with terrible lung and heart issues. I met with him and his wife and recommended against a heart catheterization. His lungs were so bad it wouldn’t have changed his quality of life. He passed away about three months later.”
An unrelated topic: How important do you consider blood thinners to be for heart patients?
“OK, blood thinners. I had this conversation today with two separate patients; both have atrial fibrillation. Both are felt to be at increased risk of stroke, but one doesn’t want to take blood thinners because of other concerns.
“What a reluctant patient will usually say is, ‘Well, if I have a stroke and die, then I die.’ The problem is that when they have a stroke, most do not die, they have a terrible consequence. I see one woman who for years didn't want to take blood thinners. We talked about it over and over, and one day she called and said, ‘I'm not doing it.’ Within a month, she had a major stroke and now she can't talk. Her children had to move back to care for her in the home.”
You don’t think she would’ve had that stroke with blood thinners?
“No. On the blood thinners, her risk of stroke would have been less than 1 percent.”
What do you see coming to medicine 10 years hence?
“For one, wireless health maintenance has an interesting promise. We could perhaps develop sensors that recognize and monitor our patients. As an example: Your mother is 85 and you suggest she move to assisted living so you don’t have to worry about her being alone.
“Well, what if she could wear a little sensor, a patch that would recognize how active she is, what her temperature is and what her heart rate is? So, if mom hasn’t gotten out of bed by 9 a.m., you would know it.
“If she’s running a fever, why? What’s her respiratory rate? What’s her heart rate? We might be able to monitor these things from her home rather than institutions, rather then hospitalizing, rather than nursing homes.”
Anything new in heart transplants?
“I’ve had a number of heart transplants. The reason you put in a new heart is because the old heart doesn’t squeeze.”
You mean the heart muscles no longer function?
“Right. The problem is, there are never enough hearts for as many patients as need them. So a left-ventricular assist device has been developed. It’s a little battery-powered motor that can pump blood that’s put into the heart.”
You're creating artificial heart muscles, right?
“Yes. I've seen people with it installed who couldn't walk before, but are now walking in the hallway, almost jogging.”
Not everyone is enthralled by magical widgets. Ahern had a patient for whom a replacement heart was not available, so he was offered the artificial-pump device. The man did some research, thought about it and passed on it. He died at home.
On the other hand, an 88-year-old woman with heart disease was urged by Ahern to adopt a diuretic and a restricted salt diet.
“She told me she didn’t want to live that way. She wants to have her pizza with pepperoni on it. I teased her. I said, ‘You're 88 and you want to only live if you have pizza with pepperoni on it.’ She's doing better, and she’s still wanting her pepperoni pizza.”
In terms of a cold calculation that “I'd rather die than give this up,” you run into that, huh?
“At least once a month.”
The Dr. Ahern his patients see is a friendly, unpretentious fellow with a sense of humor that slips in like a mouse. He’s always eager to talk up exercise and healthy eating to patients like a greeter at Whole Foods. He’s a true believer who says he seldom eats red meat or eggs. Dessert? No, thank you.
I happened to tell him my wife, Kathy, and I just returned from China, but I wanted to hurry back home to get some “real” Chinese food at Panda Express.
He didn’t even smile, but pursed his lips and cautioned about fast-food nutrition.
Oh, c’mon, doc! Don’t step on a good line.
Fred Dickey’s home page is freddickey.net. He believes every life is an adventure and welcomes ideas at [email protected]