treatment

Getting a Second Opinion

February 20, 2018 By Larry Creswell, MD Leave a Comment

There can be tremendous value in getting a second opinion. I’m certain about that. At times, though, the process of getting a second opinion can cause unnecessary angst for patients and doctors, alike. It shouldn’t. Here’s my take.

What do we mean by a second opinion?

We’re talking about an additional opinion from a doctor who has not already been a part of things–somebody who did not offer the first opinion. Perhaps that’s obvious. Ordinarily, the process of getting a second opinion involves:

Gathering information (eg, records, test results) that formed the basis for the first opinion for some new doctor to review.
An in-person visit with the second doctor for the purpose of an interview and physical examination.
A discussion with this doctor, where the second opinion is shared with the patient, highlighting the similarities and differences from the first opinion.

Most commonly, we’re talking about second opinions from medical specialists or subspecialists rather than primary care physicians (PCPs).

When is a second opinion helpful?

Here are some situations where second opinions can be helpful. For each situation, I’ve included an example of an athlete-related heart problem.

When the diagnosis is uncertain. Not everything in medicine is black and white. As they say, the practice of medicine is both an art and a science. Sometimes, even when all of the relevant information has been gathered, it’s still not possible to decide with certainty as to a diagnosis. In this situation, a second opinion may help to sort out the diagnosis by bringing additional experience as well as a fresh set of eyes and ears to the problem.

An example. The condition known as hypertrophic cardiomyopathy (HCM) can be a difficult diagnosis to establish. There are known genetic mutations associated with this condition, but only a small percentage of cases can be diagnosed that way. In many cases, the diagnosis depends on the findings from echocardiography, magnetic resonance imaging (MRI), clinical features, and family history. In some athletes, there can be particular difficulty in distinguishing between an athletic heart, simply the result of exercise, and HCM. It’s easy for this diagnosis to be uncertain. In this situation, a second opinion may help to gather consensus about the diagnosis or suggest additional diagnostic testing that might be helpful.

When the treatment carries high risk, is expensive, or is logistically difficult. The diagnosis is settled and the conventional treatment involves a fair bit of risk. Often, we’re talking about a surgical procedure. In this situation, a second opinion may bring clarity to the need for treatment and confirmation that the planned treatment is appropriate.

An example. The condition known as bicuspid aortic valve (BAV) can involve regurgitation (leaking) of the aortic valve as well as enlargement of the nearby aorta to form an aortic aneurysm. When this diagnosis is established in a non-emergency setting and the patient requires replacement of the aortic valve and the nearby aorta, there are often several related, but technically different, surgical options. There are different types of prosthetic heart valves and different types of substitutes to take the place of the aorta. In each of these variations, though, the operation carries a fair bit of risk, is expensive, and can be logistically difficult, especially if operation must be pursued some distance from home. Here, a second opinion can be helpful to be certain about the diagnosis and the need for operation; provide clarity about how soon an operation should be performed; provide additional discussion about the various surgical options, with the advantages and disadvantages of each; afford an opportunity to re-address the amount of risk that comes with operation; and offer thoughts about the expected recovery timeline and return to exercise.

When there are several treatment options to choose between. After a diagnosis is established, the usual next step is to settle on a treatment. For many conditions, however, there can be several treatment options. Ordinarily, doctors like to share these possibilities with a patient and then decide together which treatment is best. This choice might depend not only on the medical specifics, but also the patient’s social, work, family, financial, cultural, or religious situation. But sometimes, even after discussion, it may not be easy to choose the best treatment. In this situation, a second opinion can sometimes be helpful to explain, from another doctor’s perspective, the treatment possibilities along with the advantages or disadvantages of each option. This doctor might well include additional or different possibilities or share the opinion that some of the previously considered possibilities may not be appropriate.

An example. One common arrhythmia problem in athletes is atrial fibrillation, or “Afib.” This is a problem that can be nagging or persistent over months or even years. Once an athlete patient has had this diagnosis established, there are often many options regarding treatment: lifestyle changes like losing weight, stopping tobacco or alcohol use, or moderating extreme exercise; medicines like aspirin, anticoagulants, or anti-arrhythmics; and procedural treatments such as arrhythmia ablation or left atrial occlusion. Moreover, a patient will find that his primary care provider (PCP) and perhaps even his cardiologist may not actually perform such ablation or left atrial occlusion procedures. In this situation, a second opinion might help to review the various treatment possibilities from another doctor’s perspective, and get another take on the advantages and disadvantages of the various treatment possibilities.

