Giving ‘wrong’ medical advice?

by Dr Upul Wijayawardhana

“Have I given wrong medical advice?” From the time I read the interesting and heart-rending account ‘My 18 week ordeal of double trouble’ by my friend Dr Lakshman Abeyagunawardene (Sunday Island, 25 October) I have been pondering over this question. Poor Lucky has had a double whammy, on top of the lockdown, due to Shingles on his face (Herpes zoster) followed by heart block necessitating a pacemaker implantation. He suffered first due to severe neuralgic pain following Shingles, which is well-known to be one of the most severe and intractable pains, and due to the limitations imposed following the pacemaker implantation. My thoughts were provoked by the following comments:

“I had to go through the procedure of pacemaker implantation while the pain in my right eye persisted. It was after my fainting episode and pacemaker implantation was recommended that I was debarred from climbing stairs. I was confined to the guest room and this is where my agony really started. My wife did not allow me to even go to the living room which was just three steps below. Towards the latter stages, I watched news on the small TV in the kitchen. I had to be satisfied with the laptop computer that my son brought. But it was a far cry from the desktop I was used to. I missed my weekly shot of an alcoholic drink! I had not taken even a beer since the beginning of June.

I think I had a turnaround in my fortunes after the doctor did the Programming on September 27. It was this doctor’s advice that I strictly followed (more so my wife and son) because there was nothing more the Neurologist who was treating my neuralgic pain could do.”

What perplexed me was the advice given not to climb stairs which made my friend’s life miserable. I had never given this advice though I implanted many permanent pacemakers in Sri Lanka as well as in UK. In fact, I can claim credit for starting the permanent pacing programme in Sri Lanka, way back in late seventies, when pacing was in infancy. In spite of the very ‘primitive’ devices I used at the beginning, I did not impose this restriction.

A permanent pacemaker is needed when there is a failure in the electrical conduction system built in the heart to ensure an appropriate heart rate response to bodily needs as well as to coordinate contractions of the four chambers of the heart. The permanent pacing system has two major components. First, there is a ‘box’ with the electronics and a battery. Due to the huge advances in electronics ‘the brain’ of the pacemaker is tiny, the size of the pacemaker depending on the size of the battery. The second component, the leads (electrodes) deliver a tiny current generated in the ‘box’ to the right side of the heart after sensing whether the heart’s own electrical system is functioning properly or not. Invariably, two leads are used, one to the small ‘collecting’ chamber; the atrium and the second to the large muscular chamber; the ventricle. The procedure of implantation is done under strict aseptic conditions. First, the vein underneath one of the collarbones is punctured and the lead is advanced to the heart under x-ray guidance. Once a satisfactory position is found the lead is fixed and connected to the box, which is then implanted in a pocket under the skin.

When I started implantations, batteries lasted only two to five years but today most pacemakers have much smaller batteries lasting more than 10 years, due to improved battery technology. The electronics in the box then was very simple, just discharging a current when it did not sense innate activity but the electronics today is so sophisticated that the pacemaker is able to record and store heart beats continuously. Stored data can be retrieved by interrogating the pacemaker using an externally held device which is also used to programme, to tailor the pacemaker for the needs of each person. Not only the electronic circuitry and batteries but also leads have improved very significantly, becoming slimmer and having fixation devices at the end to make sure the lead tip does not displace. My nightmare, at the beginning, was lead displacement, as there were no fixation devices. This resulted in not infrequent reopening and adjustment, a tedious process.

In spite of refinements lead displacement still occurs, though very rarely, and it is to reduce this that some limitations are imposed. However, I could not find advising against going upstairs in guidelines issued by any renowned Cardiology institution. Patients are advised not to lift the arm of the implant side above shoulder level for four to six weeks. It may well be this recommendation that had been misinterpreted or miscommunicated.

Notwithstanding allegations of overdoing procedures for gain in the private sector, some of which are true unfortunately, I am well aware that the standards of practice of cardiology are very high in Sri Lanka. As a ‘veteran’ who contributed to the establishment of the speciality of cardiology on a firm foundation I can look back with a sense of satisfaction. Therefore, these comments are not meant, in any way, to be critical of the Electro-Physiologist who implanted the pacemaker but to highlight the importance of communication in medicine; an art we had to master on our own. I do not know whether things have changed since and Medical Schools are teaching how to communicate.

Am I guilty of having given wrong advice to patients? Yes, but in my defence, it was mostly ‘authenticated’ wrong advice. What do I mean by that? We give medical advice on the basis of existing medical knowledge which on hindsight may prove wrong. Concepts change with advancing knowledge; accordingly, we change management as well as advice. When I was a young doctor, we advised patients with heart attacks to have strict bed rest for six weeks. It transpired later that it did more harm than good. With new evidence we changed and treatment revolutionised. Now, a patient with a heart attack has an angiogram straight away and the ‘culprit’ vessel is dilated with a stent. Patient is out of bed the next day! I can go on giving many examples. Medicine keeps changing, like any other science. That is the difference from religion where belief is the foundation, not exploration and experiment.

When I was in active practice, I found it difficult to keep pace with advances in my speciality till the world wide web came into being. Since then updating knowledge has become so easy. Before that, I may have given wrong advice without realising that knowledge has passed me by. At least, we know our limitations but wonder whether those who practice static systems of medicine protected for political and historical reasons realise that they are giving outdated advice. We need to be in touch with new developments and revise our advice accordingly. Admittedly, it is no easy task but one that should be done, as misguided advice can make life intolerable for patients, as Lucky’s story clearly illustrates.