Too Important to Die
Synopsis
Cardiologist Dhruv Kazi recounts the heart-stopping tale of an emergency medical encounter in North Korea.
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Hosted by Emily Silverman.
Produced by Emily Silverman and Marina Poole.
Edited by Marina Poole.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
Illustrations by Stephanie Muscat.
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The Nocturnists: Stories from the World of Medicine
Too Important to Die
Episode Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
Part of being a doctor is springing into action when you're off the job — when someone feels faint in the grocery store, for example, or when they slump over in the theater, or when a stranger's heart stops…on a moving train… in North Korea. That's exactly what happened to our next guest. I'm Emily Silverman and this is The Nocturnists: Stories About What It's Like to Work in Medicine. In this episode, we'll talk to cardiologist Dhruv Kazi. He'll walk us through that heartstopping tale and, afterward, we'll talk about his experience as an exchange student in North Korea, and why some patients are treated as VIPs and some aren't. Have a listen to his story.
Dhruv Kazi
“Kazi, I think someone's having a heart attack.”
Well, as a cardiology fellow at that time, I'd heard those words on numerous occasions. But, this time was different. I was on the Pyongyang Express returning from North Korea to Beijing, China. We were a group of 12 students mostly studying humanities. I was the one medical person on the team who had spent a week in North Korea as part of an exchange program.
We had studied North Korean history, had played a friendly soccer match at the local university and, of course, visited the gargantuan communist monuments that dotted the capital. That included a maternity hospital where every piece of equipment had a red tag that said "generous gift from the president." There was also the mandatory visit to this colossal mausoleum of Kim Il Sung, the founding president of North Korea, who was still the eternal president more than a decade after his death. Every night, we returned to a high rise hotel and had good laughs over bad beer.
But, in private moments, we reflected on the horrors of the day, the sunken cheeks of the people who are crammed into the trams on their way to work even as the chubby smiles of their eternal leaders grinned from the lapel pins that they were all required to wear. All this talk of fertile apple plantations even, as we knew, that in the 1990s there had been this destructive famine that had killed so many North Koreans that that was the only way the country got out of the famine. They had food for those who survived. It was surreal…absurd…exhausting.
The train ride back involved crossing a border that was a river between North Korea and China. On one side were abandoned fields and a ferris wheel. On the other, these tall skyscrapers that marked China's rise into the global economy. Parallel to the train tracks was this pedestrian bridge that had been bombed in the Korean War, so that only half of the bridge now stood. The Chinese could walk halfway across the river and stand on this viewing platform and gawk at North Korea. The other half of the bridge was missing, so the North Koreans had nowhere to go. As our train crossed the border, we did this little celebratory dance of freedom — even though we'd actually just crossed into China.
We'd had dinner, we're settling in for the night, when a grad student said, "Kazi, I think someone's having a heart attack."
I rushed in the general direction, the toilet door was ajar and outside lay an obese man flat on the floor, half-naked. His pants bundled around his waist, no shirt on, and his scrawny travel companion was frantically trying to wake him up. I do what any self respecting cardiologist would do in that situation. Without saying a word, I reached for the carotid pulse. There is none.
So, I start chest compressions and call for help in English. Two of the students I'm traveling with are trained in CPR, so we decided to take turns for chest compressions. One of them speaks Mandarin, so he translates for the train conductor to go get the first aid kit. I'm hoping for a defibrillator. The other speaks Korean, so we asked the travel companion, "What's going on? Does the patient have a medical history? How long has he been down?"
His eyes wide with terror and his voice raised in panic, the man tells us that this is a senior member of the North Korean leadership. He had a stroke three months ago, but recovered, and is now on his way to Beijing for physical therapy. He, himself, is the personal neurologist who's supposed to escort the man to Beijing. He looked great that morning — went to the bathroom — but when he didn't come back after 15 minutes, the neurologists got suspicious. Called a train conductor and they forced open the door…found him unconscious on the floor with vomit all over him. That's when he called for help.
"The man is too important to die" he tells me. “Too important to die".
We take turns doing chest compressions, but the story adds up. In a country with extreme food deprivation, you have to be a senior leader to get access to enough calories to be overweight. This is the first obese man I've seen all week. As a part of my initial check, I had done a finger sweep of the oral cavity. In a land where no one has enough food to eat, only the absurdly wealthy can have gold in their teeth.
