| Taipei Tzu Chi Hospital: Excellence in Catheterization | ||||||||||||||
| By Huang Xiu-hua Translated by Tang Yau-yang Photos by Yan Lin-zhao | ||||||||||||||
Every Second Counts Every second counts in using catheterization to open up clogged arteries of the heart. It is a race in which the very survival of the patient hangs in the balance. This pressure-cooker profession is not for the faint of heart. Even so, cardiologist Chang Heng-chia, who has been in this business for nearly 30 years, loves his job more and more by the day.
An emergency call shatters the stillness of the night. A nurse rushes to the emergency department, checks on the patient, obtains the essential information, and then runs right to the cardiac catheterization room. There she powers up the equipment and prepares the needed instruments. Technicians put on lead aprons, scrub up, don surgical robes and caps, and stand ready for the patient. Upon his arrival, they administer anesthesia, turn on the defibrillator, and affix ECG electrodes. Finally, a cardiologist inserts a catheter into an artery to start the process of opening up a blocked blood vessel. This well-choreographed procedure plays out several times a week at Taipei Tzu Chi Hospital, and daily in winter as low temperatures often precipitate cardiovascular diseases. After a heart attack, the damaged heart cannot pump as much blood as the body needs. To do the most good for the patient, the cardiologist has a window of 90 minutes in which to remove obstructing matter from blocked vessels. Cardiologist Chang Heng-chia (張恒嘉), deputy superintendent of Taipei Tzu Chi Hospital, leads a team that performs these unclogging interventions. For the last nine years, the team has been on call at all times, always at the ready to pull off these life-saving treatments. Noble qualities “I feel really bad when I see a patient suffering shortness of breath,” Dr. Chang said, explaining why he had chosen this high-pressure medical field. “When my emergency treatment saves a patient, I feel tremendous joy. Words just can’t describe that feeling.” Chang was born in Huwei, a small town in Yunlin County, southern Taiwan. His father worked for a bank as an assistant vice president before joining a textile company. Before Chang, there had never been any physicians in his family. Following his family’s wishes, Chang strove for a career in medicine. He earned admission to Kaohsiung Medical College, now Kaohsiung Medical University. Chang’s grandfather, who had always doted on him, suffered from emphysema as a result of chronic pneumonia. In the summer before Chang was to start medical school, the disease worsened. The old man had great difficulty breathing and had to rely on an oxygen mask. Chang’s heart ached to see his grandfather suffering like that, but he could not do much for him. One night, it was Chang’s turn to attend to him. “How you suffer when you get sick,” his grandfather mumbled to the young man at his bedside. “You must study what’s ailing me when you become a doctor and do your best to help others.” The disease took the old man’s life less than a month later. However, his advice and expectations stayed with Chang as he embarked on his medical career. His grandfather’s hope for him constantly reminded him to strive to be a good doctor so he could help relieve the suffering of sick people.
When Chang was training to become a doctor, a relative told him a story which also helped shape him into a good physician. The story helped steer him clear of a morally reprehensible but common practice in the old days of medicine in Taiwan. Chang’s relative had been scheduled for a minor operation at a hospital. Someone hinted to him that he should pay the surgeon before the operation to buy better service during the surgery—not a regular payment of hospital charges, but a bribe for the surgeon’s personal pocket. Though the relative did not want to comply, he did so eventually for fear that the doctor would not do his best. In a corner of a hallway, the relative delivered the money to the surgeon. The operation went well after all, but when the relative told Chang the story, there was contempt in his voice and facial expression. He even described the deftness with which the surgeon had accepted his bribe, apparently having had much experience on the receiving end of the deal. “He gained some money, but he certainly lost his integrity and honor. Is that worthwhile?” the relative fumed. That was enough to warn Chang to keep away from that bad path. After he became an attending physician at Chang Gung Memorial Hospital, he sometimes encountered patients who tried to bribe him for better care. He always declined, going so far as to write letters to them describing the bad experience of his relative. He would also write that he treated all of his patients with the same high level of care, and that no extra money was needed for that. He asked the patients and their families to rest assured that they were getting his best service.
