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Paul Goldfinger, MD, intern. 1967. East 97th Street at Park Ave, near the Mt. Sinai Hospital staff housing.

Paul Goldfinger, MD, intern. 1967. East 97th Street at Park Ave, near the Mt. Sinai Hospital staff housing.

 

By Paul Goldfinger, MD, FACC

(Originally published in 2008, Ocean Grove Record, Steven Froias editor. Also in 2013 on Blogfinger. Some of you may have missed it.)

“C’mon doc…let’s take a walk.”  Ordinarily this request wouldn’t seem odd, but it was 2 AM, and the idea of getting some sleep seemed much more sensible. But he was my boss, and such a request from the chief medical resident was not to be ignored. “Sure, John; that sounds terrific.”  John was an insomniac, with an insatiable love for the excitement of the big New York City hospital where we worked.

 

I was a twenty five year old intern, and we had just finished admitting seven acutely ill patients to the medical floor. My white jacket was wrinkled, and the tunic shirt, which had been clean, starched and buttoned up to the neck, was now sweaty and open at the throat. My pockets were stuffed with pieces of paper containing hurried notes scrawled as we put out one fire after another. Now it was time to catch up and do chart work. We sat at the nurses’ station, which was strangely empty, except for the rustle of an occasional nurse buzzing by.

 

My internship had just begun, and those long summer nights “on call” were extraordinary times of intense learning, exhilarating joy, crushing sadness and profound fatigue. We usually were up most of the night and had to work all the next day before finally getting some sleep. This was not a job for anyone over the age of thirty.

 

The interns came from all over the country, and each one seemed to have certain strengths which reflected where he went to school, so we learned from each other. My med school had emphasized practical “how to” knowledge, while others stressed theory. The latter group didn’t know which end of a suppository was up, but they knew all about the latest research trials. By the end of the year, it had all evened out.

 

Despite the hard work, everyone was very enthusiastic. Many times, someone would come in on their night off. I recall one time when a first year resident strolled in at 1 AM wearing a tux, followed by his date in a long gown. He went in to check an interesting new admission. The patient was quite impressed (as was I) and thought that we had a very classy staff.

 

The hospital by night was much different compared to its daytime demeanor. All the frills and frenzy were gone. There were no rounds, no conferences, no visitors, and no noise…only the bare necessities: people caring for people. It seemed like the place had been transformed into a sanctuary where a sort of medical swat team had formed to stand guard and make sure that everyone got through the night.  I liked to step outside in the early morning and breathe the fresh air blowing off Central Park across the street and watch the lights twinkling and the taxis cruising along the nearly deserted avenue. You needed to do that to clear your head of the hospital’s heavy atmosphere, even if only for a minute before the beeper went off.

 

As chief resident, John liked to wander about and make sure that things were going well. He and I walked through the underground tunnel that connected the various buildings, carrying paper cups of warm coffee. The sounds of our steps and voices echoed through the halls as we approached the emergency room.

 

En route we met the “dirty half dozen.”  This was the night surgical crew prowling about like a wolf pack looking for fresh meat. The surgical residency lasted five years, so there were five on each night plus a surgical intern. They were a motley assortment, dressed in green, all male, given to grunts, low humor and two day beards. “Hey Finger…got any hot gall bags for us?”  These guys were always hunting for OR cases and would operate on a salami if they could get consent.

 

The ER was a brightly lit, nonstop, wild and crazy place populated by drug addicts, policemen, drunks, crying kids, bag ladies and, of course, a textbook collection of patients. The interns who worked there seemed to be more cocky and raunchy than most, and the nurses were a hardened bunch who had no fears and who were incapable of being shocked.

 

John was asked to see a beautiful young European woman who stood out in that crowd. She had been partying and was due to fly home the next day. She was nearly hysterical about a small sore on her lip. John knew that it was a harmless cold sore and he told her so, but just to make her feel totally confident and happy, he gave her a shot of penicillin. I was learning the art of medicine and witnessing a small triumph.

 

Our next stop was the cardiac surgery ICU.  John had been a cardiology resident the year before, so he liked to stop there. Another reason had to do with a certain charge nurse who worked the night shift. While they chatted, I gazed about at the blinking monitors and listened to the humming and buzzing of respirators, suction machines and other assorted devices. The soft sounds of the machines and the voices of competent medical people were reassuring even to me, so I supposed that the patients sensed it also.

 

We returned to our floor at about 4 am to check in on our “sickies” and to discuss some of the cases. It was traditional for the resident to “teach” the intern prior to wrapping it up for the night. It was painful trying to stay awake during those early morning lectures, but the personal attention was amazing, and, besides, interns weren’t supposed to sleep.

 

Finally I was able to drag myself to our “on call” room. I would become unconscious even before my head actually collided with the pillow. If I were lucky, the phone wouldn’t ring for an hour or so. At 6:30 am we had to be on the floor to do “scut work” which included drawing blood, starting IV’s and running ECG’s before the 8 am start of rounds, where we had to present the new cases to the whole staff.