When it’s mandatory. Because of various regulatory frameworks, it’s sometimes necessary to get a second opinion before a patient can receive a particular treatment. Regulations at the local hospital level, from insurance providers, or from the federal programs like Medicare and Medicaid may all come into play in this regard.

An example. For patients with severe, symptomatic narrowing of the aortic valve (aortic stenosis), we often recommend aortic valve replacement (AVR). In recent years, a new approach for AVR, trans-catheter aortic valve replacement (TAVR), has become available for select patients. To satisfy requirements of the FDA and the Medicare program, patients must get opinions from two heart surgeons before they qualify for the TAVR procedure. In this situation, the second opinion is essentially mandatory.

When is a second opinion not helpful?

In an emergency situation. Second opinions are usually not logistically possible in an emergency situation. Here, patients must usually rely on the doctors that are tending to their emergency condition, even in the situations I’ve outlined above.
When the patient is already in the hospital. Once admitted to the hospital under the care of one or more doctors, it can be difficult to pursue a second opinion, at least in the common sense. If the condition or situation is not an emergency, sometimes it’s possible for partners of specialists to add their opinion, less formally, about a particular issue.
When two or more previous opinions are already similar. There is a diminishing return with multiple second opinions. When there is already a chorus of similar opinions, it’s likely the next opinion will also be similar. In general, it’s probably not wise to chase after the opinion you want. If you search long enough, you might find that opinion, but remember that there is usually value to consensus among the opinions you’ve received. Outlying opinions should be treated cautiously.

How to find a second opinion?

Ask your primary care provider (PCP). For patients who are fortunate to have a PCP, this may be the best source of a recommendation about how and where to seek a second opinion. Your PCP will know the local medical landscape. In many cases, he may have referred you to the specialist for your first opinion. But he will also know which doctor to suggest next, whether that’s another doctor in your community or one that’s farther away.
Ask your specialist. You can certainly ask the specialist who provided your first opinion. Some specialists will be more helpful than others when it comes to identifying a good choice for a second opinion. You may find that it’s easiest for your current specialist to suggest a partner who might also take a look at your situation.
Do some (online) research. There’s a lot of information online about specialists who you might visit for a second opinion. Perhaps there’s too much information. It can sometimes be challenging to sift through all of this information and make judgements about its quality. You may find that you will need to travel some distance to see a particular specialist. The danger here, though, is in not understanding the medical details sufficiently to select just the right doctor. And sadly, sometimes if you choose the wrong type of specialist, this may not become obvious until after you’ve invested in a visit. Another approach may be to select a large medical institution and have that institution help with finding just the right doctor to see you after they get some information from you and perhaps gather some medical records.
Word of mouth. At first, word of mouth may sound like a great way to find a doctor for a second opinion. Indeed, you may have friends or family that could suggest a doctor that they’ve seen and liked. The challenge here is that it can be difficult to find just the right doctor unless your family or friends have the exact same medical problem that you do.

Doctors get second opinions, too

Sometimes doctors obtain second opinions without their patients even knowing. This is just good practice. In this situation, the process may happen behind the scenes. Your doctor may share your particulars with a colleague to ask for help in settling on a diagnosis or settling on the best treatment. Your surgeon may ask a colleague to join him in the operating room to help decide what to do with an unexpected finding. Your pathologist may “send out” your biopsy specimen to get an additional opinion from a center of expertise. These sorts of second opinions are everyday occurrences.

When to change doctors

We should wrap up with talking about when to change doctors. So far we’ve been talking about getting additional, or second opinions. Most often, this is done with the intention of continuing to receive care from your first doctor. But what if you’d like to change doctors? There’s nothing wrong with wanting to receive your ongoing care from the doctor who gave your second opinion. That’s your decision and your doctors should understand making a change like that. I suggest that straightforward discussion with your doctors is the best way to make such a change.

Finally, let me mention two particular situations where you should consider finding a new doctor:

When you are concerned about honesty, transparency, or communication with your current doctor.
When you have reasonable concern about experience on the part of your doctor, clinic, or hospital.

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Laurent Vidal and Cardiac Arrest

April 30, 2014 By Larry Creswell, MD Leave a Comment

Vidal

The news last Thursday was startling. Laurent Vidal, the 30-year-old French triathlete, reportedly suffered a “heart attack” and cardiac arrest during a swim training session. You may recall that Vidal is the star of the French triathlon team and finished 5th in the London Olympics. By report, he complained of chest pain and later collapsed in cardiac arrest. News accounts indicated that he was revived, regaining consciousness, and was transported to the hospital for further care. Follow-up reporting suggested that therapeutic hypothermia as well as induced coma had been employed in his treatment. Over the weekend there was very little reporting, though, at least in the English news media, so I don’t have any additional information about his condition to share here. On Monday came a Tweet from Vidal: “Hello world.” I’ll take that as a good sign and wish Laurent and his fiancé, fellow triathlete Andrea Hewitt, all the best during his recovery.