History of stroke — this was probably a recurrent stroke or another heart attack. 10 minutes without CPR, 10% mortality per minute. We had very slim chances of bringing him back. But we continue to do chest compressions. 20 minutes, no pulse. So, I walk over to the neurologist to give the bad news.
"I'm sorry, our patient is dead. Is there family I can speak with?" He grabs me by the shoulder and shakes me. "You don't understand! He is too important to die. Too important to die on the train," he says.
Is he crazy? He's a neurologist. Even in a country with a dead president, power doesn't grant you immortality. People die. This man is dead. And then the penny drops. What he is saying is that the man is too important to die on his watch. That if he dies on the train, his own life or more is on the line.
I turn to the train conductor, "How many minutes to the next train station?" "25 minutes," he says and I'll radio ahead for an ambulance. Sure, great, but I want the ambulance to meet us at the train door, not outside the station. I don't want to interrupt CPR as we're transporting the guy. "Great," he says and walks away.
And we go back to CPR. It's 25 minutes of chest compressions. The only sound is the metronome of crunching ribs and the clanking of the train coupling. Fields flow past in the silence. It's a dark starless night, in the distance the twinkle of light. Farmers coming in after a hard day's work.
25 minutes, the train rolls into the station. As predicted, two men walk in, survey the scene, don't say a word, grab our patient, put him on a stretcher and take him down to the ambulance that's waiting for us. Two nurses in starched white uniforms are in the ambulance. They put on chest pads. From the window, I can see the rhythm on the defibrillator. It's a narrow regular rhythm, one that one wouldn't normally shock. His hands fling up in the air as they shock him anyway.
Then it's time to leave. The train heaves out of the station. And I can see the red lights of the ambulance speeding away into the distance. Our job isn't done. I debrief with the students, assure them that we've done everything we could have done, that the 10 minutes without chest compressions is forever for the human brain. The conductor needs me to write a letter saying that he had done everything that could be done. I don't see the neurologist again. Maybe he hopped onto the ambulance. Or maybe he didn't. Maybe slipping into Beijing in the dark of the night was his best option.
I lie awake on my sleeper berth wondering about the week's events. Those gargantuan communist monuments I'd seen. The dead president smiling in his casket. The anonymous millions killed in the famine. I think about that maternity hospital that is bringing babies into North Korea's uncertain future. This code blue that we ran for 25 minutes of chest compressions on this dead body. I think about the mortal fear in the eyes of the now missing neurologist. "Was I afraid?" one of the students had asked me.
No. My brain had just switched into doctors mode and then it just felt like another day's work. But, my mind kept wandering to that bridge across the river on the border. That half-bombed pedestrian bridge. A reminder perhaps of older frontiers that death and dying can easily cross, and some that they do not.
Emily Silverman
All right, I am sitting here with my friend Kazi. How are you?
Dhruv Kazi
Doing great. How are you?
Emily Silverman
I'm good. Thanks for coming over.
Dhruv Kazi
Thank you.
Emily Silverman
So, normally I start off these interviews by asking about everybody's path to medicine, but with you I actually want to do something a little different. My first question to you, because I've been wondering this for months since I heard your story. Please tell me, what were you doing in North Korea? What was this exchange program that you were a part of? Because I don't know anyone who's been to North Korea.
Dhruv Kazi
Yeah. I was, um, so this is how it came to pass. I was sitting at my dining table working on a paper because I was a health services research fellow at Stanford at that time. And I saw this email about this exchange program through a couple of Canadian students who were trying to increase contact between the North Korean people and people from other countries. I figured it would be interesting. So, I message them, try to find out more about the program. And what made this particular program different was that it wasn't just, okay, come on, we'll take you on a tour through North Korea. The focus was people to people contact. So, we started out in Beijing in seminars with students at one of the universities there. We then took the train to Pyongyang. And that's where we ended up spending five days. We had interactions with university students, high school students. We played a soccer game that was really fun. I was terrible at it. But it was fun, nevertheless. And then on the way back, that's when the story happened.
