The Heart of Psychiatry

Preston: [00:00:00] So without further adu, Margaret, take it away. Welcome back to 

Margaret: call her Doctor. No, just kidding. Just to call her Daddy Swoop. Hi guys. Welcome back to the podcast, uh, season two Preston. How are you doing? Are you feeling wiser? 

Preston: I don't know. Like I, what's my character arc here? I think, I think I'm calming down, Dylan.

That's it. 

Margaret: Um, we are, this episode should be coming out around the time when we're switching academic years, 

Preston: right? Yeah. So I'm going from like annoying little brother to like, annoying cousin, I think through the, through the lens. Why is 

Margaret: cut? You just left the family tree. 

Preston: It's because I'm branching out on my own, you know, like I'm, I'm.

I'm gonna sprout my wings and fly soon, but not until I finish my third year. 

Margaret: You're independent. Well, someone in my kind of training life is here with us today. This is one of my training mentors, Dr. Margo Funk, uh, who is a psychiatrist, has been a really great mentor to me and is gonna help us today [00:01:00] with her area of specialty and psychiatry around cardiology and psychiatry.

Dr. Funk, thanks for coming and being on today. 

Dr. Margo Funk: Thank you so much for having me. This is, uh, I'm really looking forward to it. 

Margaret: Well, we'll see what you say at the end of that, 

Preston: these variable. 

Margaret: Yeah. Thanks for people. Don't leave reviews on Yelp. Um, so we always start with an icebreaker most of the times with our guests just so we can kind of start with the human part of medicine first.

Um, and my question for you as we ourselves and our listeners kind of go into the next academic year is when you started residency intern year and Preston, this is for us too. What was the thi topic you were most afraid of running into on like overnight call when you were by yourself or that you would be like, I don't know what to do in that situation Because one of mine was QTC.

Uh, 

Dr. Margo Funk: yeah, I didn't even know about the QTC, uh, then, so that, that certainly wasn't mine. Boy, that is a good question. [00:02:00] I remember we took, we took our first overnight call first year at the va, and I, I think I was most concerned about the, the phone calls that we might get and having potentially suicidal patients on the other end and not really knowing what to do if, if they were threatening to hurt themselves over the phone where there's not a lot of control.

Yeah. 

Margaret: Yeah. And it's like, what are you gonna, what are you gonna do as an like, are you gonna call the police and like get a wellness check? What are we, yeah, I. Part of me is that I didn't have intern psychiatry call for that reason. I feel like mine were QTC and then on medicine it was insulin like, actually it wasn't on medicine, it was, I did the first half of the year in psychiatry and hadn't done medicine yet.

And it was during covid. And so med school at the end got kind of like, there were no sub eyes. And I was [00:03:00] afraid of like, I'm gonna be on call over, like, by myself in the psychiatry unit. And someone with like uncontrolled type one diabetes is gonna be like, blood sugar 400. And there's like, what do I do?

But it's like, not technically a medicine consult. Uh, that one would be, but, and then that happened like three times in the first month I was psychiatry and I was like, okay, I feel less scared. Preston, what were you scared of last year? 

Preston: Ooh. Um, so both of you mentioned, I, I guess, uh, Dr. Funky mentioned like suicidal patients, which I resonate a lot with.

I had like a. A couple scary moments like that my intern year where I was like basically on a three-way call with like, the patient, my attending. And I was like, what do I do? Like, what else do I say? And like, those are all like, kind of scary. I think what I'm always like most afraid of is, um, really, uh, like violet, uh, codes.

So we call 'em code greens, you know, like behavioral codes. Um, I think it's like really tough to confront [00:04:00] patients in those, those scenarios. And like, it's important for me to like, wanna be the doctor that like shows up to the code and doesn't just like, put the orders in, but also like, it is really like intense being in those moments.

So I remember being like, like when seeing that patient was like kind of agitated or anxious early the evening being like, okay, Preston, like this is what you're gonna say. Like, you're gonna be firm but you're also gonna be fair. Like, here's how you like approach this high intensity situation. Um, I didn't, I didn't really think a lot about medical stuff, which I should have.

7. Because we actually had, um, a patient in u glycemic, DKA get admitted to our unit and that was like a straight nightmare. Um, you know, so blood sugar was not 400, but their, their like pH was like 7.2 and they were vomiting, like coffee ground emesis and all this stuff. So we had to still had to call medicine.

So I probably should have been worried about that, but I was just trying to pipe myself up to be confrontational. Really. 

Margaret: I feel like the, uh, I feel like all of these things and it's like not knowing like situations where you're gonna have to like, pull in an attending or pull in your senior, [00:05:00] but especially the ones where it's not clear cut what you do next.

And if it's gonna be annoying if you like call them like, it's like if the blood sugar for me was like, it's two 90, then it's like, do I manage this by myself? And like, yeah. 

Dr. Margo Funk: I I, I had a situation when I was an intern overnight and there was a patient that was hypoglycemic, like blood sugar, 40. And, you know, I get called by the nurses and they say, well, we, we have Kool-Aid, so let, we'll start with, with some Kool-Aid and we'll give him that.

And, you know, they call back, you know, maybe 15 minutes later, like nothing, it's not helping. Like he's almost had like a gallon of Kool-Aid. Okay. And so we, we try it again and, and then it turns out it was Diet Kool-Aid. Oh. I was like, oh man. Okay. So, so what I, at the va, I, I learned [00:06:00] like go immediately to the floor.

Like you, yeah, yeah. 

Margaret: Uh, yeah. Well, I mean, this, this will come out in mid, like mid to late. It's probably June or July when listeners are listening to this. And, you know, we're starting our second season of this podcast, but I also think this time of year is always anxiety ridden, even when you're. Like Preston going into becoming like a three and kind of our junior or senior and know a little bit the way of the land.

Um, I wonder for you in, in your roles and academics, like, do you feel like with the year turnover, do you stop getting nervous at some point? Is there hope for us? You do. Okay, good. You do. Stop getting nervous. 

Dr. Margo Funk: You know, it's, it's funny though to, to talk about this because I think looking back there was so much that I should have been afraid of that I wasn't.

Uh, which is probably a good thing. Uh, but there's, there's just a lot that you, you don't know, that you don't know. I think when, when [00:07:00] ultimately you're on call and response. I didn't even know there was 

Preston: Diet Kool-Aid. I just, yeah. I thought there was d Capri Sun and, and me 

Dr. Margo Funk: too. 

Margaret: Yeah. Right. 

Preston: So I'm just, I'm an orange juice man from here on out.

You know, 

Margaret: we are not comforting the interns right now. It's like, don't worry guys, it gets worse. 

Dr. Margo Funk: Um, 

Preston: but you 

Margaret: always call, 

Dr. Margo Funk: call for backup, 

Preston: right? Yeah. I ignorance is bliss. And, and don't be afraid of, well, maybe not in medicine, but I dunno, my, I've never really been that afraid of annoying people. Maybe it's like a part of my personality.

Margaret can attest to that, honestly. So when I call and attending at two in the morning, I'm like, Hey, I'm unsure. They're like, uh, and then I'm like, alright, well look at us. We're here now, so let's 

Margaret: figure it. 

You're awake now. 

You, you're like a puppy That's like you and 

Preston: me. 

Margaret: Well, I mean, we should go on a walk now that we're here.

Um, so I, I think let's, let's get into this subject. 'cause this is a complex subject. Um, I am in [00:08:00] charge of this episode's outline in the name, and it is the heart of psychiatry because I like to be pithy like that. Um, but before we talk about any of the like concrete content. I you mentioned you're like, I didn't even know QTC when I was an intern, so I wonder if you could tell us in your own words a little bit about the kind of work you do now, um mm-hmm.

And what cardiology cardio psychiatry really is. 

Dr. Margo Funk: Yeah. Yeah. So, uh, so right now I, I have the really, it's a privilege to see patients who suffer with some sort of cardiac illness. Um, and, and that's the, the only patient population I see right now. And typically I will see either folks who have suffered a cardiac arrest, uh, and survived.

