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[The following is excerpted, with permission, from the Manual for Stress Echo by Larry DeBord.]

Chapter 12
Working with the Stress Echo Patient

 The Typical CAD Patient

 Female Patients

 Male Patients

 Patient Comfort

 Communicating with the Patient

 Music

 Instructions

 Patient Quotes

Before describing the technical components of the stress echo procedure, we will discuss the importance of the technologist establishing rapport with the patient. Patient cooperation is absolutely essential to getting the best images. But it is also personally important to us that our patients leave with the feeling that they have been treated professionally, respectfully and courteously. And courtesy is just good business practice.

Obtaining the cooperation of the patient is often as important to image quality as transducer technique and the selection of the ultrasound system.

When a patient makes an appointment to have a stress echo, he is given a letter listing his appointment date and a map to the office. This includes a rather complete description of the exam and attempts to allay fears. It instructs the patient to fast for at least four hours prior to the test and to dress appropriately. It suggests how much time to budget for the trip. Included with the letter is a short form requesting age, height, weight, cardiac history, risk factors, medications, and previous procedures. It is much more efficient for me to transcribe their checked answers to my work sheet than to ask the questions myself and it allows a more pleasant introductory conversation, not having to probe about age, weight, etc. Our referring doctors keep a supply of these letters to give their patients when scheduling stress echoes. (A copy of this letter is in the Appendix.) This letter, along with a reminder phone call the day before the exam reduces no-shows and late arrivals and increases the efficiency of the office.

The typical CAD patient we see in our lab is a post-forties, overweight man with a history of smoking and a life of lethargy, a man who perceives fatigue as pain, exertion as loathsome, and eating ad libitum a God-given right. He is reluctant to pedal a bike or walk a treadmill. He may be post angioplasty, post atherectomy, and/or post MI. He may complain of diffuse chest pain, shortness of breath, arrhythmia, or maybe of just being tired all the time.

He is typically a challenge to ultrasound imaging because of the smoking and obesity. Due to the surgeon’s gardening, his heart may be surrounded by echo-malevolent scar tissue or the heart may be displaced or rotated to a novel and echocardiographically inaccessible site. He can be the sonographer’s nightmare.

Most new patients are worried or fearful. Post angioplasty patients may be confused as to why they have been asked to exercise so soon after their invasive procedure and hospitalization and while they are still sore in the groin and wonder if a serious scheduling error has been committed. Post infarct patients are apprehensive about any exertion and are difficult to motivate to exercise. They may get frightened, especially when they hear the announcements of their blood pressures elevating (normally) during exercise, and they may suddenly stop pedaling. These emotions should be confronted in order to gain their cooperation. Learn to calm your patients by addressing the problems through conversation and sincere expressions of empathy or avoiding the topic with ball scores or music. Many patients fearing impending heart disease, are very relieved to hear you say at the beginning of the exam that you do many "normal" studies.

Considering the nature of the exam, and the anatomical placement of the heart, women particularly are subject to insensitive treatment. I make every effort to respect their modesty, though it is a challenge considering my roving over their chests with gel and transducer while they are in the less than dignified position of laying on their backs with legs spread and gripping a bicycle, and they are huffing and puffing with all parts of their bodies bouncing and rolling from the exertion. We try to remain good-humored about the struggles and blind to the necessary familiarities and indignities.

The female patient is given a gown with instructions to leave the opening in the back. Having the opening in the front allows easier access for the sonographer, but having it in the back makes it easier to keep the patient comfortably covered. Especially during pedaling, it is virtually impossible keep her covered if the gown opening is at the front. This is another one of those points that seems too obvious to merit mention, but I frequently see labs that are an affront to common courtesy and display a dumfounding level of disregard for a woman’s feelings by unnecessarily exposing her. Exposure not only to the tech, a total stranger that still smells like his lunch, but also to other staff members who pop in to deliver mail, use the phone, get paper clips. This patient might just wonder, if you’re that rude, can you be smart?

