Dr. Ravi Yarlagadda (center) training cardiologists in the implant technique

Today I implanted cardiac resynchronization pacemakers (CRT-P) in two patients suffering from advanced heart failure.  Both procedures went smoothly and should provide measurable differences in the functional ability of the patients’ weakened hearts.  These implants also provided the ability to perform a secondary purpose of my trip, proctoring cardiologists on the implantation of pacemakers.  The cardiac devices donated for my trip to Vijayawada are thus serving two very important purposes:  improving the lives of the patients who receive them, and training local physicians to continue these lifesaving procedures after I return to Hartford. 

 

I assumed that the six cardiologists I was to train on pacemaker implantation techniques practiced locally.  I could not have been more surprised to learn that one had traveled from one of the most remote corners of India!  This gentleman hailed from Shillong, a northeastern town in the foothills of the Himalayas.  In order to join me at NRI Hospital, he drove several hours to the city of Gauhati, flew three hours to Delhi, flew another three hours to Hyderabad, and caught one final 90-minute flight to Vijayawada.  Like the other five cardiologists I will proctor, he practices interventional cardiology.  This means he specializes in invasive procedures like diagnostic angiograms which examine the condition of the coronary arteries.  No physician in his corner of India currently implants pacemakers.  Gaining the skills to provide these life-saving devices will bring immeasurable value to the patients of his community.

A taxi in Vijayawada

Catheterization lab staff

It was also my pleasure today to provide an educational lecture to the students at NRI Hospital’s affiliated medical school.  I spoke to roughly 50 medical students about the foundational concepts of heart rhythm disorders, diagnostic techniques and treatments options.  These students were particularly taken with the concept of implantable cardiac defibrillators (ICDs).  Certainly they are aware of this technology, but ICDs are nowhere near as prevalent in India as they are in the United States.  By terminating lethal cardiac arrhythmias (like ventricular fibrillation) which can cause Sudden Cardiac Death, ICD’s truly save lives.  After I discussed this concept one student said “ICD’s sound like they literally bring patients back from the dead.”  I agreed with him.

 

After providing education to cardiologists and medical students, I myself learned today some remarkable things about the attitudes and expectations of patients and families in India towards the invasive procedures I provide as a cardiac electrophysiologist.  I want my patients to make informed decisions regarding their healthcare.  During scheduled consultations, I talk in depth with the patient about their cardiac condition because I want to make sure that they are comfortable in their understanding of their specific heart rhythm disorder.  I also fully disclose any risks which may be involved.  In the US, patients rarely agree immediately to go forward with any therapeutic procedure.   Instead, they take several days to consider their options.  They hit the Internet, read up on their diagnosis and proposed procedure, and get back to me in a few days.   These actions are all reasonable and understandable, however, not a single patient or family member in India has taken them!   I am told instead, “It’s in your hands, Doctor.  Tell me what is best for me.” 

 

Following a procedure in the US, I am often impressed with the sophisticated knowledge families have about the technical aspects of a procedure.  I am asked if I experienced any difficulty placing the pacemaker wires, or where I found the originating source of an arrhythmia I have ablated.  After a device implant procedures at NRI, families are asking me more fundamental questions: “Is Dad alive? Will he be okay?” 

 

I don’t fully know what to make of these differences between my Indian and American patients.  Neither nationality has a greater claim on the understanding of their diagnosis and treatment or concern for their loved ones.  Do the differing reactions reflect cultural differences with the trust established between a physician and patient?  Or, do they represent dissimilar attitudes toward the acceptance of risk and mortality?  These thoughts are weighing on my mind tonight. 

 

Tomorrow brings two more device implants.

 

Dr. Ravi Yarlagadda