Many of them will have an ICD in place and may have then suffered more from ICD storms where they get repeatedly shocked. Um, and then I, I see a cohort of [00:09:00] transplant patients who have these just, uh. I mean, usually terrible stories of, of lifelong medical illness. And oftentimes their, their heart suffers because of, let's say, a childhood cancer and they had chemotherapy, and then that's affected the heart.

Uh, so it's the, the people that I see have, have been through a ton of trauma, um, with their medical illness. And, and so it's, it's really, really for me, like a joy and a very centering thing to get to work with them. 

Margaret: Mm-hmm. 

Dr. Margo Funk: So when I, I see folks, you know, in my clinic we, we do a mix of, of both medication management and therapy.

Um, I love both pieces. I really like trauma-focused therapy, and so that like fits in really nicely with this population. And then the medication management can, [00:10:00] can be very complex and. Really like getting into the QTC for real. Mm-hmm. And, and doing risk assessments in people that are very, very high risk.

And so that's, that's fun too. Um, 

Margaret: how did you like learn about, obviously there were times probably in residency where you learned about QTC calculations and then also working with medically complex folks, but how did you end up kind of being in this really sort of specific, uh, consult, liaison, psychiatry role?

Like, did you aim at it or was it like, kind of like, oh, I'm gonna do CL and oh, I really like this population. How did, how did you end up working? Supposed so specifically with these folks, 

Dr. Margo Funk: it completely by happenstance and different opportunities that arose, 

Margaret: she followed 

Dr. Margo Funk: her heart, so.

[00:11:00] So, so let's see. So I, I, I went into medical school thinking I would be an ob, GYN and, uh, really liked women's health. And, and then I ended up doing a, a master's in, in GY onc and did a lot of lab work and really liked the pathology part. So then I thought, oh, be a pathologist. I really liked that, all that precision work.

And then psychiatry was my last rotation of medical school. And of course, you know, as we, like, it was awesome, right? You see people get better, it's so meaningful. So I decided to go that route. Um, I had not, not many inklings about a desire to go into CL until probably my, my third year, uh, where we had a lot of cl time.

And I, my favorite attendings were CL attendings. They were just, you know, so smart. We. We really learned, like never miss Catatonia, [00:12:00] never miss narcolepsy, uh, all sorts of things, right? And, and so then I had a chance to be the, the CL chief resident. And, and, and that's where I think I really started to love the field.

Um, I didn't, I did not do a CL fellowship, uh, my, my life situation. Can you say that in Boston? Is that a lot? I know, I, well, I know. Well, uh, yeah. It, it's, I mean, it's been like clawing my way to, to get to this point. Um, yeah, my life circumstance at the time was that my husband was, he was starting fellowship in cardiology, which is another piece of this whole, you know, story.

And, and so we moved to his fellowship location, which was at Cleveland Clinic. And so I started as a CL attending there, and that's probably where I learned the most cl uh, in that first year of being an attending. Um. And, and because Cleveland Clinic was so heart [00:13:00] specialized in just seeing a lot of complex patients there and getting 

Margaret: reps in with those Absolutely.

Common consults. Yeah. Our listener base is like half people ston healthcare and half people thinking about it or thinking about mental health. So just to say, CL is consult, liaison, psychiatry, which is like when someone's in the hospital and a psychiatrist comes and sees them or in the emergency department and can also be outpatient with specialized clinics like Dr.

Funk does both of those. Um, and then would you define ICD just for folks who may be therapists or less familiar with it? 

Dr. Margo Funk: Yes. It, it stands for an implantable cardioverter defibrillator. It's basically an implanted device in the chest connected to the heart that will shock the heart out of a potentially fatal rhythm.

I remember the, 

Margaret: the. First time, I guess, like I encountered your expertise in this was when you lectured us on it. Um, and, and I [00:14:00] think it was on QTC, uh, which we are lucky to have you at our program. I did send Preston like earlier today. I was like, this is the resource document that is on, I think the a PA website that you helped co-create, um, in 2018.

So we're gonna take a quick break and when we get back, we will get into the QTC, the QTC of it all, um, as well as then kind of later in the episode, talk about treating patients who have this kind of medical trauma, who are struggling to, who you wanna help live a meaningful life with. Limitations from cardiac conditions, um, and also processing what's happened, leading to them getting to your clinic.

And we have some practice 

Preston: vignettes too. 

Margaret: And we do, sorry, I forgot to think I have to edit, splice that together. Can we like get like a DJ remix and just 

Preston: put the red tail hawk scream? Let's go to the break.[00:15:00] 

So, um, Dr. Funk, as someone who is not a cardiologist or married to a cardiologist, can you explain to me what the Q QTC is? Because I, I feel like I've memorized how it is on, like, on, on an ECG, but I don't really know what it is really. 

Dr. Margo Funk: Yeah. Okay. So let, let's, we'll, we'll start at broadly and, and work our way in.

So on the EKG, the, the QT interval. Is is quite literally the interval between the end. Uh, well, the beginning of your QRS complex and the end of your T-wave, um, that interval actually represents both, uh, depolarization and repolarization 

Margaret: of 

Dr. Margo Funk: your ventricles. And interestingly, um, the thing that we're actually really worried about with the QTC is repolarization abnormalities.

We actually don't [00:16:00] care that much about depolarization now we do for other things. Mm-hmm. But, but for the purpose of this, uh, where we see bad things happen is when someone has a repolarization abnormality, meaning they, there's a delay in how long it takes the cells in the ventricles of the heart to kind of recover after one action potential or cycle.

And then. Bad arrhythmias can pop in, if you will. 

Preston: Gotcha. So in in layman's terms, I, I don't know why I think about the gun a bit like a, like a firearm. Maybe it's 'cause I'm in Texas, but So depolarization is like firing the gun. And repolarization could be seen as maybe reloading it, and if the rhythm of reloading it gets offset, the whole thing can jam.

Dr. Margo Funk: That's, I love it. Yes. 

Preston: Okay. So perfect. That's where all the, the non-medical people hopefully can psych that [00:17:00] psychiatrists 

Margaret: love gun metaphors. Famously. Yeah, 

Preston: sorry. Okay, sorry. Please continue on. We're we're following now. 

Dr. Margo Funk: Okay, so, so the, the arrhythmia that we are really concerned about is something called torsad depu, which literally means twisting of the points in French.

This is a polymorphic ventricular tachycardia. Um, when you see it on an EKG. It, it basically looks like a waveform where you have Yeah. High amplitude switching to low amplitude back to high. And it looks like it's literally like twisting around, uh, a single line. So torsades can present in many different ways.

You, you may not know you're having it, uh, you may pass out, uh, you may come close to passing out. For some people it looks like they're having a seizure. Uh, and you can die. [00:18:00] Hmm. Uh, you can have just straight up like sudden cardiac death. And, and that's the thing that we're really worried about. And so with the, the QT interval, this is the one marker on the EKG that is kind of classically known as the best, best marker of risk for torsades to happen.

Preston: The distance between these two points. 

Dr. Margo Funk: The distance between these two points. 

Margaret: So when, this is what your EKG looks like, uh, what is happening in the heart at that moment? 

Dr. Margo Funk: So, so the ventricles at that point are contracting really, really fast, 

Margaret: both 

Dr. Margo Funk: ventricles so yes. So fast that there's a risk of going into, uh, ventricular fibrillation, uh, which is, uh, can kill you.

So, so you get, you get going very, very, very fast and that's what's happening on that, that up and down wave. 

Margaret: And it, it can kill you because you're not pumping the blood efficiently. It's just kind of like a [00:19:00] useless, sort of like spluttering 

Preston: pump. Correct. Right. It's just like kind waving in the wind like that.

It's not refilling with oxygenated blood. So kind of hard to live. I, I would imagine you're kind of stuck. Yeah. 

Margaret: Okay. So 

Preston: that, that's scary stuff to work with as a psychiatrist going from like. Nominally treating pretty healthy patients, which is like who I usually treat, especially the outpatient setting, to now all of a sudden this life-threatening cardiac condition.