Calm under pressure Identifying with the compassionate spirit that Master Cheng Yen showed as she founded the various Tzu Chi hospitals in Taiwan, Chang joined Taipei Tzu Chi Hospital in 2005, just prior to its opening. His charge was to establish a cardiac catheterization lab. The unit took in its first patient on May 31 that year, and it has remained active ever since. The lab team is fully aware that heart disease is like a ticking time bomb. When patients are delivered to the hospital, the team has to respond very quickly. Therefore, team members have chosen to live near the hospital. Nurse Chen Cui-lan (陳翠蘭), for example, can reach the emergency room on foot in just five minutes. Radiology technologist Zhong Qing-hua (鍾情華) always keeps her cell phone on her, and when she gets an emergency call, she runs in big steps to the hospital, even in the middle of the night. Chang finds it comforting that the first nine cardiologists who joined the hospital in 2005 are still around. The hospital later established a peripheral vascular center, and three of these cardiologists have shifted to treating clogged blood vessels in the lower extremities [see the next article]. To meet the high demand for cardiology department services, the hospital has been adding one cardiologist a year, for a total now of 13. Cardiologists often face life-and-death situations, and as a result are often under tremendous pressure. However, they have to stay calm under duress. The more urgent a case, the calmer one must remain. “If the heart stops beating, we [strive to] get it pumping again,” Chang said. “If the blood pressure falls off a cliff, we pull it back up. If the breathing stops, we rush to restore it.” It is not unusual for a patient to arrive at the hospital already unconscious. Reviving him often tests the cardiologist’s skills. Chang said that his religious beliefs help him in such circumstances. He quietly chants the name of the Amitabha Buddha, and in just a few seconds he is calm enough to make critical decisions. At times he still experiences a churning stomach, tightness in his chest, or a headache while working on a patient, but as soon as the patient turns the corner, all his discomfort and fatigue dissipates. Usually, the only indication of the high-pressure procedure is the drenched clothes on his back.
Sympathizing with patients’ families When treatment leads to improvement in patients, medical care providers can take comfort knowing that their efforts have done good. But things do not always go so well. Despite their best efforts, physicians may come up short of the expectations of the patients or their families and be wrongly blamed as a result. One case shocked Chang more than any other. In 2003, when he was still at Chang Gung Memorial Hospital, he treated a woman in her 60s for a heart attack. The woman was critically ill when she was brought into the emergency room. Chang judged that her only chance to live was to immediately undergo cardiac catheterization. The woman’s husband, who had delivered her to the ER, could not decide whether or not to proceed with the surgery. The man called his daughter, Wang Xiu-feng (王秀鳳), and put her on the phone with Chang. When he told her about his conclusion, she asked, “What is cardiac catheterization?” Then she expressed her doubt to the doctor: Her mom had never had a heart attack, so how could she be in critical condition? It seemed so out of the blue. Wang rushed to the hospital. When she arrived, the mother had already been through the procedure and had been rolled out of the cardiac catheterization room. Smiling, she told her daughter that Dr. Chang had used angioplasty to unclog a blood vessel for her. She was then taken to an intensive care unit to recover. Unexpectedly, her condition took a sudden turn for the worse and she went into shock. The doctor hurried to save her. A nurse came out to inform the family of the situation. After a while, Chang emerged, his steps heavy. He said to the family, “It doesn’t look good. There’s a 90 percent chance that she’s beyond hope.” Wang was devastated. Unable to handle this sudden blow, she snapped at the physician, “You killed my mom!” That hurt Chang badly, but he knew that, under the circumstances, her concerns about her mother naturally overshadowed everything else. He softly explained her mother’s condition and what he would do next for her. “If she were my mother, I’d agree to keep the emergency treatment going,” Chang told the daughter. This statement, delivered with sincerity, touched her and helped her regain her good senses. She knelt in front of Chang, crying and begging him to do his best to save her mother. A long time later, Chang again emerged from the ICU. He asked for one person who was closest to the patient to go into the ICU with him. “If that person can awaken her, then we have a chance. Otherwise, she is gone, medically speaking,” Chang explained. Wang ran towards her mother and called out, “Mom!” Amazingly, the patient’s eyelids fluttered slightly. Chang continued his rescue work, and another hour passed. The mother eventually regained consciousness. The first words she said to her daughter when she came around were: “This doctor is good. He’s worked so hard to save me. You shouldn’t have doubted him.” The woman was later discharged and went home healthy. However, she passed away half a year later as a result of complications from long-term peritoneal dialysis. On the eve of the first Mother’s Day following her death, Chang received a bouquet of flowers from an unlikely person: Wang, the one-time antagonist who had accused him of killing her mother. She had sent the flowers to Chang on behalf of her mother.
