The Ideal Candidate
AA
The ideal candidate for pulmonary vein ablation for atrial fibrillation is a relatively young, otherwise healthy person with occasional Afib who has failed at least two anti-arrhythmic drugs. Pam was 47, otherwise very healthy, and the spin that Hugh Calkins put on her case is that she failed three anti-arrhythmic drugs and that she came to him for a pulmonary vein ablation procedure in order to avoid the prospect of open heart surgery.
In fact, she had not gone to see Hugh Calkins about arrhythmia. She was referred to him because she was having problems with a pacemaker, and records show that she had not failed drug therapy for atrial fibrillation. A physician who was working in the best interests of the patient would have seen that in her records—if he was inclined to look. But Hugh Calkins was looking for something else; a way, as he put it, to “steer a patient” toward having the procedure.
In 1998, Pam went to see a cardiologist because of occasional fainting and dizziness. It was determined from a series of tests that she had a condition called Syncope and that a pacemaker was in order. An electrophysiologist named Grant Simons would implant it. We met with Dr. Simons. He is a pleasant man with an easy smile. We both liked him, and Pam took his advice.
“Successful implantation of a dual chamber pacemaker,” he exclaimed in his report of the procedure on July 2, 1998. And that’s definitely where he wanted to leave it.
She was doing fine in the hospital when I went to pick her up, all smiles and I’m glad that’s over with. I was going to take her to our favorite little neighborhood restaurant. She signed the forms, changed into into her street clothes, declined the wheel chair, and said thanks and good night to all. And then she walked out into the hallway and collapsed. Nurses and aides rushed over. We formed a circle around her there on the floor. I remember someone slapping her hand, saying “Come on honey, wake up…” And Pam did wake up and she said “I almost passed out.” The nurse said “you did pass out, honey,” and there on the floor, Pam began to cry. She raised her right hand to her left shoulder, which was covered by a sling. “I thought this was all over,” she said.
A nurse got hold of the cardiologist on call who had them check out the pacemaker. Upon hearing that it was working fine, the doctor said that it was OK with him if Pam went home. So I took her home. The first thing she did was run to the nearest bathroom in the house and start retching and heaving.
I called the cardiology group. A few minutes later, the covering doc was on the phone. He sounded like he’d been interrupted. He sounded annoyed. I said I just got Pam home from the hospital and she is violently ill. He said that wasn’t possible. He said that the only way Pam could be that sick would be if a pacemaker lead had perforated her heart and no such thing had occurred here. Pam was probably ill from the anesthesia, get a prescription filled and she’ll be OK.
She rode out the night on swells of nausea.
Then she began to get a feeling like she was being poked in the ribs by a hot needle with every beat of her heart—which was pretty much what was happening. The tips of pacemaker leads are designed to screw into the wall of the heart. If they get screwed in too far, they go through the heart and send little jolts to the chest wall muscles.
But if the chest wall muscles were being paced, that would mean that Grant Simons had poked a hole in Pam’s heart. And that just can’t be. So he elected to adjust the pacemaker settings and change her medications in the hope that he could make the problem go away. In choosing to deal with the error by adjusting pacemaker settings along with the doses and types of medication, Simons had set Pam on the path to Room One at the Hopkins EP Lab, and Hugh Calkins saw her coming.
∞
Calkins writes repeatedly for public consumption after the fact that “She failed treatment of a number of anti-arrhythmic agents… all of these agents were both unsuccessful and poorly tolerated.”
Correspondence between doctors tells a different story.
In a clinic note from August 2000, Calkins lists as “Reason for Visit” a “Second opinion regarding management of pacemaker lead malfunction.” Calkins notes that the symptoms of the “pacemaker lead malfunction” become more severe when she takes her anti-arrhythmic drugs. Actually, the pacemaker lead was functioning exactly as designed. The problem was that a doctor had driven it through her heart wall. But to plainly state the facts would go against the physicians’ code, so pacemaker lead malfunction it is.
In any event, anti-arrhythmic drugs were controlling Pam’s Afib. In August of 1998, Grant Simons wrote that “the patient is doing very well with a combination of Flecainide and atrial pacing with only rare episodes of atrial fibrillation when she forgets to take her medicine.”
Ron Berger was the first doctor that Pam saw at Hopkins about problems with the recently implanted pacemaker. In notes that we normally would never have seen, Berger writes that Grant Simons was wrong to have taken Pam off an anti-arrhythmic drug called Flecainide. Simons thought that the drug was actually causing Pam’s Afib. Berger said that it was the pacemaker “malfunction” that was causing Pam’s symptoms, and he had figured out how to reprogram the pacemaker so it wouldn’t do that anymore. Therefore “she could certainly be placed back on Flecainide” because that way “she spends most of her time in normal sinus rhythm.”
The drug to which Pam had been switched was called Sotalol and Simons writes that “patient states that this medication has been helpful and she has had much fewer palpitations. Patient is doing well on Sotalol.” He notes however that the drug seems to give her trouble sleeping. Her local cardiologist, Dr. Barbara Bean, switched her to Rythmol and wrote a note to Hugh Calkins saying that Pam’s “Atrial fibrillation is well controlled on Rythmol.”
According to the doctors, Pam had not failed anti-arrhythmic therapy, so was technically not the ideal candidate for catheter ablation for atrial fibrillation.
But she was close enough for Hugh Calkins’s purposes.