One thing that I know we always get worried about in the hospital is like, how much do I actually have to worry about this? I think that's kind of like where we're going, um, from here on out. So the rule of thumb that I've been taught, and, and I'm gonna be curious like kind of what Margaret's learned in her CL realm is like, if it's kind of over 500, then the hairs stick up on, on the back of your neck and you should like pay attention to like kind of lower QTC prolonging things or QTC prolonging drugs.

'cause a lot of things can prolong the qt, but I've never really followed like [00:20:00] a good or robust algorithm. I've, I've just kind of seen a lot of people wing it and they, they get kind of uncomfortable if it's over 500 and then through with no other rhyme or reason. They're like, ah, let's use a Abilify, which is less QTS, prolong prolonging than something like Haldol.

But that's kind of all the reasoning I get. So I, I actually hadn't come across your tool before. So when, when we think about the risk of this actually happening in the hospital, how much should be we, we be worried in just a normal patient to like the sickest cardiac, cardiac patients? 

Dr. Margo Funk: Yeah. Well, I, I think that that's where you, you hone in is are they sick or not?

Mm-hmm. You know, the, the QTC is this marker of risk. It's gonna basically show you on an EKG what is happening underlying. So that's one, one piece of the puzzle. But I think the greater piece is what are all of the other risk factors that the patient has that may also contribute to their risk. And so [00:21:00] when I see a patient with a lot of risk factors, that's when with the 500 QTC, I'm, I'm getting worried versus a completely healthy person.

So, so risk factors, what are they? Uh. Female sex actually is a risk factor. It's probably estrogen related, uh, kind of unclear. Um, older age is a risk factor. I'm gonna say. 

Margaret: Does post menopause help women? But then they're in the older age factor, so maybe not. 

Dr. Margo Funk: You know, it's interesting, I've, I've seen women of all ages who have had torsos.

In fact, in fact, as I think about it, it's mostly been younger women, but they've had a whole host of, of things going on. So, so women, older women, it can certainly happen in Mendo two. Um, if the patient has any cardiac problem already, um, that's gonna be a risk factor. Certainly if they have a known cardiac genetic [00:22:00] problem, uh, or if anyone in their family does, that's something to think about.

If they've ever had a prolonged QT in the past, you look at that, certainly if they've ever torsed in the past, that's a respect. Mm-hmm. Um, a family history of sudden cardiac death is a great one that I think everyone should ask about. Hmm. 

Margaret: Um, 

Dr. Margo Funk: actually in any patient if, if you are gonna be giving a high risk medication, because they, they may not put together, um, that, that they need to tell you that.

And unless you ask, you may not find that. Um, and, and that's a huge one because that mm-hmm. That could be an indication that there is something genetic and maybe that's never been evaluated. Um, so, so that's one electrolyte disturbance is huge. So, hypokalemia, um, hypo, emia, hypocalcemia, uh, typically the, the torsos patients I've seen have been extremely hypokalemic [00:23:00] at the time of their event.

Like, like low, low, like ones low tunes. Wow. 

Preston: And these are all electrolytes that help with repolarization? Yes. Which is our goal. Okay. 

Margaret: Yes, that's exactly right. One of the reasons I first started ba asking Dr. Funk more questions about this stuff is given, I've talked about this in the podcast, interested in eating disorders.

Is this kind of like malnutrition or purging an eating disorder folks electrolyte disturbance, and then if they're truly like tic or mal under underweight, this kind of bradycardia, which I think is also an another risk factor. Yep, yep. 

Dr. Margo Funk: Sure is. Yes. So I, it that's a setup for this to happen. Mm-hmm. Um, and I, I've seen patients with very similar to what you've described Margaret, um, who have had an an episode.

So yeah, I think any, anything that's going to either disrupt your [00:24:00] electrolytes or cause GI losses and so even someone who is, is having, let's say norovirus and they're just like losing a lot. Um, that could put them at risk. Let's say they have another risk factor or they're 

Margaret: mm-hmm. You know, 

Dr. Margo Funk: who, who knows what, what's going on.

But that can happen. Um, certainly if, if your kidneys are not, not working well, your liver isn't working well. So if you're not able to clear certain medications that are higher risk, that can be an issue. Of course, overdose of certain medications, uh, is a risk factor. Bradycardia, like Margaret, you mentioned, uh, typically is present when you see this happen.

Mm-hmm. And so what'll happen is there'll be bradycardic, you know, fifties, forties, and then suddenly that heart starts racing and then, and then it goes into torsos. [00:25:00] 

Preston: These are subjective risk factors and they're good to put together the picture. I guess I, I'm just curious what the numbers look like. Is this one in a hundred, one in a thousand, one in 10,000 that they're being modified, one in a million, kind of where the initial risk starts and then where these risk factors move them up and down on, on the spectrum?

Dr. Margo Funk: Do we have the data on that? No. No, we don't. 

Preston: Oh, interest not. Okay. 

Dr. Margo Funk: No, there's no good date on that. And so how, how it's typically approached clinically is, is really the combination of risk factors. Um, the more you have, the higher your risk is going to be. Um, you know, one thing we haven't talked about yet are the medications themselves.

Mm-hmm. So, like, that's, that's the piece we're worried about, right? Yeah. And, and so the, the reason why medications, uh, cause this increased risk is that they actually interfere with that potassium. Uh, so mm-hmm. So like you mentioned, right? Like that's, that's part of how the, the electrical system works [00:26:00] so that in order for a cell to repolarize, uh, a bunch of potassium has to move out of that cell.

And if the potassium is not there, uh, then you are at risk. Uh, so, so one thing that can happen is that a medication can come in and block the channel that that potassium goes out through, and then you have basically a delay of the potassium getting out of the cell. Mm-hmm. And that is what will make your QT interval longer.

So the longer it takes for that potassium to go out, the longer your qt and I think even more importantly than the QT, is actually what your T Wave looks like. The T wave is where this is gonna show up and it's when your T wave, instead of being just like a nice hump where you can see where it ends very [00:27:00] clearly.

It's like this yucky slurred out like long, you know, very gradual slope downward. And that, that to me is like what makes me the most concerned when I see that. 

Preston: So it goes from the Rockies to the Appalachians? Yeah, basically. Yeah. Okay. I 

Margaret: think of it as a drunken tea wave because it's like just slurring out, not where it's supposed to be.

Yeah. Just let passed out on the line. 

Preston: So that, that's really interesting. I never thought about like how these medications prolong the qt, so, so all these like various random things from antipsychotics to SSRIs is through interference of these potassium channels that kind of cause that to be sluggish all the way, I guess.

I mean, it makes sense. I feel like it was right in front of us, but I never put that together. It's interesting. 

Dr. Margo Funk: Yeah. Now there are few medications that can actually interfere with gene expression of proteins that are necessary for those channels to work properly, but for the most part [00:28:00] it's, it's literal direct blockade of the channel by the drug.

Margaret: One of the things we haven't mentioned with, with this that I think is important, it was important for me, like as an intern in second year to like start asking different questions about this, which was we keep saying QTC, which is the QT corrected, um, as if there's one way to do that. And I feel like the most common thing that I like went to, I would say four times out of five whenever I got a consult on cl, like from a primary team in the ICU.

Like, Hey, this person's QTC is 500. Can you, like, what do we do? Can we still give them Haldol? They're, they're pulling at the lines and almost like four out five times. I would be like, lemme just recalculate it and see and like look at the heart rate. Um, do you wanna say a little bit about that? Because I know it's not for all hospital systems, but primarily the automatic read is Bette's way of calculating the corrected one and that I'll let you speak to this 'cause you can do it way better than I can.

Dr. Margo Funk: Yeah, yeah. No, but you're ex, you're exactly right. And I'm [00:29:00] glad to hear that, that you're telling them to recalculate 'cause that is correct. So, uh, so, so I guess backing up just a hair, the, the reason why we have to correct the QT interval is because at different heart rates, what we actually measure the QT to be is going to be different.

So imagine like the hearts beating really quickly. All these beats are really close together. What you measure of the QTS is going to be shorter than if. You're bradycardic, there's a lot of space between beeps. Mm. But that patient doesn't have differences in their ability to repolarize based on, on those different heart rates.

