A Cardiologist Speaks from the Heart - With Dr. Ankur Kalra | The Empowering Neurologist EP. 120

I've encountered these several emotions, you know, through my work as an interventional cardiologist who has dealt with, you know, families who've lost loved ones from heart attacks, but also other cardiac emergencies. Also the broken heart syndrome. I mean, broken heart syndrome is very real.

Hello everyone. Welcome again to The Empowering Neurologist. I'm Dr. David Perlmutter. Interventional cardiology, these are the people who are on the front lines of the middle of the night when somebody goes to the hospital with a heart attack. These are the people who do the interventions by threading a catheter into an artery and opening it up. They literally have somebody's life in their hands. It's a stressful job, but it's also a very meaningful experience, at least for the person who's on the program today, Dr. Ankur Kalra, author of this book of poetry. Now, this book of poetry is inspired by his life experiences, not only in the cath lab, but certainly outside the cath lab as well. You know, it's not something you would typically expect a person who's involved in this type of work to sit down and write a book of poetry about what life is really all about through his eyes, but he did, and we're going to talk to him today. Let me tell you a little bit more about him. Dr. Ankur Kalra is an, as mentioned, an interventional cardiologist and medical director of clinical research for regional cardiovascular medicine at the Cleveland Clinic. He's the section head of cardiovascular research at the Cleveland Clinic in Akron, Ohio, at Akron General Hospital, and he's associate professor at the Cleveland Clinic Lerner College of Medicine and the founder of a nonprofit startup called MakeADent.org. He is director of the Barry J. Maron Hypertrophic Cardiomyopathy Center in New Delhi, India, and he's also the host of the cardiology podcast show called Parallax. He has presented late-breaking science at national and international scientific cardiovascular meetings and has published over 200 scientific manuscripts in various peer-reviewed journals. Promises to be a very interesting interview, and I'm looking forward to it. Hello, Dr. Kallra, how are you doing today?

Good, how are you? Thanks for having me on the show.

I wanna just recount how we met. You were in a clubhouse that I was involved in when I probably should have been paying attention. It was actually 'cause you were, I think we called upon you to speak, and I was reading your bio, and it talked about that you had written a book of poetry. And it's, you know, for whatever reason, it's not something we would typically expect to see listed in a bio from, you know, an aggressive interventional cardiologist. So we wanna unpack that, that's for sure. But first, if you could, Let our viewers know, what does an interventional cardiologist do day to day?

Sure. So again, thanks for having me. And, you know, I would like to delve more upon how I, you know, got into poetry. You know, just to answer your question, an interventional cardiologist is a cardiologist who spends most of his time in the cath lab doing procedures. So what we do in the cath lab is, for example, if anyone is in the throes of a heart attack, it's the job of an interventional cardiologist to go in acutely And open the blood vessel that is blocked that is causing the heart attack. You know, that's what we do. In addition, you know, interventional cardiologists have subspecialized within interventional cardiology to also do procedures related to heart valves or, you know, blood vessels in the legs. So I also do heart valve procedures wherein we now have the technology and the advancement in the field to go in with wires and catheters and replace heart valves. You know, that patients are born with, you know, typically diseased valves. As one ages, these valves tend to get thickened and calcified. I'm talking about the aortic valve for those from a medical background. So that's what an interventional cardiologist does.

The main thing then that you're doing are these angioplasties with or without stent placement for occluded or nearly fully occluded coronary arteries?

That is correct.

Can you tell us how effective is that procedure in both the short term and in the long term?

Yeah, so, you know, it's in the throes of a heart attack, you know, that procedure is life-saving. And that's been demonstrated after multiple randomized clinical trials and has become the standard of care. As interventional cardiologists, we are held accountable to what we call door-to-balloon time. From the time the patient hits the door and is diagnosed with having a heart attack, the clock starts ticking now because time is muscle. As I'm sure you would know, for a neurologist, time is brain. Time is muscle for an interventional cardiologist. And within 90 minutes of patient hitting the door, you know, the blood vessel should be open. That's when the patient derives maximum benefit of the technology and the skill and the procedure. So it's become standard of care for what we do on a day-to-day basis.

So there's a lot of late nights then involved in that.

A lot of late nights and a lot of adrenaline and, you know, at times lots of, you know, early morning hours. But, you know, I can tell you that it's very fulfilling. It's fulfilling because the bond that you make with these patients and their families is the bond that, you know, makes you want to keep doing this again and again and again. And the letters and the greeting cards that you get on patients' annual, you know, quote-unquote STEMI anniversaries— it's called ST-elevation MI— it's such a major event in their lifetime that they sort of remember it and they put a date to it. And, you know, they— it's, it's It's just incredible that many of my patients, and the same goes true for my colleagues, patients would send us greeting cards and make us, remember to give us a phone call on their STEMI anniversary to sort of thank us for what we did. And that's very fulfilling. That's what we train ourselves to do, and those are the days that we live for.

It's clearly a life and death situation. And then when you reveal that you've written this very, very beautiful book of poetry, I'd like to say, gosh, those seem a little bit at odds. But in reality, you're deeply in touch, even in the cath lab, you're very much in touch with what life is all about, how precious it is at that given moment when people are on the edge. And it really was expressed, I think, beautifully in your book.

