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surgery. What do we do? How do we do it? When? For the most part, I either know the answers or can come up with a strategy to arrive at them. When I’m sure, I make the call. When I’m not, I check with Dr. George. The key is knowing the difference.
    This kind of pressure means that newly minted Fellows tend to share a dark humor: “Another good day. I didn’t kill anyone.” That humor turns out to be one of the few bonds among us, as we intersect in hallways, on breaks, or when two of us are seeing the same patient for different reasons.
    A few days go by, and just when I start to think that consults isn’t so daunting, I’m thrown into a situation that reminds me of the gravity of what we do. It’s my second week on the rotation, and I’m brought in on the case of an eighty-one-year-old woman, Midge, who has come in for surgery to remove a tumor on her liver. The tumor turns out to be malignant, and she’s slated to begin cancer treatment. But it’s only after complex surgery when she’s in the intensive care unit (ICU) that a routine electrocardiogram (EKG) reveals strain on her heart with mildly elevated cardiac enzyme levels. I’m being consulted because we need to figure out whether (a) the EKG and enzymes are evidence of an evolving heart blockage or (b) they’re relatively predictable signs of stress following major surgery. The stakes are high because the two possible diagnoses indicate almost polar opposite treatments. Post-op stress means Midge should be watched carefully. Evolving coronary blockage means a series of steps, including an invasive procedure such as catheterization, and/or blood thinners, which carry their own risk for a person who has just had abdominal surgery—that is, bleeding. There isn’t any yes/no test to determine the right conclusion. It’s a judgment call. And it’s up to my team to make it.
    The basic issue is one of supply versus demand. Supply issues are what heart attacks are made of. An acute compromise of blood supply (coronary plaque rupture/clot) results in an urgent or emergent trip to the cath lab while blood thinners are administered, similar to what happened with Randy. Unless the supply is reestablished by angioplasty (opening the blocked artery), the heart muscle begins dying, meaning that, without intervention, the patient may also. On the other hand, an increase in myocardial demand (the heart muscle’s need for oxygen and the blood’s nutrients) can induce strain on the heart muscle, and sometimes result in heart cell death. The solution to this problem is different, since it involves relieving the stress, treating the infection, eliminating the dehydration, controlling the bleeding. In this case, you have to fix the underlying stressor.
    In Midge’s case, we need to figure out whether she is having a heart attack caused by plaque rupture and a new clot lodging in one of her coronary arteries, or is simply experiencing postoperative cardiac stress because of her surgery. Heart cells die when supply and demand don’t agree. Figuring out why they’re out of balance, and what to do, is part of the nuts and bolts of cardiology.
    I spend a full hour going over Midge’s chart. I question the surgical resident. I speak to the ICU nurses. And I attempt to assess her directly, although Midge can’t talk because she’s been intubated and is currently dependent on a mechanical ventilator. The resident introduces me to Midge’s family as the cardiologist who will care for her heart while Midge recovers from surgery. It’s a small untruth: There’s no upside in telling nervous relatives you’re only “studying” to be a cardiologist. I take my time to understand Midge’s background, and ask her daughter and a family friend about Midge’s level of physical mobility and about any previous heart problems. I learn that Midge leads an active lifestyle: She walks for forty-five minutes to an hour every day with her daughter, has no history of heart problems,