So we've gotta figure out like, how do we correct that? And that's what the C part is for the QTC. And so what Margaret is mentioning is that most EKG machines, uh, have a built-in correction formula. It they use [00:30:00] the, typically they use the, the first formula that was ever used back in the 1920s. It's called the Baz formula.

Uh, and, and it is a method to correct the heart rate. Unfortunately, what, what we know is that the Baz is, we're gonna say Bette is bad. So you remember the two Bs together. So Baz is gonna overestimate your QTC at high heart rates, and it's gonna underestimate at low heart rates. And it's really not so useful.

So, so if you have an EKG machine or system in the hospital that uses p the most do, um, what you're reading is very unreliable for one. Mm-hmm. And so it, it needs a recalculation. The other piece of this is, is even beyond the c correction part, is that you should always do your own QT measurement anyway.

Um, the machine is gonna put together this amalgam [00:31:00] of, of waves. It may not catch things like a slurred T wave may not look at it in the right way. And so it's really up to you if you wanna do it right. In my opinion. You measure it yourself. 

Preston: Do you have a caliper that you bring around? 

Dr. Margo Funk: I don't, I don't, but I, I, I rely on like I.

Our, our system is muse that we have in the hospital on the computer. So I just like zoom in a lot. Uh, sometimes I'm, I may get a little piece of paper that mm-hmm. Helps me measure 

Preston: mm-hmm. Measuring pixels that, that's more accurate than a caliper. Anyways, 

Dr. Margo Funk: don't let the cardiologist, goodness, 

Margaret: it's card Psychiatry podcast.

Podcast leave. 

Dr. Margo Funk: Yeah. So, so I guess, you know, getting back to your original question, Margaret, about, you know, the, the formula Bette, uh, Bette is bad, but there are several others that are perfectly fine to [00:32:00] use, and I, I think, you know, there are many calculators that you can find online or apps that now allow you to plug in the heart rate, plug in the QT interval and it'll, it'll spit out, uh, whatever the QTC is according to the other formulas.

So Hodges is a formula. Framing him is a formula Fri um, Frisia is now used by the FDA when. Mm-hmm. They are doing drug monitoring. They used to use Baz. I think in 2017 they switched because they also realized Bette is bad. Mm-hmm. So any of those I think honestly are fine. Just don't use the Bette. 

Margaret: I remember being like, when I would be on call and I would be like waiting for some other thing to come in, whatever, or avoiding writing a note, I would, I think MD Calc has ones where you can just switch between, like you can put in the information and then switch between the formulas just to see like how each of them corrected differently.

And like, BTS was always like, not always, if you were at the heart rate of 60, it was the [00:33:00] same as the others, but other than that it would be like 50 off or something. Um, just to see how they calculate differently. And it make, it does make a big change. Especially 'cause like a lot of the people that we're seeing in the hospital who are either agitated or sick in the ICU.

Their heart rate's kind of high. Sometimes when they get, especially when they get in, they're asking us these questions and so then if it overestimates the risk of the, or overestimates, I guess the QTC and their, therefore their risk of being on antipsychotic, it can prevent people from getting necessary medical care, which I know is something that you teach us every year and is such a, this combination of like complex medical ideas and calculations with complex interactions with a team in like a high acuity setting, I think is, makes it really hard for everyone involved on both all sides.

Dr. Margo Funk: Yeah, totally agree. And, and if I learned it from you, 

Margaret: so[00:34:00] 

I agree. Otherwise I'd be scared of the qt I, I know, right? 

Dr. Margo Funk: Yeah. You know, every, everyone kind of comes to the table with their, their own thoughts when. I think if you can establish relationships with the people that you're gonna be encountering most like your ICU attendings, your ID attendings, um, because many antibiotics, uh, and microbial antimicrobials can prolong the qt your renal folks, we actually didn't mention this as a risk factor, but if you're on hemodialysis risk is huge of torsos.

Uh, but one, one other thing, Margaret, that I wanted to mention about why it's important to measure and, and look at the EKG is a, a common error that is made is you'll get the call QTC is over 500 and you go and you look at the EKG and, and actually it's a really wide [00:35:00] QRS complex because the patient has a, a conduction delay.

And so if we go back to that, that piece about the QT interval is both depolarization and repolarization and we don't really care about the depolarization. That's what's represented by the QRS complex. So, and that's wide. We actually don't care as much. We really caring about what is after the QRS complex and so, so here's, 

Margaret: I'm, I'm, I'm imagining you saying this, like a medicine second year.

It's like, and they're like, why are you weighing in on the psychiatry? 

Dr. Margo Funk: I'll tell, I'm, I'm gonna be risky, but say that, you know, our psychiatry residents know a lot about this and 

Margaret: I mean, yeah, we do. We do. Like Margaret does. Yeah. That's why I'm like, it's like, how do I word this? I'm like, you know, I'm just thinking about this paper.

I read about Haldol. I'm like, slowly get there. Preston's gonna show up withers on Monday in the hospital and be like. 

Preston: I'm [00:36:00] gonna tell everyone how much I don't care about depolarization.

Dr. Margo Funk: I love that. So, so when you're in that circumstance and you see that 500, you know, you know, like this is not actually representing repolarization. That's the part we're concerned about. Mm-hmm. So there's an alternate interval that we can use, which is the JT interval. Mm. So the, the J Point Timberlake interval, yes.

The J point is the end of the QRS complex. You can correct the jt the same as you do, um, using one of the four nos to correct the qt. The cutoffs are different and they're a little, they, they're not well defined. Uh, but this is gonna give you a much more accurate picture of what your risk actually is.

Margaret: Mm-hmm. 

Dr. Margo Funk: Because often what I see is. We get in this scenario, let's say it's a [00:37:00] weekend, the primary team saw 500, over 500. They stopped the antipsychotic. But actually, you know, the patient has a bundle branch block that we're not actually concerned about. Or maybe they have a pacemaker and because they have a pacemaker, they also have a wide QRS and, and it's just, just part of being paced ventricular.

Mm-hmm. So they'll stop the antipsychotic, the patient decompensates. And none of that needed to happen if you had just looked at the EKG and, and understand what you're looking at. I think that's why it's so important to understand the electrophysiology. 

Margaret: Mm-hmm. 

Preston: That, that gets you through this huge initial gate, which is, should I be scared or not?

I see this on a, like, you know, I'm taking CL consults all the time, is we, we share the fear of the primary team. Oh, I, I just take at face value. The QR S is or the QTC is over 500. Let me adjust the medications for you. But [00:38:00] you know what I'm hearing from this discussion, it's important to take a step back and be like, do we even know that's true?

You used mm-hmm. Your computer used the bad formula. You didn't even follow up with your own calipers Timberlake and uh, and the J TC formula just prove you. We don't even have to worry. You know, it's powerful. 

Margaret: I feel like this is an area similar to a lot in, I think C Psychiatry or MINDBODY psychiatry, but beyond the overlap of eating disorders and cardiac concerns, it, you get this population of people that are.

Medically complex in some way and psychiatrically complex in some way. And then there's a problem of like lack of ownership because it's in the specialization model. It's like who has the full picture to make decisions when there's risks and benefits on both sides of that decision. Um, and I think one of the things that we're speaking to with the team dynamic and then this kind of thinking about how to do this [00:39:00] well, is this kind of thing of like, are is the team scared and we're scared.

So we're kind of in this like stalemate where we don't know what to do to help the patient. 

Dr. Margo Funk: Yeah, I, I think that can be really, really challenging. Um, I think, you know, if let, hopefully you have access to medicine interns. You can help teach them as a consultant mm-hmm. Uh, about some of these basic things.

Uh, you know, they will carry that on and, and that tradition will continue. I've seen that happen in places where, you know, this is not a known thing, and then like, suddenly you're like, okay, people, people know about the QRSs. Mm-hmm. And we need to be like, you know, looking at that. Um, I think, I think it's, it's all about the relationships and, you know, if you've gotta, you've gotta set up a good relationship with your cardiology teams, uh, so that they can trust you.[00:40:00] 

Margaret: Mm-hmm. That they 

Dr. Margo Funk: feel like, you know, okay, like this person's got it. Uh, and, and that can take some time. 