Male patients remove their shirts, of course, so be aware of the room temperature, particularly with the elderly. You may be warm and glowing from your aerobic imaging acrobatics, but the patient is merely laying there, may not be in the pink of health, and may be in a draft. And if your air conditioner is as unreliable and as hostile as ours, the patient’s health may be compromised by this noninvasive procedure. Keep a light-weight blanket nearby.

In the stress echo exam, courtesy is of practical importance.

After the patient is prepped by the assistant for a modified 12-lead, as described later in the Exam section, he is escorted to the stress echo room. I introduce myself. Unless otherwise invited by the patient, I address the patient formally by his or her last name. I try to have the patient’s name clearly displayed on the ID screen of the ultrasound system when he enters to let him know we have already begun preparations specifically for him.

I ask if there are family members waiting whom he would like to invite to watch the resting portion of the procedure. This is almost always welcomed and we frequently have a room full of mothers, brothers, husbands, wives and children, uncles, accompanying cardiologists, and bodyguards looking over my shoulder. Having the family nearby often relaxes the patient. I have learned, however, that women of some cultures are very uncomfortable and embarrassed with their husbands in the room while she is being examined, especially by a male technologist. Use judgment. The guests are asked to return to the waiting room during the exercise phase (except for the translator).

Discover his verbal skills and use words and manner of speaking that the patient understands. This requires that you listen to him and to monitor his response to your words. If you do not establish this rapport, you will fail to get maximum cooperation and the best possible images..

The foreign patient who speaks no English is a challenge, but one that can be met with common sense and common courtesy. In San Francisco we commonly work with Cambodians, Italians, Russians, Thai, Germans, Chinese, Iranians, Indonesians, Vietnamese, Filipinos, Hispanics, Greeks Iraqis and other cultural groups. They may have lived here for thirty years, and still speak no English, but have children or grand children with them who do. In this situation, even when there is not a translator present, I give salutation and make a little quiet small talk as I punch buttons or arrange pillows, making sure I do not sound like I am asking questions or making demands. I make eye contact and in a normal tone of voice, speak as though he can understand me and attempt to convey " . . . everything is just fine without you having to speak or understand a single word of English."

It is not effective to speak more loudly
to one who speaks no English.
It just makes you look silly.

I am embarrassed that so few professionals in the world of medicine have learned the simple social graces of addressing other human beings. It is sad, but we have all met health providers that display all the sensitivity of asphalt. For instance, knowing no English does not necessarily indicate deafness or idiocy. Nor does it suggest an immunity to the rudeness of having someone shout at him. It always embarrasses me when the doctor speaks to the technologist in a normal tone of voice but when addressing the patient raises his voice to about 100 decibels as though he were talking to firewood. A man from Djakarta understands that he is being addressed. He understands this just as well as the man from Atlanta. From what I have seen, maybe better.

I insist that the interpreter repeat everything I say. As my breathing commands are translated, I mimic with hand gestures: raising my right hand, palm up, for "breathe in," palm toward him with fingers spread in the universal "stop" sign for "hold it," and lowering my hand, pointing down, for breathe out. Very few patients fail to learn this quickly. Do not be tempted to gloss over the instructions, but patiently work through the translator so that the patient knows what is expected of him. Ask if he has questions.

The hearing-impaired present special problems. A person in left lateral decubitus wearing a hearing aid in the left ear will experience uncomfortable (painful) acoustical feed-back when he places that ear against the pillow. Be prepared for him to remove the aid. Offer to place it in a safe place for the duration of the exam. If the patient puts it in his pocket, it could fall to the floor to be stepped on. He won’t hear it, but you might hear a thousand dollar crunch. A hearing-impaired person without his hearing aid can be very uncomfortable, acutely feeling his handicap, feeling foolish for not being able to hear you and feeling even more foolish when you yell at him. (Note how often he apologizes for not hearing you.) Maintain eye contact. Speak with clarity. Do not speak louder or slower than necessary. The hearing-impaired do not take pleasure from being shouted at. I know. I’m one.

