Friday, August 23, 2019

A change of heart

Dr Alin Gragossian was in the middle of her third year as an emergency medicine resident at Drexel in December of 2018 when she became critically ill and ultimately required a heart transplant to survive. She now joins us just 7 months after her surgery to discuss her remarkable journey.

I was an ICU resident, so I was doing my admissions. As an ICU resident, we run the codes on the floors. That particular day, my attending noticed that I was getting really short of breath with every sentence that I was speaking.

Not only that, but when I was going to the code — I usually take the stairs everywhere when I'm in the hospital, just to get some exercise — I found myself stopping in the middle because I was so short of breath going up the stairs. That happened again another time when I was on the subway. This all happened in a few days and progressively got worse until December 21, which is when I went to the hospital. I tried to make an appointment with primary care, but this was right before Christmas, so many places were closed and I didn't have time.

Then things got worse, and on that particular Friday, I went to the emergency room. They got a chest x-ray and I remember everybody said I looked sick. My attending came in and he said, "You don't look good; something's definitely wrong."

As ER doctors, we have a really good way of telling when someone's about to crash. But I was like, "No, I'm fine." He said, "Your lips are blue. You look very pale. Your heart rate is in the 140s." And I said, "I think it's just anxiety." It definitely wasn't.

I wanted to leave against medical advice, but he did not let me. By then, I was admitted just to find out what this was. Initially, we tried to empirically treat it as a possible pneumonia. It looked like a multifocal viral pneumonia. Looking back, it was pleural effusions, but it was very unclear as to what was going on.

I was so lucky to have been in the hospital because I would have died if I had been at home. I looked up at my monitor and I remember that my heart rate was going down. It was in the 50s, then 40s, and then 30s. And that's the last I remember.

I asked the residents what had happened after the fact, a couple of months ago. One of the residents said that they couldn't feel pulses at all. I was blue, cold, and sweaty. She said I looked at her and I said, "Please don't let me die tonight." Every time I say that, I get chills.

Eventually, later on in the day, we got an echo and it showed hypokinesis and dilated chambers, and my ejection fraction was 5%. My heart was the problem, so I was switched to the cardiac critical unit. And then once I went there, I had to go to the cath lab.

When they did my first right heart cath, they were worried because my cardiac index was 1.2 initially, and all the numbers were just terrible. At that point, the cardiologist said, "We're going to take you back upstairs, we're going to start you on milrinone, and we're going to have to talk about what to do next."

I remember the attending came in and he said, "This looks like it's pretty chronic. It doesn't look like it's a myocarditis that happened overnight. We're going to have to transfer you in case you're going to need advanced heart failure therapy" — so a VAD, a balloon pump, an Impella, or a heart transplant.

Eventually I was transferred to the University of Pennsylvania, where I received all of my care…

It was a big shock. I remember I was sad, angry, and in shock, but the way I was thinking — and they called it the most ER doctor way of thinking — I said, "I just need the heart to get out of here." That's all I cared about.

I was like, all right, we have a diagnosis, we have a treatment option, and I've got to get out of here. That was my way of thought. I did have a transplant therapist talk to me every day. I journaled all the time. I tried to process it as well as I could.

At the end of the day, I didn't see it as a terrible option. Some people see transplant as the worst thing that they're going to get. I saw it as the coolest thing ever because it was a second chance at life. I didn't see it as an end; I saw it as a new beginning…

There was this weird sense of if that's going to happen, it's going to happen. There was this very unusual sense of calm around it. But for the most part, I also trusted everybody. Ironically, I was going to be starting on critical care fellowship — we're in medicine; we do a lot of cool things. There was a part of me that was very sure that things would be okay, if that helps.

Of course, there was a part of me that was afraid. But I was enlisted and then I got the transplant…

Around 7:30, the nurse came in with the phone. I don't remember her name and I don't remember much from the conversation other than, "We found a heart; do you accept it?" I was so in shock that the first thing I said was, "Yes. I'll go call my mom now."

At 2 AM I was going to the OR. As they were wheeling me in, I remember that that's when I was finally like, "Oh my God, they are going to open my chest and take my heart out — and that's good. I'm going to be on ECMO."

That's when it all hit me. I remember I looked at my mom, and I said, "Mom, what if I die?" She said something along the lines of, "If you needed to die, you would have died already. You went through almost-death at least four times during your hospitalization."…

She made me feel better by saying that and she kept telling me, "There's so much more you need to do in this world. You would have already died if you needed to."

Around 4:00 or 4:30 AM, they sedated and intubated me. I think at that time they did some more work and then they started on my surgery after a couple hours. That was the day of my surgery…
For the most part, what motivates me right now in my life is my organ donor and her family. I'm not living for them, but there is a part of me that's living for her…

That's how I see it. That's one of the ways I move forward. In all honesty, this is my second chance at life. There are people who don't accept it. I think a lot of it has to do with your mindset. I think it also has to do with how chronic it might be. Maybe because this was so acute, I reacted to it differently. I'm not sure.

For the most part, people always tell me that I'm one of those people who — there could be three people coding around me and I'm just very calm about it. Maybe that's just my demeanor; I don't know. In the emergency room at work, they always tell me that I'm patient and calm. And I'm like, well, I don't know, maybe…

My dad, when he was in his late 30s, went to his primary care for some reason. He was tachycardic and ended up, incidentally, finding out that he has cardiomyopathy. His ejection fraction at the time was 15%. Because we didn't know the rest of the history, they thought it was probably from myocarditis.

They put my dad on carvedilol and a couple other medications. They wanted to enlist him, and he only tells me this now. I'm like, "Dad, you should've told me this. It would have been great to know this a few months ago."

They told him that he needed to get enlisted for a heart transplant. He was the perfect candidate; he was young and healthy otherwise, and his EF was so low. In the meantime, he needed a defibrillator and all that, but he refused everything, just like his daughter. Stubborn, just like me. He refused those and then he started some medications.

His EF right now is around 40%, so he was able to remodel his heart and they were able to work on it like that. Because he got better and we didn't know the rest of the history, they thought it was due to myocarditis. It's really important to know your family history…

I think it's important to be empathetic toward your patients. Communication is key. There are many little things I learned while I was hospitalized, especially about patient care. Because I'm in emergency medicine and I was going to be doing ICU, I saw many things that I could learn from or possibly do differently later.

One of the main things was communication. As doctors, we don't realize that we each have different goals from different specialties. When a cardiologist would come in and say, "Her heart is failing" but then the ICU doctor would come in and say, "She's stable," my parents felt very confused. I understand it because I'm a doctor, but somebody who is not probably wouldn't.

The main thing I want to tell others, especially in healthcare, is to remember the reason why you went into all of this. I like to tell my co-residents that we get jaded often, especially in the ER and in the ICU, and we don't see what happens with our patients very often.

I'm like, hey, look at me: I almost died and here I am jogging 2 miles a day. Remember that what you do really matters. It really does. And don't be so jaded.

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