Margaret: Mm-hmm. Uh, 

Dr. Margo Funk: it helps like if you're on a CL service, that they trust your attendings and then as residents, you know, you've got that going for you. Um, I think in places where CL services are highly respected, it's easier.

Uh, and there, there may be some places where, you know, primary services don't even know what psychiatry 

Preston: Yeah. 

Dr. Margo Funk: Is. Right. 

Preston: It's funny you should say that because, um, I rotate at a couple different sites. We, so we have three hospitals that, that we do cl um, here in my city. And the cl services have varying reputations among the primary teams there.

So, um, the, the type of consults they'll reach out to you for varies a lot on the, the complexity of things. And so, so it's interesting that like all this expertise, all, all this knowledge almost doesn't matter if the social [00:41:00] political framework isn't there. 

Margaret: Yeah. Yeah. 

Preston: Someone told me that 80% of it is really how you get along with people and 20% is your objective competency.

Dr. Margo Funk: Yeah. Because, I mean, you know, they've gotta actually be willing to hear what you're saying. 

Preston: Mm-hmm. Right. So, so, Dr. Funk, um. I'm calling you. I'm, I'm the medicine intern. You'll go back to your residency for a second. Hey, this is, uh, this is Preston. I'm with medicine calling for a new consult. Um, yeah, so basically we have this lady, Ms.

Garcia, uh, she's here for a depression of psychotic features. Um, she's, she's like, otherwise medically stable like normal. Cle make normal magnes and like her meds are fine. We just have her on like some Trazodone 50 and sertraline 50. But, um, because of her psychosis we wanted to start on Risperidone, ris, Risperidone, is that how you say that word?

Risperdol? Um, one at bedtime, but her QTC is five 15, so we were just kind of worried. Um, and so that's kind of why we [00:42:00] wanted to get you on board 

Dr. Margo Funk: and I would say sure, we'd be happy to see her. 

Preston: So, um, now, now kind of, that's actually a very realistic consult that I feel like I would get. Um, getting consult at this.

We have, um, kind of the risk factors laid out. So we have a 30 5-year-old woman. Who's severely depressed with psychotic features. Okay, so there's her indication she's on Sertraline and Trazodone, which both can prolong a qt, but she's Norma Emmic and Norm Magnes and has no other risk factors. So her, her liver is fine, her kidneys are fine.

Her heart is otherwise fine. 

Margaret: Her family's fine. 

Preston: Yeah. Her family, no family history, but the QTC is five 15. 

Dr. Margo Funk: What, uh, what other medications is she on? 

Preston: So she's only, she's only on these psych meds. The sertraline 50 and the Trazodone 50. 

Dr. Margo Funk: Okay. So one, one thing for us to think about first is that sertraline is actually a very safe [00:43:00] medication.

Margaret: Mm. Uh, 

Dr. Margo Funk: and, and so I would not consider that, uh, a high risk medication at all. In fact, that's, that's what I usually prescribe for high risk patients. 

Margaret: Wow. 

Dr. Margo Funk: Is the sertraline. Trazodone is interesting. Um, it actually does have some risk to it. And, and this is something that we should be aware of, but I, I guess, you know, what I would wonder about is why is her QTC five 15?

Like, what, what is happening in her heart to show up that way on the EKG? 

Preston: And I don't know, I just, I just read it off the machine. I didn't do anything else. 

Dr. Margo Funk: Yeah. So we, what we could start with is looking at the EKG. 

Preston: Yeah. And so I guess to, to make it up a little bit more, we look at the EKG, you see that she's, her heart rate is, is, uh, 55.

She's, uh, turns out she runs a marathons in her free time. 

Margaret: She's psychotic. And in between that she runs, 

Preston: she, she just got really depressed after. Oh, right, right, right. Okay. She didn't qualify for the Boston [00:44:00] marathons, so that's why she's so depressed. Um, and then she shares, she shares with you that, um, she's had some anxiety and has been taking her friends per olol that she got from Mexico.

Okay. 

Dr. Margo Funk: So, well, I, I think that could be it, something we could mitigate her risk with. Mm-hmm. By getting rid of the propranolol, which may be making her bradycardic. 

Preston: Um, yeah. So maybe the bradycardias come from the propanolol and then we, we take that away and we rerun our formula through Friedrich. That's the right one.

Friedrich's in 

Margaret: Freda 

Preston: Frederica, yeah. Mr. Frederick. And it's actually, it's four 70, so it turns out it was never prolonged in the first place. 

Dr. Margo Funk: Ah. Mm-hmm. So, there you go. So I would say proceed, although I might not go with the two anti-psychotics. Oh no, she's, I'm sorry. It's ly not Sarah. Yeah, yeah. Yeah. 

Preston: So crisis [00:45:00] averted.

Dr. Margo Funk: Crisis averted. Okay. So, so I guess I have a question for you. 

Preston: Mm-hmm. 

Dr. Margo Funk: Before the propranolol did, did we recalculate the qtc? 

Preston: Um, I don't know. I just made this up. 

Dr. Margo Funk: Yeah. 

Preston: Hey, role. But we, yeah, so we recalculated before it was, it was, it was four 90. 

Dr. Margo Funk: Okay. So I would've still said proceed. 

Preston: Yeah. Mm-hmm. Okay. So here, here's the next situation.

Um, I'm the, I'm the intern covering the ICU at night and we have a, a patient here, Mr. Simmons. He's a seven 2-year-old. He's got vascular dementia. He's also, um, here for pretty severe pneumonia. And, uh, he's delirious. He's on Levofloxacin, Zofran and Furosemide. His potassium is 3.2. His mag is 1.5. He's, uh, he's pulling out his IVs.

The nurses kind of like, they're, they're blowing me up right [00:46:00] now. I really want to give him some Haldol, but I'm kind of scared 'cause his QT is five 20. So how do we think through this case? 

Dr. Margo Funk: Yeah. So he does have a lot of risk factors. Uh. I mean, you named pretty much all of them. Yeah. So, uh, that, that one could possibly have.

Margaret: So Mr. Har, Mr. Uh, torsad, DePaul mon into the hospital? 

Preston: Yeah. Yeah. What, what was that verb used like if they've torsed before 

Margaret: Tors again, again, he literally 10 minutes ago went, 

Preston: he's speaking French and he keeps saying, I will tor 

Margaret: He's just twisting a string over and over again. This, 

Dr. Margo Funk: so, okay. So, so for this, for this guy, this is actually complex.

Um, because Vy Hall Perol is actually not as, as risky as we think, and we treat it really got 

Margaret: beach paper, right? That's 

Dr. Margo Funk: that's right. Scott Beach paper. [00:47:00] Yep. So, so Scott Beach and colleagues have a lovely paper. All about IV haloperidol. They go through all of the evidence space and, and really what we learned from that is that the risk of IV Haldol is essentially the same as PO or I am Haldol.

Uh, and I think an easy way to conceptualize this is that one, there are not many studies, uh, that can study like randomized controlled trials to study torsos for one, um, fair, because you just can't Right. Like that. Mm-hmm. Yeah. Make them sick enough to be in 

Margaret: ICU and 

Dr. Margo Funk: Exactly. So if you're, if you're getting IV Haldol, you're probably pretty sick.

Uh, you probably have a lot of risk factors that are also contributing. Um, and so when you, when you study that in a patient where you can't actually parse out all of these other risk factors, um, that becomes part of the picture. [00:48:00] And so I. I think there could be some scenarios where we could potentially give IV Haldol to this guy.

Preston: So I guess we could modify some of these risk factors before we give IV 

Margaret: Haldol. Mm-hmm. 

Preston: So 

Margaret: yes, 

Preston: I could give him, um, 0.8 or like 80 milli equivalents of potassium. Tried to get his K back up to four. He could also 

Margaret: your ID friends if they wanna 

Preston: Yeah. Change. If, if Id wants to switch from Levofloxacin to something else that could be, um, still covers pneumonia, but not be, uh, so QT prolonging.

