A well-groomed man, six and a half feet tall, arrived for a consult. We were meeting to discuss removing his vena cava filter, implanted when he had a submassive pulmonary embolism. As he strode toward my office, he took my hand and said, “Hi Doctor. Thanks for saving my life.”
How do you respond to that? It’s so amazing and humbling, it befuddles me every time. I don’t have a great response, even six years into practice.
As image-guided surgeons, interventional radiologists are often tasked with saving a life. But we don’t always get thanked for it, so when we do, it can catch us off guard.
It’s routine for us to stop someone from internal bleeding related to a pelvic injury after a motor vehicle crash, ATV accident, or gunshot wound. The situation can be dire. Often, there’s no time for thanks. Sometimes the patient’s family is too shocked to grasp what is happening as they numbly sign consent to proceed.
Somehow, I seem to get thanked by patients with pulmonary embolism (also known as “PE,” or clots in the lungs). Some of the quickest bonds I’ve had with patients were in this scenario, with a worried spouse looking on, and the patient’s heart straining against the burden of thrombus.
PE is a problem which can affect people of all ages. The young man who thanked me was the type more likely to be found in a club than hanging out at the hospital.
As fate would have it, I had two patients with the same problem that day. The hospital was full, and they spent the night across from each other, boarded in an ad hoc ICU bay in the emergency department. They lay flat and stationary, waiting for the treatment to percolate. Decades apart in age, these men underwent the same procedure. And when I arrived at the bedside the next day, they were comparing notes on their symptoms!
Shortness of breath
A heavy feeling on the chest
Inability to take in a full breath
Pain on inspiration
These are some of the symptoms patients are grappling with when I arrive at their side. While some pulmonary emboli are silent, others vociferously announce their deadly intent.
The symptoms come from large clots which most commonly originate in the deep veins of the legs. Clot can form in a number of scenarios, but some common ones include periods of inactivity, like a long car ride, or a blood disorder which puts the patient at increased risk of clot formation, like cancer or a genetic abnormality of the blood itself. The clots can stay in place, causing leg pain and swelling. Or, they can move, swept upward by venous blood returning to the heart. This is what causes a life-threatening problem: PE.
If enough clot arrives at the lungs, it can limit the ability to re- oxygenate venous blood. The heart has to pump harder, against the partially clogged pulmonary arteries. If the clots are large, or the patient’s heart is weak to begin with, blood pressure can dip dangerously low. The heart might even stop, or arrest. In these scenarios, we must act quickly.
Recently, in such a precarious position, my patient smiled blithely from the bed, oxygen tubing tucked in his nose. He listened politely as I offered to dissolve, or lyse his clots, using targeted drip lines called catheters. In this way, I could deliver a potent medication right where it was needed. His wife perched anxiously at the foot of the bed.
I described my plan to access a vein in his groin, through which I’d drive north toward the arteries of the lung, under x-ray guidance. There, we’d measure the local pressure, and position a catheter in the artery supplying each lung. The catheters would deliver a potent clot-busting medication, an enzyme, to actively dissolve the clot overnight.
They expressed hesitation, as I reviewed the risk involved: unintended bleeding elsewhere in the body. Hoping to ease their misgivings, I told them what we’d be doing if this were me or my family member. Finally, the patient told me he was “sold,” comparing me to a car salesman.
I gave them an overview of their alternatives, including a less aggressive IV infusion, and the now largely historic alternative of plucking the clot out surgically. A new device holds promise to accomplish similar results without the strong medication, thereby decreasing the risk of untoward bleeding. I’m lobbying administration to get the device in our hands, so we can treat an even greater number of patients with PE.
There’s an art and a science to the decision whether or not to intervene in patients with PE. It’s true that over time, clots in the lungs will dissolve through the body’s own intrinsic mechanisms, if the patient makes it through the acute episode of course. For all patients, it will be a long road to recovery.
Sometimes, the clots don’t completely dissolve, forming webs like scars that stretch across the pulmonary arteries. They remain as a reminder of clot that once threatened the patient’s life. Chronic or recurring clots can lead to high blood pressure in the lung, a dangerous long-term problem. Elevated pressure in the lungs can cause strain on the heart, which then has to work harder to move the blood forward. The vessels and the heart enlarge in response to the new physiology. Patients can feel short of breath or fatigued. Over time, they can have limitations to exercise, or even the ability to walk around the block.
The goal of a thrombectomy or thrombolysis, a clot removal procedure, is to clear as much of the clot, as quick as possible. This not only rescues the patient in the short term, but it speeds up recovery and improves lung function in the long-term.
Trying to crowd-source my question, I asked my dad what he thought I should say, when a patient thanks me for saving their life.
“Just say it’s your job,” he replied.
But I wouldn’t want to be so flippant. I am honored to have the opportunity through my daily work.
Being equipped to save a life is a highly privileged position, and one worth working toward. It takes 4 years of college, 4 years of medical school, 5 years of residency, and a year of fellowship. During those years, you learn medical language, with which you’ll communicate with colleagues. You sacrifice time with family and friends. While your friends are partying, you’re plotting your MCAT strategy. In training, you’re corrected 100,000 times. It’s a long, hard road to gain the capability.
So consider how you’ll respond when the time comes. When you have your head down, it’s easy to forget about this part- the human part.
When a patient thanks me for my work, I throw it back at them:
“You did a great job!”
Often, what I’m really thinking is,
“Thanks for not bleeding during the treatment!”
We walk a fine line to save a life.
So it’s worth reflecting on the gravity of what we do in medicine. The next time this happens, I pledge to take the moment in. I’ll maintain eye contact, and not deflect the thanks. I’ll feel the full spectrum of the praise and gratitude. Because I’d like to keep doing this for a while. And keeping our emotional tanks full is better for everyone involved.
So when you’re thanked for your work, “You’re welcome” is a good start.
If it’s offered, accept a hug.
That day in my office, as I accepted my patient’s warm handshake, I added-
“You’re still off the cigarettes, right?”
The path can be riddled with failures, even if you're doing it right. In this recording, I share some of my gaffes with you.