Lakeside Medical Musings

Heartbeats

While unpacking the last of the stored-away boxes from our move out to the lake, I came across my Dad’s very old, very beautiful electrocardiograph and, as if it were a time machine itself, I was instantly transported back in time…

 

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As I’m sure you know, an electrocardiograph measures the electrical impulses from the heart and represents them as tracings on a strip of paper creating a diagnostic tool, known as an electrocardiogram, EKG or ECG.  When I started my practice, I bought my own modern EKG machine from a medical supply house.  It was sleek and lightweight, housed mostly in a plastic casing, and it was as essential a tool of the medical trade as a chef’s knife is to the restaurant business. But when my dad started his internal medicine practice in 1953, an electrocardiograph was a status symbol that helped define a physician, an internist, as an elevated member of a particular group in society.  It was boxed in rich walnut with beautiful brass fittings and had the physician’s name – not just the medical device company’s name – engraved on a brass plate affixed to the front.  It was the first piece of equipment a new physician purchased, or was gifted, prior to opening a practice. Upon his retirement, my father passed the torch to me and gave me his electrocardiograph — not to use, but to cherish.

As an internist, the EKG has been the literal heartbeat of our practice – clearly, pun intended — for much of the last seventy years.  From the 1950’s straight through to the 1980’s, it was frequently the only diagnostic test that was performed in many internists’ offices.  Every patient received an electrocardiogram during their yearly physical exam — the value of which could certainly be debated. Now that I, too, am retired, my father’s EKG resonates as a golden piece of my memory.

In 1978, when I became a Junior Medical Student (JMS), hospitals were run much differently than they are today.  Many of the tasks that are now routinely assigned to nurses or technicians were performed then by medical students.  This was called “scut work,” etymology unknown, but a term in use in hospitals from the 1950’s, referring to “lowly or menial work.”  Starting IVs, drawing blood, tracking down lab results and retrieving X-rays were all considered scut work and were assigned specifically to the JMS.  The Medical College of Georgia prepared its students quite well to perform these menial tasks, as the students’ amount of sleep on call nights directly correlated to their efficiency and competence in mastering these repetitive jobs. Depending on their skill level, a 2 am call to a medical student to restart a patient’s IV could either be a grueling thirty-minute ordeal or a five-minute turnaround that barely required the interruption of an adept student’s REM sleep. And the quicker a student mastered these tasks, the more time was available to them to learn actual medicine.  I always enjoyed the scut work that I was required to do, probably because I was both good at it and fast.  There was no patient on whom I was unable to obtain a blood draw or start an IV, so when I began my internship at Parkland Hospital after my graduation from MCG, these thoroughly mastered skills gave me the confidence to compete with my fellow interns, many of whom had received their medical degrees from Ivy League schools.  We State School graduates had the distinct pleasure of feeling superior to the Harvard and Yale — especially Yale — graduates who had never started an IV or drawn blood on any patient.

Performing an EKG was one of the first essential skills I mastered as a JMS.  Notably, this particular task was considered above the level of scut work, but it was always performed by students.  These days, of course, an EKG is done by techs with mostly automated machines, but in 1978, an EKG was done by hand and with great care.  Rubber straps with a metal contact, called limb leads, were placed on each arm and leg.  The chest lead, which was a thoroughly annoying suction cup, was placed on the patient’s chest with some goop to make it stick. The standard 12-lead EKG shows the electrical activity of the heart from twelve different perspectives.  The limb leads were identified as I, II, II, AVR, AVF, and AVL, and the chest leads were V1 through V6.  Lead I showed the electrical activity from the point of view of the left arm to the right arm, lead 2 was from the left leg to the right arm, etc.

 

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After painstakingly applying all the leads precisely, the operator’s job was to then turn the dial on the EKG to Limb Lead I and begin the recording, marking the EKG paper to indicate Limb Lead I by holding down the marking button which produced one dash on the paper strip. The dial was then turned to Lead II and marked with two dashes, and so on, down the line. The chest lead produced tracings from different positions on the chest.  In 1978, going all the way back to my dad’s day, there was only one actual lead for the chest recordings.  This lead had to be meticulously placed on the right upper chest in the exact position in relation to certain anatomical landmarks, the Sternal Angle of Louis being the first such landmark, to record the first chest lead, V1.  The EKG machine was turned on for a recording of 5 or 6 beats, marked with a long dash followed by a short one, then turned off, and the chest lead was moved to position V2 on the patient’s chest, the machine turned back on, each time appropriately marking the recording paper.  Needless to say, this was a cumbersome process that took a good bit of time to perform, and the chest lead suction cup frequently popped off the patient’s chest so the operator needed to re-stick and re-record, often many times over in the same position, to get an accurate read before moving on to the next position.  Performing an EKG as a Junior Medical Student was the first real clinical skill that I developed that was actually helpful and time-saving to the overworked and exhausted intern to whom I was assigned.

Law 11 from Samuel Shem’s classic work, the oft-quoted The House of God:

SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK, AND I WILL KISS HIS FEET.

We medical students took great pride in performing EKGs quickly and accurately, in the heat of the moment, when a patient was complaining of chest pain. Giving a not-too-long, not-too-short, but just-right, strip of EKG paper to our intern allowed us to feel a sense of accomplishment in a world that was very new to us. EKGs were then, and still are today, one of the best diagnostic tools available when a patient is experiencing acute chest pain.

I very much enjoyed my time as a medical student. The first two years were virtually all book- and lab- learning, with very little interaction with actual patients.  It was hard work and long hours.  Carl, my best friend, and I would frequently study together until the wee hours of the night with only a dinner break, frequently driving to a Chinese restaurant – cheap and fast — and, while we were deeply supportive of each other, we were also very competitive. I do miss those days.  As we moved into our JMS year, we developed clinical judgement and mastered technical skills, an EKG being one of the first.  Carl went on to become a well-respected cardiologist in New York, and while we haven’t kept in touch, I assume he has similar somewhat conflicted memories of the agonies of medical school and our introduction into the world of electrocardiography whose machinery seems so antiquated now.

My father and I, like all fathers and sons, had our conflicts, but we did have medicine in common, and when I look at his EKG machine, it brings back many strong memories of him.  Ruth and I decided we didn’t want to put dad’s beautiful EKG machine back into a closet, so we found a place for it on our favorite table in the living room. I spent much energy this morning polishing the old brass name plate – Edward H. Scherr, M.D. – and thinking about my dad.

 

 

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