And then we could hang a bag of magnesium sulfate as well. Do we do 

Margaret: that? Does that actually happen in real life clinically? Do we replete with K or magnesium? 

Dr. Margo Funk: We, we do replete with K and, and usually I think it's a, an IV push of the Mac, like prophylactically. Yes. Okay. Actually, yes. Yeah, [00:49:00] that's, that's actually very wise to do if you can.

Mm-hmm. I mean, if he can tolerate it, that's the thing. Mm-hmm. Yeah. Right, right. Like if he's super agitated, putting more lines in him may not be the greatest, but if you could, I would. Uh, or maybe he could drink some, some potassium. 

Preston: Yeah. 

Dr. Margo Funk: Orange diet, potassium, some bananas at his bedside.

Preston: We're like, we have some diet Kool-Aid for you with 

Margaret: mm-hmm. A lot of 

Dr. Margo Funk: potassium 

Margaret: in it. 

Dr. Margo Funk: Um, but yeah, switching, switching the antimicrobial could certainly be done. 

Preston: So here's my question. Yeah. I've, I've heard Haldol's, iiv, haldol's was actually kind of an issue, but the other one is Trazidone. What are your thoughts about that one being kind of this villain of the QT.

Dr. Margo Funk: It actually is a, a real villain. 

Preston: Oh. 

Margaret: Can we get the myth confirmed sign from [00:50:00] MythBusters on here? I was thinking it was an 

Preston: anti-hero, but it's a real villain. 

Margaret: Can we get myth busted for Hal? And then the myth confirmed. 

Dr. Margo Funk: It's, it's actually real villain. Yep. Yep. It's, uh, 

Margaret: stupid. 

Stupid.

Preston: Okay. 

Margaret: I think like every time I'm on, I've been on call in residency at one of our hospitals, it's like this is every, every 24 hour shift. It was like this would happen. So like we have a lot of, I feel like there's, it's more frequent in some settings. Uh, and definitely my training. I feel like I've gotten very good.

Like I think I, I did an ICU psychiatry elective for a couple weeks and we read all these papers. So I, but I don't think that's common to all psychiatry residencies to like talk as much as we do in our, in. Training about this? 

Preston: No, this is unique and it's, I actually am going to two months of consults after this, so I'll be [00:51:00] taking all this information with you.

Margaret: You're about to own, you're about to come with your calipers and a mission. Yeah. 

Preston: And like I'm gonna be Yeah. Hitting people over the head with the JT intervals. Yeah. Plus left and rush. You should, 

Dr. Margo Funk: yep. Yep. I gotta tell you what the cutoffs are though. So you knew that too. 

Preston: Oh yeah, please. 

Dr. Margo Funk: Uh, yeah. So they're, they're different in men and women.

Yeah. There's, there's one paper about this, so I, I think you can kind of, you know, estimate. Okay. Um, men 3 55 milliseconds and women 3 72 for the jt. Those seems for the c. Yeah. Correct. It's gonna 

Preston: tattooed right here. 

Dr. Margo Funk: Yeah. Yeah. 

Preston: When I'm pre-rounding, I'll just be. Cross-referencing every E-K-G-I-C. Okay. Well, thank you for entertaining me on these real life clinical scenarios.

Um, my, uh, my hospital admin's coming here to usher us along to the final part that Margaret wants to get to. 

Margaret: Yes. Okay. We're gonna take a quick break and then when we're back, we're going to talk about outpatient clinical care and thinking about taking care of our [00:52:00] patients who have been through or are going through cardiac concern, cardiac events, and how to best support them.

So, I guess when someone comes to see you in your outpatient psychiatry cardiology clinic, what's like the most kind of common presentation you're seeing that they end up seeing you? 

Dr. Margo Funk: Yeah, it's, it's usually PTSD symptoms or just high anxiety after either a cardiac arrest or, uh, an ICD storm. Which is where their, their implants with defibrillator may fire many, many times.

Uh, at what, you know, in, in succession I've seen up to like 30 times, um, that someone's been 

Margaret: shocked. And how often does that happen to someone with like an ICD? I'm sure it depends patient to patient, but is that a com? Like [00:53:00] is it expected if someone has one that'll happen at some point in their course with it?

Dr. Margo Funk: I think yes. Hmm. Um, I think yes. I think it, it, it depends on what is the reason why the IC D was placed in the first place. 

Margaret: Mm-hmm. 

Dr. Margo Funk: Um, so, you know, ICDs can be placed for a number of different reasons. Sometimes it's primary prevention, you know, let's say someone had a, a massive heart attack and they, they now just have really bad ischemic cardiomyopathy and, and you know that.

Mm-hmm. They may be at risk, uh, they might implant one then, but you may have people who. Have had a cardiac arrest present to the hospital. They live, and then it's discovered that they have either something genetic happening or whatever it is. And, and then the ICD is placed, and it's in those folks where it's pretty typical for shocks to happen.

Hmm. 

Preston: So to describe it for our [00:54:00] non-medical listeners, and IICD storm sounds bad enough as it is, but 

Margaret: you're not gonna say it in ICD storm. 

Preston: It's like being shocked. Like the two panels like you'd see in a medical show. You said 30 times in succession. Is that, is, that's like functionally being tailored.

Similar, 

Dr. Margo Funk: yeah. So, so that's, it's interesting that you bring up the panels. So what I've heard from patients is that getting shocked by your ICD is actually very different than the paddles. That the paddles are much, much worse and terrifying. Uh. For a number of reasons. People have told me they can hear the electricity crackling in the air.

They can smell burning. Like, they're like just terrifying. Experience. Getting shocked by the ICD can feel like different things. Some people don't even notice that they've gotten shocked, um, which is interesting. [00:55:00] Some, you know, they, they classically describe it as feeling like you're getting kicked in the chest by a horse.

You know, I don't, I don't, most people have not gotten kicked in the chest by a horse. So hard to compare. Hard to compare. Um, so it's, it's different for everyone. Some people tell me like, this is just terrible. Uh, and very traumatic. The, the other piece is that sometimes people are conscious, sometimes they're not.

Margaret: Mm-hmm. 

Dr. Margo Funk: So they, they may get shocked 30 times and have not been conscious through any of it. They usually do. Okay. It's the ones that, um. What what basically happens is like they'll torso, they'll, they'll, you know, go unconscious, you get shocked, you come back and then you fall right back into it, you get shocked again and come back and, and it just like keeps happening.

And, and it can be for various reasons, not just torso, but mm-hmm. 

Margaret: But 

Dr. Margo Funk: it's, uh, it [00:56:00] can be pretty terrifying when that's happening to you. 

Preston: Mm-hmm. And, and so they come to you with ptsd, TSD from this and you say, I have a medication, but it may also increase the risk of to sod. 

Dr. Margo Funk: So we, we do a really careful kind of risk assessment there.

Mm-hmm. Um, most people are able to tolerate an SSRI. Uh, I do have a few people that I, I will not put anything on except a benzo, um, which can be safe in, in the right person. Um, sometimes I like that EKG looks so terrifying, uh, that, that I'm, I'm not going near them with anything. Even like Zoloft. Even Zoloft, I have, I have a couple that I wouldn't even put on Zoloft just because they, you know, was, I'm thinking about they have had many episodes of VT Storm.

ICD Storm. It's just, it's a [00:57:00] very recurrent thing with them, and many of them have gone through, you know, numbers of ablations, um, sometimes experimental therapies to try to get it under control. And so for them, like, I'm not gonna add anything into the mix. They're, they're also usually on one or more very high risk antiarrhythmics.

And so that's another piece that mm-hmm. That I consider. 

Preston: And so, just thinking out loud, if, if they have treatment resistant depression or PTSD are other classic options like E-C-T-T-M-S or ketamine are also off the table. Because I imagine they're meeting exclusionary criteria with their complex 

Margaret: heart history.

It's a good question. 