The doctor wrote Wang a letter that went something like this: “Your mother was most kind to me. She endured a lot of pain when undergoing treatment, yet she always wore a smile and never hesitated to let me know that she had trust in what I was doing for her. I appreciate her kindness, and I will always miss her.” Another year went by, and he again received a bouquet from Wang around Mother’s Day. One year later, she showed up at his clinic and said to him, “We really appreciate what you did. You gave my family six extra months to be with Mom. During that time we were able to help her fulfill many of her wishes. She did many things that she had really wanted to do.”
Doubters abound It has been 11 years, and Chang continues to receive the yearly bouquet from Wang, which she delivers personally to his clinic. She herself has become his patient, as have her father, younger brother, and husband. Chang is literally their family doctor. Having seen how Chang cared for her mother, Wang realized how challenging a physician’s work can be, and her initial distrust of him became total confidence. However, many other patients or their families have yet to come to this realization and appreciation. News reports about adversity between recipients and providers of medical care have abounded, but Wang now understands that such incidents can be avoided or made less severe if the receiving side is more trusting. When trusted, a doctor can be undistracted to deploy the treatment strategy that is best for the patient. Chang, on the other hand, believes that doctors can also do a lot to help ease the tension. “When a patient is critically ill, it is understandable that the family becomes worried or even angry,” he said. “Their reactions, however, must not cause the physician to become indifferent. Instead, he should continue to do his best to serve the patient and their family. Eventually they’ll come to see your efforts.” Chang has shared his experience with the Wang family with younger doctors. His advice to them: “The more tempestuous their attitudes towards you, the calmer you must remain.” Trying to see things from a family’s perspective will help a physician make sense of, and hence empathize with, their behavior. Once that is done, adversity dissolves, mutual appreciation arises, and the patient benefits. Furthermore, a doctor must not fret over being woken at night, not get too worked up when patients or their families wrongly blame them for not doing enough, not be knocked off balance by the mercurial swings of a patient’s condition, and not lose heart when, despite the best medical intervention possible, the patient dies anyway. Only after having repeatedly survived these trials can one become, in Chang’s mind, an experienced, mature physician.