Emily Silverman
Wow. So this trip. So, was this health themed? Or was it people of different disciplines?
Dhruv Kazi
It was very much people of different disciplines. Most folks in the group were studying international relations or political economy. I was the only person representing the health system. And they did have one visit to the maternity hospital in Pyongyang, which was very fascinating, probably one of the most interesting parts of the visit for me. But most of it was focused around the politics of North Korea.
Emily Silverman
What did this hospital look like?
Dhruv Kazi
I should caveat this with saying that everywhere we went to in North Korea, we were supervised. So we were only allowed to see things that the government wanted us to see. So with that caveat, the hospital felt pretty modern, not a slick hospital you would see in North America, but certainly not one that you would expect to see in a low and middle income country.
Emily Silverman
Hm. You said that it was a program with the intent of facilitating cross-cultural communication. Do you feel like the North Korean people who you did interact with learned something from you, or from this team that you were with? What was the exchange on their side?
Dhruv Kazi
I went in saying that this would be interesting, but skeptical about how much I would learn from the program and how much the locals would interact with us. And I came away very pleasantly surprised. At the university, I learned that being a translator is a high income job in North Korea. And so most university students that we interacted with spoke more than one language. So, often it was Korean, English and German. And, I think there was a general sense, there was general awareness that what they were going through was a unique experience, with its pluses and minuses. And they were hoping to learn more about the world outside, from us. Some of the most honest, I guess, conversations happened with members of our team who spoke German because then we didn't need a Korean translator. And then there were some brief but very honest exchanges.
Emily Silverman
Can you tell me a little bit about after the event? Did you ever get any follow up or figure out what happened? Or did it just kind of dissolve into mystery?
Dhruv Kazi
Yeah, so a couple of things. I should say that, I mentioned in the story that as the events were unfolding, my brain had clearly shifted from being a person on a visit to North Korea to being a physician in charge of a critically ill patient. And so it was almost algorithmic and mechanical as I was doing what I needed to do to get that person to a safer place. And what I hadn't appreciated quite in the moment is the effect that it was having on the people around me. And I mean, the students who were with me were all non-medical students. For one of them, it brought back memories of a personal loss from a few years ago. For others, there was this intrigue about what had just happened. I mentioned that the train conductor was really afraid for his security. But it wasn't until we got to Beijing, then someone said, "Well, were you ever afraid?" that it had crossed my mind that it was an unsafe situation and that the events could have been different if this had transpired before we had crossed the border into China, if we had still been in North Korea. I didn't make an effort to find out who it was. I felt like it was best that way. And for the sake of everybody involved.
Emily Silverman
That makes sense to me.
I'm really interested in this idea that you talk about in the story of a person being too important to die. And I think, in your story, there's an extreme example where things are tinged by status and politics. But there's even a watered down version of that, I think, just in everyday life. Where there's this perceived immunity to death that we put on certain people. Is that something that you've noticed in your day to day life, maybe before or after this event? Or was it really just this one event where you felt that?
Dhruv Kazi
I think in the context of this story, it was specific to this politician or this political authority, who, if the person helping him felt like if he died on the train, he would get into trouble. I think there isn't a close analogy to what happens in the US. I work at a safety net hospital, as you know, the Zuckerberg San Francisco General. And I do perceive though, that within the US health system, that our people for whom we do more, the assumption is this person is really important, so should we should order more tests, we should do more, offer more therapies. And it's not clear to me whether that helps, and I tend to lean towards believing that it probably hurts the person. You've heard this idea that when someone really important comes into the hospital, they want to be treated by the chief. And you're like, no, you want to be treated by the person who sees the most patients, which is probably the late, early-career, physician.
Emily Silverman
Right. Or even getting your blood drawn. You don't want the chief of medicine to place your IV or draw your blood. They're probably the least equipped person in the hospital to do that.
Dhruv Kazi
Right. Or do a complex procedure. Often the folks, you know, who do more of those on a day to day basis or earlier in the career, are the most talented.
Emily Silverman
I'd like to talk, actually, a little bit about being a cardiologist.
Dhruv Kazi
Sure.
Emily Silverman
Because, in one sense, cardiology is very simple. There's a heart. It's a pump. It has electricity that runs through it...