Dr. Margo Funk: I would say probably nothing is ever off the table. Uh, like ECTI mean, you, you can do ECT in someone with an ICD, uh, you, you turn it off by putting a magnet 

Margaret: on 

Dr. Margo Funk: the chest over the [00:58:00] ICD and that will, will turn off the shock function so that they don't get shocked, you know, with the ECT.

So you, you could do that, um, you know, of course, depending on the whole clinical situation. Yeah, yeah. I've, I've not seen data with ketamine, uh, and risk of ketamine. That's a, it's a really interesting question. 

Margaret: I feel like with ketamine all it, the thing I always see is like any. Time we've done a referral for someone with re ketamine.

If they have like any cardiac issues at all, they like are 

Preston: auto no on clearance. Um, yeah, I'm, I'm actually rotating in a ketamine clinic right now and that's kind of their, their motto, but I don't know if it's based off of data or just like abundance of caution. 

Margaret: Mm-hmm. 

Dr. Margo Funk: Yeah. And I think that's where, where the question is, right?

Like what is actually the evidence? I, I don't know. 

Margaret: Mm-hmm. 

Dr. Margo Funk: I've not seen any QT data for ketamine. What, 

Margaret: what about lifestyle factors? 'cause one of the things I was thinking about is when I was on CL and we would do like heart eval [00:59:00] or heart transplant evals, um, and just the amount of life like limitations that, that is different obviously than uh, having like an ICD.

But when you think about talking to your patients about lifestyle parts outside of medication, so like exercise, I'm thinking of like alcohol. Some people would argue diet and mental health connections, these non-medication things, like how do you talk to them about those three things? 

Dr. Margo Funk: Yeah, that's a great question.

So, so again, it's, it's gonna depend on the patient and, and what is the cardiac issue for them. You know, with transplants, it's actually pretty interesting, um, that, you know, alcohol is, is contraindicated, like, you know, don't want to use alcohol. Diet is even really important for transplant patients early on in the course.

Hmm. So that they don't, um, they don't expose themself potentially to [01:00:00] pathogens that could get them sick because they are immunocompromised much like a pregnant woman. Like you wouldn't eat sushi or lunch meat. Kind of similar in the early days of transplant. Um, you know, for everyone it's kind of different.

I, in many of my patients, they are. Trying to get back to some sort of exercise. And the fear component of doing that is, is the barrier. I actually have many athletes that, that I see and people who have really like lived a lifestyle of, of health 

Margaret: mm-hmm. 

Dr. Margo Funk: Um, and being active. And so the, the fear component can be huge.

Uh, so it, it's, it's often like not me trying to talk to them about things that could help. They usually know. Uh, and, and it's more about what are, what are the psychiatric or psychological barriers or just, you know, [01:01:00] barriers from, you know, conditioning standpoint. Mm-hmm. You know, people with, with heart failure may not be able to, to work through just the fatigue that they have.

Right. To be able to exercise. Um, you know, it's, you know, even, even someone who. Has been through, let's say, like a recent ICD storm mm-hmm. That actually damages the heart when it happens. And so it, it can take some time to recover even from that. Mm-hmm. Um, just think about your heart getting hit with that much electricity.

Yeah. Over and over again. So, so I think many people they really like want to get back to exercise. Mm-hmm. And it's a matter of can they physically and then can they overcome the anxiety and the fear. 

Margaret: Yeah. 

Dr. Margo Funk: I will say like an SSRI, in that case, I, I've just seen be so, so helpful in so many people is really, really just turn things around for them.[01:02:00] 

Mm-hmm. It's kind of remarkable to see like, people terrified to just get off the couch to now, you know, going to spin 

Margaret: class. It's, it's, it's, um, that's pretty cool to see. You 

had mentioned at the beginning of the episode that, you know, PTSD around this event that's happened. If there was someone who's in, you know, a general psychiatry clinic and they have a patient who maybe, let's say four months ago they had a heart attack and they ended up needing an ICD placed, and they come and they're struggling, like they're coming to a generalist for the first time.

What does it sound like when people, when you're, when you're trying to help them suss out sort of this medical PTSD around this event? 

Dr. Margo Funk: So oftentimes they, they may, may not outright tell you symptoms, uh, one because they think that they're the only one that could [01:03:00] possibly be experiencing this or that they're crazy.

Um, or just, this is so weird. I would never tell anyone. So we actually have to do some sussing out. Uh, of the patient and a really great tool, uh, for someone with an ICD is a scale called the Florida Shock Anxiety Scale. What a name. It's lovely, and it's, it's actually, it, it could be triggering, but in most cases it's really validating for patients to see this scale for the first time because it asks questions about how often are you, you know, afraid of, of being alone when your ICD goes off.

How often are you afraid of causing a seam when your ICD goes off? Very common. How often are you afraid of shocking someone else in the room when your ICD goes off? Um, are you [01:04:00] afraid to get angry or let yourself get angry? Are you afraid to participate in sexual activity because you're afraid of the IC going on?

So a lot of, a lot of, um, really discreet, specific scenarios it goes through in the scale. You don't have to use the scale, uh, but you can take some of those things and pull them into your interview to screen. But it's, it's often, you know, avoidance of being in public, people seeing something happen if something happens or being alone when it happens.

And then many people, you know, do avoid the place where they've been shocked before. Uh, I hear from a lot of people, like they'll keep the bathroom door open if they're showering or they're using in the restroom, uh, in case someone can hear them. So they can hear them yell out if they need help. Mm-hmm.

Or if they were to pass out, um, not being in the same [01:05:00] room where it happens, that can be a trigger. So, you know, some very po you know, common PTSD things that you would think about, but then there are these other more device specific things. 

Preston: I think if I was trying to scare someone, um, I would use so as a very backwards lead.

And, but hear me out for a second, I would use that kind of variable, um, punishment, you know, shock them randomly so they couldn't anticipate what it's coming. And then you can almost indu induce like a learned helplessness around it. Mm-hmm. So it's like wearing this, this randomized shock collar. So, so I can really understand how these, these people become worried about doing anything, you know?

Yeah. Correcting one pathology is almost like, um, operant conditioning to induce another. 

Dr. Margo Funk: Yeah. That reminds me of, of things too, like, just like an Apple watch, you know, or, or devices that are keeping track of, of heart rate. Um, people [01:06:00] become obsessed with those. And, and can't stop looking and monitoring.

They feel any little sensation in their body. And that fear of getting shocked might come up. 

Margaret: Do you feel like, so let's say we help the PTSD or we help the anxiety medication wise. You mentioned your clinic is also, I know there's some group part of it that happens, um, and then your own psychotherapy approaches.

Um, can you speak a little bit to that part of the work being with this population? 

Dr. Margo Funk: Yeah, so I do a, a lot of DBT actually with these folks, um, do a lot of radical acceptance. Um, you know, some distress tolerance, but the radical acceptance piece tends to be pretty big as well as Wise Mind, you know, and they're, they're pretty basic concepts of, of DBT, but, um, they tend to resonate with these folks quite a bit.

Um. [01:07:00] So I, so, you know, we, we, we talk about that. Um, I think we, we do work on, you know, setting goals of, of what they want to work towards. You know, sometimes that just may be like, how far do they walk? Um, but, but honestly, for the most part, it's, I think just the validation of someone being in the room with you and hearing your story and being able to say, yeah, other, I, yeah, I have other patients who tell me the same thing.

It, that can be really huge, um, to know that they're not alone in it. And so that, that, that then I think brings me to, we have this ICD support group, uh, which right now it's, it's mostly an educational space. It's for a very large group. It's a hybrid on Zoom and in person, um, and open to anyone. Anywhere with an ICD.[01:08:00] 

And it's a great place for people to meet each other, to hear about other experiences and just like know that they're not alone. That's the most 

Margaret: important piece of it, I think, is that You said open and like, is it, if listeners have this, like, is this, is it open just to people in our clinical area or is it open to the public?

It, 

Dr. Margo Funk: it actually is open to anyone who wants to attend. 

[an actual real eagle]: Mm-hmm. 

