Hurry up and wait

There are some conditions in medicine where waiting seems to be the norm. Like aortic stenosis. When you think of it, it is amazing that heart valves (all of them) open and close 100,000 times a day for 80+ years, without servicing, and nothing goes wrong. Then one day, Jenny McCulloch comes into the office. She’s not her usual 82-year-old self. You know her because she’s the pride of the local women’s walking group. She volunteers, plays bridge, and is a keen gardener. But today she says she’s tired, and is more winded than a non-smoker ought to be. What is this—old age, a bit of extra weight, deconditioning or what? “I’m aging quickly, young man, and I don’t like it,” she says. Read: The heart's rhythm and blues Pretty quickly you rule out anemia, heart failure and lung disease. But there’s a systolic murmur that seems more prominent than last year, loudest to the left of the sternum, and audible all the way up to the right earlobe. The echo confirms your clinical impression, and you give her the ‘aortic stenosis’ talk. Jenny is keen to proceed with the surgery needed, a tAVR (which she Googled), and is met with “Eh, not quite yet. Valves are replaced when the gradients are high (i.e., the valve is stiff), and when symptoms are significant. Until then you are under periodic review.” Fair enough, a valve inserted too early may fail too early—but she is 82! So, she spends the next six to12 months worrying about dental care, occasional palpitations and overexertion raking leaves. She can’t travel far on her holidays. She wonders how Hank will cope when she dies. Jenny’s family worry, of course. This waiting game doesn’t serve anyone very well. Read: Coronary Angiography Now Hank, in the waiting room, has a different problem. “Yes, I was a smoker,” he admits. “But that was long, long ago. One pack a day. I gave it up over 20 years ago, cold turkey. Best thing I ever did, outside of marrying Jenny. And I’ve got my puffers to help me out if I need them.” Hank doesn’t get out much, his legs just won’t carry him more than 100 yards, hence the walking frame at his side. “They told me to keep walking through the pain, it will build up collater-alls, whatever they are.” His leg arteries are clogged up with cholesterol, his blood pressure is managed with three drugs, and he struggles with a pre-diabetic diet. Obviously, he has heart disease, but isn’t active enough to have symptoms. He resigns himself to painkillers, weight gain and a short leash. The Golden Years aren’t all they were made out to be. Waiting, for Hank, isn’t quality time. What other symptomatic diseases do we ‘wait’ on? Well, hip and knee arthritis would be on the list, although to be honest the recent focus on joint replacement has changed that dynamic considerably. Obesity surgery seems to be a blessing afforded to a few, maybe rightly so; most will never conquer the dietary constraints needed for prolonged success. Low-back surgery seems to be a no-fly zone: it must have lousy results, but I’ve seen the flip side—patients becoming sedentary, and narcotic-dependent in their retirement years. And lastly, but by no means least, is anxiety. A condition we know has something to do with neurotransmitter deficiency in the brain, which often responds to PRN lorazepam (short-term) and drugs like escitalopram (long-term). I know many doctors are reluctant to jump in with treatment (because of College surveillance, or the fear of patient addiction). Even a psychiatry referral would be worth the effort. Anxiety is such a disabling condition, and yet so fixable. Mental health services may be limited across Canada, but we shouldn’t ask patients to wait with this crippling condition. Read: Time is muscle

Casebook of a Community Internist

Hurry up and wait

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Blog Author

Hector Baillie

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