Dhruv Kazi
It has some pipes...
Emily Silverman
And it has some pipes, where blood flows. And so I find that, you know, super super specialists, they're either an electrician and they deal with the electricity, or they're a plumber and they deal with clogged pipes in the heart — and could it get any more simple than that? But then, on the other hand, I find that the nuances and the decision-making about testing and what to do and what not to do, and the fear of missing something cardiac really adds muddiness and stress to the picture, both on the side of the patients and also on the providers. So, anyway, could you tell us a little bit about why you chose cardiology? And then kind of what your thoughts are on the ambiguities in the field?
Dhruv Kazi
Yeah. So as you know, I did my medical school in India. I grew up in India. I was 17 when I started in medical school. I was 22 when I was done. And so it was as if you were learning medicine when you weren't quite an adult. You hadn't had the life experiences that medical students here have had. And I ended up falling in love with cardiology because I had a very impressive professor who we admired not just for his clinical skills, but also his bedside manner. That's what started my love affair with cardiology. And so I came to internal medicine with the idea that I was going to do cardiology.
I think what you say is absolutely correct. That cardiology is, on the one hand, extremely simple and straightforward. 80% of what we do is not complicated. I would like to think 80% of what we do is easier than what an internist does. Because as an internist, you're trying to balance all of the systems in the body, all of the interactions with medications, whereas I have one organ system to worry about. I think it's the remaining 20% that makes my job very interesting. Because you end up in the zone of ambiguity as you described it. Trying to figure out, of all the problems that the patient currently has, which of the problems is most likely to cause his shortness of breath? What can I do to this 80 year old patient that would make her life better?
And often that involves trying to think about the patient as a whole. Think about their cardiology problems, but in the context of their social situation, their life aspirations, their goals, what they want to do over the next five years, and then have very nuanced conversations about, well, in this case, we should do this procedure versus the other or just pass on procedures altogether. And that's the part I enjoy the most. There are a lot of questions in cardiology that we can answer based on data. Those are straightforward, fairly algorithmic. But there are a lot of questions for which the evidence runs thin. And then, as a clinician, one has to use one's best clinical judgment. That's fun.
Emily Silverman
And that's fun.
Dhruv Kazi
And it's very rewarding. Because you come away with the idea that you have made this person's life better in a way that not everyone could have.
Emily Silverman
And it's interesting that you comment on the evidence-free zone. And it's funny because I feel like, of all the different fields in medicine, cardiology has probably one of the more robust evidence bases, in a sense. But there is so much, even in cardiology, that is unknown. And then you're kind of left to your own devices, and using your instincts and your intuition. And you know, when you're a young doctor, it's your one year of experience, or when you're an older doctor, maybe it's 20 years of experience, to guide your decision making. And it is fun. And I've never heard anyone describe it as fun, but I like that. I think that there's something about that that's really powerful.
Dhruv Kazi
I should also add that I look at it from, you know, I spent half my time doing research and that half of me is a health economist, and that overlays this framework about thinking about judicious use of resources, about health systems as a whole, about saying that this patient could benefit from this drug, that everything I know about this drug tells me that this patient likely can't afford it. And that we should have this conversation upfront. Because in the end, if she can't afford to take the drug, it's not going to work, it's not gonna help her.
And I really enjoy that balance, that thinking, not just about the cardiology and the other systems in the human body, but thinking about the health system as this complex organism unto itself.
Emily Silverman
Totally, and I find that in medical school they sort of teach you the medicine as if it exists in a vacuum, sort of like here's a case, here's a patient, here's a scenario, here's a disease. And this is what you do. You know, they teach you in a patient who's coming in with a STEMI, or a severe heart attack, you go in and if you see a narrowing in the pipe, you stent it open with a stent. But you know, patients who get stents are going to need to be on blood thinners for a long time. If they don't take the blood thinners, it's very dangerous.
And so someone coming in with a heart attack like that, who is homeless and struggles with substance abuse and whose medicines, you know, maybe they don't take them or maybe they get stolen every week and that kind of thing. And it's not realistic that they're going to adhere to that blood thinner regimen. Do you just forgo placing the stent altogether? I think those sorts of decision making processes aren't really taught in medical school. And I think, for people who move into a residency and then their career, it can be really jarring and confusing.