Medical excellence On this day, a 78-year-old man came to the cardiac catheterization lab for treatment. Doctor Zhan Shi-rong (詹仕戎) examined him while Chang stood in an adjacent observation room, looking in through a glass window and at the same time viewing images on computer monitors showing the patient’s condition. Looking at a frozen frame, he discussed the extent of the old man’s coronary artery blockages with other staff members, as well as the pros and cons of angioplasty and stents versus surgery. Chang pointed out two major blockages. On the left, two major vessels had severely narrowed, forcing blood to go down smaller branch vessels. If there were a heart attack, then the entire surrounding region would suffer blood deprivation and the risk of abrupt death would become quite high. The blockage on the right, on the other hand, could be more easily treated with a stent. Even though the old patient’s life was on the line, he was still able to carry on a conversation with Dr. Zhan as if nothing was wrong with him. He looked perfectly fine. Chang said that that was exactly why heart disease was so frightening. This old man came to the clinic only because he had experienced chest tightness, shortness of breath, and an inability to walk more than a few steps. But a checkup revealed that he was actually in critical condition. There was no time to lose. Chang asked a staffer to call a cardiac surgeon to take a look at the old man. Then he explained the situation to the patient’s family and informed them of the benefits and risks of the available treatment options. He recommended a more invasive procedure, coronary bypass surgery, to treat the problem on the left side. Its benefits would be longer lasting, and the need for repeated stent insertions could be avoided. After presenting his professional opinion, he emphasized to the family the importance of a healthy lifestyle. People nowadays like to eat refined food. They tend to eat too much and exercise too little, which often results in high blood pressure, high blood sugar, and high body fat. This patient, for example, suffered from hypertension, diabetes, and high blood lipids. These risk factors sped up the hardening of his blood vessels—which were already losing elasticity due to his age. Having given careful counseling and treatment to many patients in the same condition as this old man, Chang and his team have built up a reputation of excellence over the last nine years. The “door-to-balloon” (D2B) time—the time from when a patient enters the hospital to when blood flow is restored to the heart by performing angioplasty to remove a blockage—is critical to the survival and recovery of patients. The D2B Alliance, a campaign sponsored by the American College of Cardiology along with 38 partner organizations, has set a goal that 75 percent of patients should receive life-saving heart attack care within 90 minutes of arriving at the hospital. Taipei Tzu Chi Hospital has set a higher bar for its cardiology team—90 percent—and the team has cleared that high bar. The proficiency of the staff has also been shown to professionals outside the hospital. Taiwan Transcatheter Therapeutics 2014, a Transcatheter Cardiovascular Therapeutics symposium, was held at National Taiwan University Hospital. Participants came from the United States, Germany, Japan, the Netherlands, China, and Taiwan. Taipei Tzu Chi Hospital was invited to perform catheter procedures live on six patients, evenly divided between those with blocked cardiac and peripheral blood vessels. Tzu Chi physicians won accolades for conducting these particularly difficult procedures with obvious skill. For example, Dr. Ke Yu-lin (柯毓麟) led a team that performed a procedure for conference attendees. He used a high-speed rotablator to treat a patient with multiple diffused and calcified vascular lesions. This involved using a diamond-tipped burr on the head of the device to grind off some calcified blockage to widen the passage inside the blood vessel before he performed an angioplasty and deployed a stent. When the clog was opened up, the audience erupted into enthusiastic applause. Many people on Chang’s team worked behind the scenes while Ke and other doctors worked onstage. Many of them went to help even though it was their free time off work. Chang was very proud of their team effort and spirit. “We showed the conference not just our skills, but also our teamwork,” he said. “I believe our team will do better and better in the future.” Looking back, Chang said that he had gotten into medicine because his school grades had offered him a choice available to only a few—not because he had a natural love of it. However, he has grown to love it after years of practice. He is 54 now and has been in the field for almost 30 years—and his love for it continues to grow. With that love, he strives for perfection in his endeavors to save lives because, he said, “Nothing is more precious than life.”
How to Prevent Cardiovascular Diseases As told by Chang Heng-chia Eat plenty of whole grains, vegetables, and fruit. Be cheerful. Exercise regularly. Don’t smoke. Avoid obesity. Keep your blood sugar, blood pressure, and triglyceride levels in their proper ranges, and have the trio checked regularly. Get them down if they become elevated. If you do that, you may be able to improve your odds of having good health for decades down the road. Properly controlling the trio can reduce your risk of getting cardiovascular diseases. I need to point out one more thing: Early-stage heart disease doesn’t usually show symptoms. Be mindful when you notice chest tightness and shortness of breath. If the more you walk, the easier it becomes, then you probably don’t have angina pectoris, and your discomfort is probably stress-related. However, if you feel as if a rock lay heavy on your chest, if you can’t breathe and walk easily, then it is quite likely that you are experiencing a myocardial ischemia [when blood flow to the heart muscle is decreased by a blockage of the heart arteries] and the functions of your heart are impaired. If your blood pressure drops, your pulse quickens, your hands and feet turn cold, and you perspire all over, get to a doctor quick—your blood vessels might be severely clogged. A heart attack is quite deadly. You cannot be too careful. |
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