 

In recent years, there were complaints in the press about sleep deprived hospital interns and residents. Laws were passed requiring “house staff” to work reasonable hours. I didn’t agree with imposing those rules on a profession that knows how to teach young doctors in ways that go back to Hippocrates.  Yes, we were sleep deprived, but we had so much to learn, and working long shifts was a time honored way to become a competent physician. No one in our hospital was harmed by sleepy interns. The adrenaline kept us going, and there were wonderful residents, attending physicians and nurses to make sure that we did the right thing. We didn’t care about the sleep issue. What we wanted was the action, and you don’t get in the game if you’re asleep.

 

(Dr. Goldfinger trained for five years in internal medicine and cardiology at The Mount Sinai Medical Center in New York, where they had been training doctors for over 100 years and where he became a member of the first faculty of the Mount Sinai School of Medicine. He eventually got some sleep and now he is enjoying retirement in Ocean Grove)

 

 

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The CBS Evening News (11/9,) reported that “a new study that says sharply lower blood pressure leads to significantly longer lives.”

On ABC World News (11/9), Dr. Richard Besser reported, “The results were so startling, they stopped the study…early.”

The New York Times (11/10,) reports that investigators found that “among the 9,361 hypertension patients followed for an average of 3.2 years, there were 27 percent fewer deaths (155 compared with 210) and 38 percent fewer cases of heart failure (62 compared with 100) among patients who achieved the systolic pressure target of 120 than among those who achieved the current 140 target.”

Altogether, “there was a 25 percent reduction — 243 compared with 319 — in people who had a heart attack, heart failure or stroke or died from heart disease, Dr. Paul K. Whelton, a principal investigator for the study, said.” The findings were presented at the American Heart Association meeting and published in the New England Journal of Medicine.

Blogfinger Medical Commentary.   Paul Goldfinger, MD, FACC

One year ago, experts at the NIH were recommending that doctors back off  on their advice for patients with hypertension  (high blood pressure) saying that any systolic reading  (the top number) under 150 would be fine for patients over age 60, while 140 would suffice for younger people.  The 140 number had been the standard for many years.

In 2014, after years of waiting, the NIH put out their JNC 8 guidelines for treating high blood pressure. The result had cardiologists pulling their hair out over the wishy-washy results which had doctors cutting back on aggressive treatment,  and patients, especially older ones,  throwing away their pills.  This quote is from the NJC 8, 2014 guidelines:

There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion.

Now, in a large trial of over 9,000 people age 50 or older, it appears that a systolic reading of under 120 is best. The study did not include diabetics or  stroke victims.  In order to be in the trial, you needed a BP of 130-180 systolic.  The bottom number (diastolic) was not studied but it is nevertheless important, and 90 is the cutoff for diastolic readings.  And if you were younger than 75 you needed to have at least one risk factor such as heart disease or high cholesterol. in order to be in the trial.

So most people in the US with hypertension would not qualify for this trial, and the results can’t be applied to them.  The treatment phase consisted of one group who were shooting for a reading  under 140, while the more aggressive group achieved BP under 120.

The study considered drug therapy as the main way to get the systolic BP below 120 in the aggressively treated group, but no consideration was given to non-drug lifestyle therapies such as weight reduction, low salt diet, adequate sleep and exercise.

Interestingly although this academic study (done where the researchers often live in a bubble) was making believe that doctors can push readings down to 120 in older individuals, the reality, in real-life,  is that many patients can’t even get their BP under 140.  Doctors have often failed to achieve the old goals, despite an excellent array of drugs, and there are often errors made in how these patients are followed.

In the office, the BP reading is often taken in a hurry by a medical assistant whose technique is often sloppy using untrustworthy equipment.   In addition, a rushed measurement  is often misleading.  The patient should be allowed to sit quietly and then repeat the reading.  The doctor should double check it himself.

Office readings are particularly unreliable if one is interested in the blood pressure experienced by a patient throughout the day.  All my patients were recording home readings several times per day, keeping diaries of time and circumstances.  If they were stressed, or they had other issues,  they were to write it down.  They also would take readings standing and sitting. Almost every one of my patients were within scientific guidelines.

I discussed salt, nutrition, exercise, stress and weight with my patients as part of a comprehensive  prevention plan. It’s all in our book “Prevention Does Work: A guide to a healthy heart.” by Paul and Eileen Goldfinger.

It is important to point out that striving for a BP of 120 especially in the elderly, creates a risk of dizziness, fainting, falling, kidney failure and cognitive failure.   The benefits in this trial, in absolute numbers,  are not huge, despite the 24% reduction in end points such as death rates, and many experienced doctors are skeptical.  My own cardiologist is sticking to the old guidelines, and I agree, but I am inclined to want to be closer to 120 than to 140. The new guidelines are not even out yet, so don’t be too quick to play the low number game.

In 2014, I wrote a series of 4 articles “Confessions of a high blood pressure doctor.”  Part III deals with this topic of targets as of 2014. It is a good orientation piece.      Confessions Part III treatment goals 2014

Quote of the day.  In the New York Times (11/10) “Well” blog, Harlan M. Krumholz, MD, from Yale Med School, points out that this trial does not offer an absolute conclusion for clinical use at this time.

He writes, “The study opens a new option for treatment, but it is not a slam dunk that everyone who fits the eligibility criteria of the study ought to be treated.” Rather, Dr. Krumholz argues, “it is a choice that is worthy of thought and reflection.”   

And we can sure use more doctors who take the time for “thought and reflection.”

You can also search the Times for Gina Kolata’s recent essay on this subject.

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