Context: an integral tool for educating patients

Mr. Armour came to see me two days ago: He is 72, a retired mechanical engineer. His anesthetist asked me to review his arrhythmia, paroxysmal atrial fibrillation, prior to a knee replacement in the fall.“Well Bill, your master spark plug is getting rusty. The back-ups chip in when he falls asleep. They aren’t quite as organized, so the rhythm is pretty chaotic. They send a train of sparks down to the junction box, which filters some, but most of them make it down the wires to the bottom of the heart. As you know, a spark against a muscle causes contraction, a heartbeat. That’s what keeps us alive. “ “OK, doc, so why is my master spark plug rusty?”“You can take your pick. It’s 72 years old, so it’s been round the block a few times. That blood pressure of yours puts extra strain on the poor fella—he wasn’t designed to work with hypertension. Or it’s the two beer a day you say you put away most days—you are pickling not just your liver and your brain, but your heart and your electrics.”Of course, he didn’t like to hear that alcohol was a pickling agent. “Hey, if you find a dead frog at the creek, and your grandson wants to take it to Show-and-Tell, you put it in a jar with a pickling agent—vodka, gin or any clear alcohol. And when he brings it home and it languishes on the shelf for a year, it looks just the same as the day you bottled it—pickled. Just remember, your liver can only deal with so much booze at a time before it gives up, and allows the next can of beer to drive on through, and pickle you.” “I know some buddies of mine who have pickled brains!” he says. “Mind you, they are heavily into the sauce.”“Why don’t you back off on the booze, take Bisoprolol to optimize your pressure and see what happens?”He had been using an Apple watch, and an Alivecor Kardia device, to capture PAF quite nicely. “You say you had AMAUROSIS FUGAX last year. Do you know what this is? It’s a clot, arising in the left atrium, the inlet manifold, that breaks off and swims up the eye artery.” “Yeah, a curtain came down, then lifted. Only lasted three minutes.”I told him he was lucky, but wondered why it wasn’t medicated immediately. “Well, they couldn’t capture my irregular rhythm on the Holter. After all, it only happens once or twice a month.”He left with (a) education (b) some advice about blood pressure and alcohol (c) a better understanding of why I had started Bisoprolol, a ‘governor’ on his rapid rates. He could relate to an engine that was compromised. I didn’t have STP for his fuel lines (well, Apixaban is close), or the prospect of a new spark plug (well, maybe he’ll see a pacemaker in future)—but he got the picture. And that was what he needed—a discussion that related to his understanding of engines, and no LONG words. To finish my job, I need to see him again and ask him what he took away from our conversation: maybe nothing.One day someone will say ‘hypertrophic cardiomyopathy’ and lose him in a heartbeat (sic). For now, he is motivated to comply. Magic. Addendum: I drew a schematic picture of the heart, and its mechanical components. I gave it to him, so he could take it back to his wife with my explanation. Empowering patients to understand their body is a lifelong challenge, and very reassuring when it works.Further reading:Do Patients Understand? Graham, S and Brookey J. Perm J. 2008 Summer 12(3); 67-69. doi: 10.7812/tpp/07-144.Basic Health Literacy: Canada is doing poorly. Szasz, G. BMJ 12 Jan 2023.

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Context: an integral tool for educating patients

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Hector Baillie

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