Music serves an important role in the echo lab. It can help relax the patient and distract him from his anxiety over the possibility of heart disease and his fear of this exam that peers into his heart. (Music also calms the over-worked sonographer.)

Sizing up a new patient and selecting the music to appeal to him requires a special talent few have. I generally choose rather "safe" music - Chopin’s Etudes for example. It is usually safe to play nearly anything from the Windham Hill Label, but if the patient complains of the wallpaper music, I change it immediately. I seldom play rap, Welk or polka. With very stressed patients, MVP types, I select New Age music, all of which is written in a major key, it contains no sharps or flats, and every phrase ends in resolution. It works.

"That is nice music . . . who is this playing? . . . what is this piece? are indicators that the patient has stopped worrying, at least momentarily, about his "tubes being clogged."

Listening to your patient:
That is interesting . . . but how about this weather?

The patient was a man who had suffered from prostate cancer. With a booming voice to match his physique and social standing, he instructed me (and everyone down the hall in the waiting room) on the wonderful benefits of his castration: less grease in his hair, loss of all body hair, less odor under his arms and between his . . . he went on and on in painful detail.

You will notice that ten minutes after an exam begins, after the patient relaxes, his breathing becomes calm. When he is convinced that no pain is forthcoming, suddenly his endocardium is better visualized. That is a strong argument for performing a brief resting echo before digitizing the REST images, and a prescription for music and friendly conversation. And that is what makes this job great: you can work and become acquainted with interesting lives at the same time.

While the assistant is bringing the patient into the lab and is attaching the ECG cables, I continue to enter patient identification into the frame grabber, electrocardiograph and other forms. I explain to the patient the basic procedure.

You will be here for at least an hour . . ultrasound is used to image your heart . . . no pain or medical risk . . . placing this instrument over your heart . . . you will be able to see your heart on the TV . . .will record on video tape for the doctor to see . . . during the second part you will pedal this bike to raise your heart rate . . . will take some more pictures . . . we will compare how your heart pumps at exercise to how it pumped at rest . . . ask questions at any time . . . we will give you the results before you leave today, etc. etc."

I continue to explain the study as imaging begins but try not to say more than the patient wants to hear. Again, monitor the patient’s understanding and level of interest. During the resting study, I point out some of the cardiac structures ("Yes, this is normal mitral valve motion . . . four chambers . . . four valves . . . this squeezing action of the ventricle is the pump that moves your blood throughout your body and maintains your blood pressure . . . aortic valve opening and closing . . . etc."). If at this point you finally learn that your patient is a cardiac surgeon, you have done a poor job of listening.

I explain within the patient’s understanding what the measurements mean, what doppler is, and invite questions. (More specific instructions to the patient are provided in the Exam chapter.)

To achieve a suitable work load from supine bike exercise patients requires a lot of "motivation." We all try good-humoredly to push the patient to pedal longer. Suggest to the patient that he pull as well as push on the pedals (his feet are strapped in) to use a different set of leg muscles. You will be surprised to learn how many older people have never in their lives pedaled a bike. You may have to practice with them a few minutes before the test. A small percentage absolutely cannot master the coordination to move their feet in this circular pattern. They are candidates for the treadmill or dobutamine.

Following exercise, explain to your patient that you will now " . . . assemble the images just captured and will format them for the doctor to interpret. . . . you will have the results of the test in about ten minutes . . . " etc. etc. Return his glasses, hearing aid, wallet, keys, comb, crystals and dog whistle. Return the coins that have fallen from his pockets. Laugh at his joke about leaving a tip.

Be very cautious when helping the patient down from the exam table. A man is unfortunately afflicted with testosterone. This inhibits him from recognizing or admitting that his legs are weak and that he might stumble when getting off the bed. Hold his arm firmly and expect him to stumble. You will soon recognize the "rubber leg stride" as the patient walks from the table. Men are often apologetic for their "poor performances." Try to dispel these feelings. The assistant returns him to his dressing room.