Interestingly, in a report this morning, came some additional information about Vidal’s medical history. We learned that Vidal had suffered from exertional syncope (blacking out while exercising) on two previous occasions and had undergone a detailed evaluation after the 2nd episode, in 2011. At that time he was given the diagnosis of neurocardiogenic syncope, a condition that was thought not to be serious. I’m sure these previous incidents will be given new consideration in light of Vidal’s cardiac arrest episode.

I can tell from the questions I’ve received about this incident that cardiac arrest remains somewhat of a mystery. Beyond cardiopulmonary resuscitation (CPR), and possibly the use of an automated external defibrillator (AED), most people don’t have much familiarity with the treatment of victims of cardiac arrest. Non-medical folks might go a lifetime and never witness such an event. I thought I’d use Vidal’s story as a starting point for a discussion about the treatment of victims of cardiac arrest.

Cardiac Arrest

We use the term “cardiac arrest” when an individual’s heart has stopped beating effectively. The victim loses consciousness and stops breathing. When this happens suddenly, without warning, we use the term “sudden cardiac arrest,” or SCA. The victim of SCA immediately appears lifeless.

Cardiac arrest is a different problem than “heart attack.” I’ve written a previous blog post on the terminology of cardiac arrest versus heart attack. In short, a heart attack occurs when there is complete blockage in one of the coronary arteries that brings blood flow and oxygen to the heart muscle. This condition typically produces chest pain. Affected patients are evaluated with coronary arteriography and undergo procedures like coronary stent placement or heart bypass surgery as treatments.

Cardiac arrest occurs because there is a sudden change in the normal electrical activity of the heart. There is a collection of abnormal heart rhythms, called arrhythmias, that can be responsible: ventricular fibrillation (VF), ventricular tachycardia (VT), asystole, or pulseless electrical activity (PEA). With each of these arrhythmias, the heart does not beat effectively and therefore does not pump any appreciable amount of blood. The blood pressure falls to zero and a pulse can no longer be felt.

Without treatment, the victim of SCA has died. The American Heart Association (AHA) suggests a conceptual framework called the “Chain of Survival” to outline the necessary links to increase the odds for survival:

Immediate recognition of cardiac arrest and activation of the emergency response system
Early CPR with emphasis on chest compressions
Rapid defibrillation, if needed
Effective advanced life support
Integrated post-cardiac arrest care.

Initial Treatment

If a victim of cardiac arrest is to become a survivor, there must be prompt and appropriate care at each step along the Chain of Survival.

It is important for bystanders to recognize the victim of cardiac arrest–unconscious, not breathing, no pulse. The initial treatment is CPR. In the United States, the AHA and American Red Cross offer classes in CPR. For people who are not healthcare workers, the AHA teaches chest compression-only CPR, instructing the rescuer to do chest compressions centered over the breastbone, or sternum, at a rate of 100 compressions per minute. The AHA teaches that the 100 compressions per minute rhythm can be maintained by doing the compressions to the beat of the 1983 Bee Gee’s hit song, “Staying Alive.” Healthcare workers are taught how to do rescue breathing interspersed between sets of chest compressions, either in 1- or 2-rescuer scenarios. If no nearby bystanders are trained in rescue breathing, then chest compressions alone are appropriate as an initial treatment.

While CPR is being performed, bystander rescuers need to notify the emergency medical system (EMS) to summon more advanced care for the victim. In the United States, bystanders can call 9-1-1 to alert the appropriate authorities. The telephone dispatcher will arrange for emergency medical technicians (EMTs) or paramedics to be dispatched to the scene. The dispatcher can also remain on the telephone to help provide guidance to the bystanders who are tending to the victim.

If there is an AED nearby, somebody should fetch it. These devices are often located in public spaces such as schools, shopping centers, fitness centers, etc. They may also be on hand for special events. The use of the AED is often taught in conjuction with the basic CPR course. Even without instruction, the AED is designed to “talk you through” how to use the device in an emergency situation. The AED is opened and the ON/OFF switch is turned ON. An electronic voice will provide instructions to attach defibrillator pads to the victim’s chest in 2 locations. The AED will analyze the victim’s heart rhythm and determine if a defibrillation shock would be helpful. Such a shock is helpful if the rhythm is VF or VT, but is not helpful if the rhythm is asystole or PEA. If needed, the AED will ask the rescuers to stand clear and it will deliver an appropriate shock, asking you to resume CPR if the shock does not terminate the arrhythmia. If the shock is successful, the AED will instruct the rescuers to just monitor the patient. If no shock is needed, the AED will instruct to continue CPR. The AED will continue to monitor the heart rhythm and work through this same algorithm repeatedly at several-minute intervals until EMS personnel arrive on the scene.