Dhruv Kazi
Right. And in cardiology training in particular, the idea would be, yes, you would put in the stent because it's been shown in very large studies to improve survival and long term outcomes. And so I think the answer might still be for that person to put in the stent. But then we need to figure out, along with the primary care practitioners, what support does this person need? What extra help can we provide to keep them on the right medications? And that is probably the most rewarding part of my job.
Emily Silverman
That mission-driven spirit.
Dhruv Kazi
The mission-driven spirit, but also the idea that the patient's inability, that particular patient that you described…his inability to take his medications or his inability to access healthcare in an "idealized manner" is also part of our problem. It is my responsibility and my commitment to that person to do what I can to help him navigate what, at best, is a broken system.
Emily Silverman
One of the joys of being a dual clinician-researcher is that you get to treat the person, but also this organism of the system. Can you talk a little bit about your health economics research and what you're looking at and what you study?
Dhruv Kazi
Yeah. So the story there is that when I was a medical student, I mentioned that I started medical school at 17. I graduated at 22, went straight into internal medicine. And by the time I was done with my internal medicine chief residency, I needed a break. On a whim, I applied to the London School of Economics. And I said, you know, this is something I'm interested in and I know nothing about, how about I study that for a year. And it was transformational because I realized that was something I definitely wanted to do more of. It was my first time being surrounded by people who didn't speak medicine.
Emily Silverman
It is a language.
Dhruv Kazi
Because it is a language and it is a culture and we get trapped in it. And to see people who are thinking about the politics of the European Union and its effect on health systems locally and internationally. And work with folks like that was very transformational, as I mentioned, opened my mind to a different way of looking at health systems.
So, after cardiology, I spent more time training, that's what took me to Stanford. And so what I do now is try and study how health systems determine value. And value in medicine is a very loaded term. How do we measure the large returns on investment we expect in our health system? We spend 17% of our GDP in the US on health. What are we getting back for it? So the way we think about value is that compared with what we're doing currently, if there was a new drug or a new system, or a new procedure, how much more would it cost? And how much better would our outcomes be?
Emily Silverman
And I want to ask you a question that's actually been on my mind now for a while. Let's say we had very cost effective health care that kept everybody out of the hospital, happy, healthy, thriving. But we're also bounded by this truth which is also the essence of your story, that we're all going to die. And this is universal. The same truth holds for me, as holds for the leader of North Korea, in many different ways. So, if we're all gonna die and we're postponing death, you know, let's say somebody has a heart attack that would have been life threatening, but then we stave off death by putting the stent in…giving the blood thinners. And we age and we age more. And then other chronic health issues crop up like...
Dhruv Kazi
Alzheimer's
Emily Silverman
cancer, Alzheimer's, and people become slowly and more disabled, and requiring assistance and care, which is very expensive. Is it possible that the better medicine gets, the more expensive the entire system will get? As we end up with this slew of an aging population with, you know, more expensive needs at the end than maybe they would have if they died of a heart attack at age 50?
Dhruv Kazi
Yeah, that's a really tough question. In the end, the purpose of economics is to help us allocate resources consistent with our priorities. And so if we as a society decide that we do want to age and live into our 90s, then by paying for health care, we're essentially casting that vote saying yes, I do prefer not to die at age 50.
But, there is the other part of this narrative that isn't quite accurate in terms of what happens in the US or elsewhere in the world, which is that we're not a homogeneous society in terms of how we experience health and disease. And so there are some populations of the US where life expectancy, as you know, is a decade shorter. This could be a function of race, geography...
Emily Silverman
Zip code...
Dhruv Kazi
Zip code, gender identity. And so even though we think of healthcare as prolonging our life into the 80s and 90s, the truth is that in many parts of America it's about prolonging your life into the 60s and 70s, which are pretty high quality years of your life if you're healthy. And so we have to decide how far we want to go on pushing life expectancy as a country, but we certainly need to prioritize health investments in parts of the country that are suffering and are far behind the rest of us.