Dr. Margo Funk: Um, and we, we could, you know, I could share that, that link with you all. Uh, for anyone who's interested, we do it, we do it quarterly. Mm-hmm. Right now I would, my dream is to have actual groups, um, with different patient populations. Uh. When and if the the time allows.

Well, let's get you more patience. And I can be, I know, I know. It's, it's fun. I have a steady referral mm-hmm. Stream at this point because there are a lot of people suffering, you know, and that's, that's [01:09:00] actually one, one other piece I think that's important. I hear from a lot of people, like, you know, no one, no one ever knows that I had a cardiac arrest, that I was dead, and then I came back to life.

Like, we pay all this attention to cancer. Right? But like, this is kind of hidden. Like, I don't tell people that, that I was dead, uh, that I, you know, had to be cprd and resuscitated. And, and so I, I think a lot of these patients just feel like they're hidden. Um, and their stories aren't known. Their experiences aren't known, and there aren't people like really who have their back.

Mm-hmm. Uh, and I think that's an important piece for. To think about. I 

Margaret: think you're right. I mean, as someone who has a family member with like an aggress who's had an aggressive cancer over the years, people always ask me like, how are they doing? Like, checking in even as the related person. But when someone has a heart [01:10:00] attack, there's not really a language around recurrence in the way that there isn't right?

Cancer. But there's still that real risk and then the anxiety of the risk of is this going to suddenly come back and harm me? But you're totally right. There's not like a language publicly for that. You don't ask like, Hey, are you worried you're gonna have a heart attack again? Like, that's not something we inquire after.

Dr. Margo Funk: Yeah. 

Margaret: Yeah. 

Dr. Margo Funk: I, I love, I love how you say that too, about not having the language for it. Mm-hmm. I think that's, that's totally right on. 

Margaret: Well, 'cause how many people have a heart attack and then it's like, now your risk is zero for this happening again. Like it isn't, it is like cancer in some ways. That way that it's not, I think with cancer, we have the public imagination that this comes back and you're maybe always kind of anxious that it's gonna come back.

But we, we don't, we don't talk about this that way, but it is that 

Preston: we're not set up to like support or around like sudden events. I guess. Like if a heart attack took three months [01:11:00] to transpire, maybe we would have more language around it because it's like a battle. People have time to spread the word and get behind, but it's like you're doing fine and then all of a sudden you're not, and you're, you're gone in the blink of an eye socially, like the ecosystem can't like react to that very well.

Margaret: We talk in like psychodynamic therapy, but like the fear, like the metaphorical fear of annihilation and like this is an illness that does, can suddenly enter your life and then you have to, there's a real fear. So I see how, I mean, I know Marsha Lenahan in her like memoir talked about creating DBT from her own stance of someone who had lived.

With a proto BPV sort of kind of symptom cluster and describes it as like, these are skills for living when you feel like you're living in hell. These are skills for when you feel like at any moment mm-hmm. The suffering is gonna be so much, the anxiety is like unbearable. And so I think it makes sense that radical acceptance and wise mind and then [01:12:00] compassion are important for people who have been, who've died and come back.

Yeah. 

Preston: Yeah. I mean it's not, it's not a long descent into hell. It's a trap door that opens below you and kind of like, like what Margaret said, anyone with BPD like struggles with that dysregulation or really not having any co control or what can happen. So when you talked about using wise might have made a lot of sense to me.

I'm like, if I had this random thing that I had no control over that could just take my life from me, I, I would probably need to to practice the same principles. 

Margaret: It's like, it's like, I mean, I know we called it the ICD storm, but it's literally like, Hey, what if at any moment lightning could strike you?

And I know it's like the illness part of that, and then also kind of literally like with what it's doing electrically. Yeah. Right. 

Dr. Margo Funk: Yeah, 

Margaret: yeah, 

Dr. Margo Funk: yeah. No, it's, it's exactly like that. And so, you know, for many people it's, it's just terror. Uh, but then, but, but I do, I do think the radical acceptance piece is [01:13:00] so huge here.

Um, because once you can sit with it and, you know, I, I just like love it when, when I hear, you know, my patients say, you know, it is what it is. I'm like, that's right. It's that way sometimes.

Margaret: I, um, 

Preston: this is a great segue 'cause I think we're doing a DBT episode in, um, a couple weeks. 

Margaret: Yeah. 

Preston: So we can stack these together. 

Margaret: Nice. Is there anything else that you feel like you wanna point. Our listeners direction or attention towards, towards further learning or towards any kind of pearls of advice for people who work with these kinds of 

patients?

Yeah. Or are those patients themselves? 

Dr. Margo Funk: Yeah, I think, um, I think if you're working with, with these patients, know that they, they may not ever tell you [01:14:00] anything you have to ask. And though we do that, um, there may be, you know, so much nuance about what the fears are that unless you ask directly that they, there's a lot of shame around acknowledging that.

So I think that's, that's one piece that's important from A QTC standpoint. Practice, practice as much as you can. Every EKG that you come in contact with. Do the measurement, do the calculation. And, and when you do that, try to think about the electrophysiology that's happening. So it's like, why, why is it 500?

Why is my T-wave really slurred and ugly? And if you can understand the why, you know, that, that gives you so much more power with your prescribing and feeling like, okay, I can actually give the IV Haldol or [01:15:00] absolutely no, like, I will not give anything to this patient, which is very rare. Mm-hmm. Um, but I, I think the, the more you feel confident with it, um.

The better care you'll provide. 

Margaret: I mean, I got to the point at the end of cl rotations and working with you that my dot, I have a dot phrase in epic that's like dot and then like an algorithm from the resource paper that's like, if you're interested in this, see this paper? They're never interested in it.

But I was like, see and have, that's like the one thing I have for notes that has a citation. Preston wants to make fun of me so bad for that right now. 

Preston: No, I'm thinking about like, if I could hyperlink it, make that a part of my, uh, epic note. 

Margaret: You can I do that with like the.

Preston: It's been bad news. They think 

Margaret: their psychiatry notes are long now. Wait until they get to this. Have like a, these screenshots 

Preston: of MRIs all over my notes. 

Margaret: My notes are always purple though, which Dr. Funk might know from being on cl Mine are like edited to be the font I [01:16:00] like, but hey, you can format them.

Okay. Well thank you so much for being on with us, Dr. Funk. I know you're very busy. Um, I think this is such a useful resource and one I will probably come back to. Every time we have A-A-Q-T-C lecture, I'm like learning something different about it that I could not have known as like an intern or different years.

Dr. Margo Funk: Well, it's, it's been a pleasure to be here and pretty fun. You guys are awesome. 

Margaret: So thanks for having me. Yeah. Preston, do you wanna do the outro? 

Preston: Okay. So, um, thank you to all our listeners. Um, we really appreciate all the support from season one and now that we're going full steam into season two, we're really trying to incorporate all of your ideas and our ideas to achieve synergy to use my corporate language there.

I know this was more, one more a medical, uh, intense episode, and this is because we have a really like unique expert here and we want to kind of give a chance to, to go into the weeds sometimes. And then on other episodes, we'll um, be coming back [01:17:00] out of the weeds and do a little more, a little bit more, um, forest type excavations.

So. If you wanna watch the full episodes, you can check it on our YouTube channel at it's prerow and we'll also be posting on our Instagram account. I now, I'm running the Instagram by the way. It's, it's just how to be patient. I think we have like 110 followers, so like slowly but surely we'll be directing our, one of our first 

Margaret: investors.

Get in at, at the ground level. Yeah. Podcast content 

Preston: towards there. Yeah. It just, because like Margaret and I post on our socials and do other things, but we wanted to have like this United Page for that. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aaron Corny, Rob Goldman, and Brooke.

Our editor and engineer is Jason Portizo. Our music is Bio Mayor Benzi to learn about our program. Disclaimer and ethics. Policy submission, verification and licensing terms and our HIPAA release terms. Go to our website, how to Be patient pod.com or reach out to us at how to Be patient@humancontent.com with any questions or [01:18:00] concerns.

How to be patient is a human content production.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:19:00] background.