I mentioned at the outset that the survival rate for out-of-hospital cardiac arrest was poor. It’s encouraging, though, that in localities or situations where CPR training is widespread, the survival rate can be much higher. Interestingly, in a recent review of SCA at long-distance running events, the survival rate was reported at 29% and was attributed in large part to prompt CPR provided by bystanders.

Advanced Life Support

The next phase of care might best be called advanced cardiac life support (ACLS). This care is generally begun by EMTs or paramedics who were dispatched to the scene where a cardiac arrest victim is already receiving CPR by bystanders. Information about the circumstances leading to the victim’s collapse should be passed along to the medical professionals who respond. Sometimes there are very helpful details.

Away from the hospital setting, advanced life support is usually provided by EMTs or paramedics who have specialized training in this area. In the hospital setting, many employees–nurses, physicians, and others–can take classes offered by the AHA to become certified in ACLS. As a result, there may well be ACLS-trained bystanders when somebody suffers cardiac arrest.

Advanced life support will include both chest compressions as well as rescue breathing. Supplemental oxygen will be provided and breaths will be administered initially using a bag-valve mask. If the victim is not immediately revived, an oral or nasotracheal tube may be placed into the trachea (the windpipe) to continue to administer breaths to the victim. Electrode patches will be placed on the victim’s skin and an EKG monitor will be used to determine the heart rhythm. With CPR and rescue breathing in progress, the advanced cardiac life support phase of care is governed by algorithms that are specific to the exact type of heart rhythm. There are 2 primary algorithms–1 for VF/pulseless VT and another for asystole/PEA. In the hospital setting, we actually have hand-held cards with the algorithms to help guide a team of rescuers.

Included in the algorithms will be the use of medications, if needed, as well as defibrillation, if needed, depending upon the particular heart rhythm. CPR, rescue breathing, and the resuscitation algorithm is pursued while the victim is transported to the hospital.

Hospital Care

Efforts at resuscitation continue until either the victim’s normal heart rhythm is restored or the team of caregivers concludes that further efforts will be fruitless. There is no absolute convention about how long resuscitative efforts should be continued, but there are certainly examples of patients who are successfully resuscitated after prolonged CPR. As just one example, I’ve written here at the blog about the soccer player, Fabrice Muamba, who was revived after 78 minutes of CPR.

If a victim’s heart rhythm is restored, then there are 2 major immediate goals: 1) prevent a recurrence of the near-fatal arrhythmia and 2) protect the body’s organs, as much as possible, from the effects of the disturbed circulation while the resuscitation efforts were being made. Efforts at the first goal will depend upon the known, or suspected, cause. Evaluation and monitoring is conducted to be certain that the blood oxygen levels and blood electrolyte levels are appropriate. Often, anti-arrhythmic medications will be used for this purpose. The second goal is also very important. We know that, even with CPR that is successful and results in revival of the patient, there can be insufficient blood supply to the body’s organs for a period of time. The brain is particularly susceptible to injury because of inadequate blood floow or oxygen, even for relatively short periods of time. One technique that has gained popularity in recent years is the use of induced coma combined with hypothermia (lowering the body temperature by several degrees) to reduce the metabolic demands on the brain for a period of about 48 hours. This allows potentially better recovery of the brain. We know that such an approach may improve the neurologic outcomes for at least some patients who have suffered cardiac arrest. This technique appears to have been used in the case of Laurent Vidal.

The last issue is to determine what caused the cardiac arrest. There’s actually a fairly long list of possible causes. In the sports setting, for younger athletes the most likely heart-related causes are hypertrophic cardiomyopathy (HCM)–an inherited disorder of the heart muscle; a coronary artery anomaly–an artery that developed abnormally during development; an inherited cardiac ion channel abnormality (eg, long QT syndrome); or arrhythmogenic right ventricular cardiomyopathy (ARVC)–another inherited disorder of the heart muscle. But sometimes cardiac arrest may be have a non-cardiac cause like pulmonary embolism or stroke. Even a sharp blow to the chest can produce cardiac arrest, a situation called “comotio cordis.” The evaluation of survivors of cardiac arrest is done in a systematic way to sort through the various possibilities. It’s usually possible to determine a cause, but there’s a small chance that no cause is found.

2. Dana Vollmer and ICD

3. Athletes, Sudden Death, and CPR