And these disparities are pretty remarkable even in the Bay Area. So we think about…when we talk about zip code related inequalities, the image that comes to mind is, you know, the poor South — rural areas of the South where Blacks in particular have very high mortality compared with the general population. But the truth is even within the Bay Area, that what we think about as one of the wealthiest parts of the US, there are zip codes with life expectancies that are 5…6…8 years shorter than, say, San Francisco.
Emily Silverman
Which is outrageous.
Dhruv Kazi
Yes, which is unacceptable. And it's fixable.
Emily Silverman
And it's funny because it's reminding me of this metaphor. There's the individual and then there's the system. And on the individual level, there's this mentality too important to die, you know, but then you take that mentality too important to die and you scale it up, and you see it manifested brainlessly in the system through these zip code disparities,
Dhruv Kazi
Yeah, and it's very systematic. Which is why, two things, the most powerful people to address it may not be physicians. Because we like to think that we prioritize our individual patients, but are less often trained to think about the way the health system responds to and is responsible for these geographic disparities.
But some of these disparities in health are outside the health system. They relate to education, to access to food, access to employment, housing discrimination. And so they reflect, in my mind, our values as a society. And that is going to take more than the health system to fix, but the health system is a darn good place to start.
Emily Silverman
Right. And it's something that comes up a lot in these interviews, I think. And I’m wondering, you know, as a physician, what is your role? How far do you go out of the realm of healthcare and into the realm of, you know, housing inequities or unemployment or food insecurity?
Dhruv Kazi
I think our job as a physician, today, entails more than just caring for the patient in front of us. It is our responsibility to play our part in improving the entire health system in a material way. Some of it might be advocacy. Some of it may be science — generating good, high quality evidence on the association between homelessness and outcomes, or affordability and outcomes. And some of it might be judicious use of resources within the hospital.
I think it's also important that we become effective communicators. Because you and I sitting in a room, we could have a really erudite conversation on the role of homelessness and health. We've seen it in our daily practice. And yet, when it turns to communicating that to the people of San Francisco who have to make the decision on investing in affordable housing, we don't do a good job of communicating the stories that we encounter in our daily lives. We try and inundate people with statistics, which doesn't work. And I recently encountered Tatianna Willis, who was the teen poet in residence at Youth Speaks, and she said, "the stats are great, but what's your story?" And I think we need to do a better job of that.
Emily Silverman
Well, I think that's a wonderful note to end on. I'm really grateful that you came in to talk and to talk about your research. And I feel better sleeping at night knowing that you're out there fighting the good fight and doing this great work. And, once you fix all of the United States' problems, you can move on to North Korea and fix all of their problems as well, I'm sure.
Dhruv Kazi
That's quite vast, but I'll work on it tonight.
Emily Silverman
Alright. Well, thank you so much Kazi.
Dhruv Kazi
Thank you for having me.
Emily Silverman
That was the brilliant Dhruv Kazi. And that's our last episode of the season. Wow. I want to thank you so much for listening to and supporting The Nocturnists podcast. Putting this show together was truly an adventure…and a leap of faith..and a labor of love. And I'm so proud of how far we've come since our first episode a few months ago. You know, The Nocturnists started out as this tiny live event back in January 2016 with an audience of 40 people. Two months ago, we sold out a theater of 360 seats. It's been a wild journey, and we're so excited to see where this project goes. But, we really want these stories to reach a larger audience. We think this project really matters and can help create connection in the healthcare community and the space to reflect on issues that aren't usually talked about on the job. I know it's really made a difference for me. So please spread the word about our show, fire off a link to your friends, to your family, to your student group listservs, to your colleagues, to your own doctor, to your religious leaders, whoever you think might enjoy the show. We really want this community to continue to grow.
I would like to give an emphatic thank you to executive producer Ali Block, who has been growing this project with me at my side since it started two years ago. To podcast producer Marina Poole, who has poured her blood sweat and tears into this podcast and its production. To our amazing intern Celine Ross, who has been there at all the events and has done a ton of transcribing for the show. To our other transcribers, Libby Birch, Rocha number Gianni Riddia Rune and Eliana Monroe. Stephanie Muscat for her badass podcast cover art. Yosef Munro for the beautiful theme music that he composed for us. And Blue Dot Sessions for contributing all of the other music. And now for the last time of Season One, thank you for listening. And see you next time.