Thanks, Dr. Perlmutter. Yes, the cath lab humbles you. I would like to say that life humbles you, but I think more so than life, I think it's the cath lab. That humbles you. And the reason I say that is that, you know, there are incredible success stories and, you know, that's what, you know, keeps us going. It motivates us. Every now and then you would run into a scenario which, you know, you sort of take back with you and sit down and reflect upon what all happened, you know, during the emergency scenario and how you reacted to it and what all you did and what all you could have done or what all you should not have done. Those are sort of the experiences that stay on with you. You enjoy internalize them as a proceduralist. And, you know, patients may or may not recognize this or think in this fashion, but I know other proceduralists who may be listening or who I'll be sharing this episode with in the future would relate to this, that the last thing that you want as a proceduralist is a complication in the cath lab because those are very hard emotions to deal with, to grasp, and to then move on. You know, but as any proceduralist will tell you, that if you had a complication or if you are not having complications— now I'm not trying to advertise that complications are what happen on a day-to-day basis. Thankfully not, you know, thankfully the skill and the field and the technology all have advanced to a significant great deal that we have incredibly great outcomes. But every now and then you would have a complicated case and those cases, you know, stick with us for days and weeks and they become part of our thought process and they become a reference point, you know, as we move along to do other complicated cases. You know, we try to learn the best that we can from them. And then the other aspect of being in the cath lab or working in the cath lab is mortality, which is inevitable. I mean, if you're gonna do high-risk cases with patients who are in the throes of a heart attack, which is a life-threatening emergency, yes, again, there are many success stories, but every now and then you will lose a patient. And then to speak with the family and go through the emotions as a physician, you know, 'cause we have our families too, so just putting on the family man hat and sort of experiencing those emotions with empathy and with compassion with our patients is another hard emotion to deal with. And, you know, we carry these with us when we go home, when we see our kids, when we're with family. And after we're done with, you know, the day's work, before we go to bed, you know, at least that's my own practice, is that I try to journal what went well and what didn't go well. Just be with yourself during that final 30 minutes before you go to bed and end the day. Still end the day with gratitude because You know, the kind of work that we are privileged and honored to do is, you know, I believe very few on the planet are able to do. And, you know, it sort of put things in perspective, you know, when people complain or criticize. And then when you look back at the kind of work that you're doing, it just puts everything else into perspective.

Pronounce the title of the book for me.

It's pronounced as ibadah. So it's an Arabic word.

Meaning servitude?

You know, Arabic, like Urdu, it means servitude. Yes.

You know, a lot of what you just talked about, I think, is, is very well manifested in the book. Each poem describes, uh, I think, issues— correct me if I'm wrong— that have occurred, uh, in your life, uh, outside of the cath lab, and then, uh, are then interpreted by the artist who, with each poem, has provided a, a piece of art with a, a descriptor underneath in terms of what is the take-home message, what is the meaning of this experience that you described, uh, in Am I pretty much on target?

Yes, you are on target. You know, I would like to say that these experiences are not necessarily my own lived experiences, but have been lived vicariously through my patients' lives. As I have gone on to do my job as an, as an interventionalist, and because I have the habit of journaling emotions that I encounter not only as a physician, but, you know, through my patients, the emotions that I see in families and patients' lives, I try to journal them because I feel that as humans, you know, that's our equity. Emotions are our equity. And, you know, we need to bank them. So I have a habit of banking emotions, not only for myself, but also for my patients. And that's how I'd like to connect with them. That's how I like to connect with my own loved ones, you know, my family members and my friends.

There's a lot of, a lot of really brilliant choice of words. And I was very taken by that. You know, it's the craft of the literary craft, especially when, you know, you're called upon by the constraints of poetry for rhyme, etc. It's beautiful how you worked really sophisticated, meaningful words into the flow of poetry. There's a theme in many of the poems of relationship loss. So these are through individuals for whom— with whom you've interacted. Some of that may be personal. That theme, I think, ultimately plays out interestingly with a kind of life lesson, as the descriptor underneath the artwork would have it. It's interesting to me because it kind of, uh, Circles us right back to the lessons learned in the cath lab.

Yes, that's true. I've tried to journal different emotions. I agree with you that the predominant emotion of the book is that of loss. So if someone's loved and then someone's lost and then there's heartbreak, that's the emotion that I'm trying to tinker with as an artist and as a poet. Even for me, you know, just writing this book was very cathartic because, you know, like I said, as physicians, We carry these emotions with us. And, you know, all of us have different outlets of how to express ourselves because, you know, you do need an outlet whenever there is a buildup of emotion. It needs to come out. And, you know, for me, you know, fortunately through words it came out in the form of poetry, or that's how I would like to think about it. And then I said, um, you know, I think these are, these are shared experiences, these are lived experiences by many, and it would be important to give all these experiences a spiritual meaning. Because I, as a person, I feel that the life is not happening to us, that the life is happening for us, and that the universe is not happening to us, the universe is happening for us. And the universe is constantly trying to communicate with us and send us messages, and it is up to our own intellect and, you know, spiritual awakening or spiritual path or spiritual journey that we should try and imbibe these messages from the universe. So I wanted the poetry to not be a standalone in and of itself poetry book, I wanted to team up with an artist who would then, you know, give an artistic rendition to the words that I've written. And with the artistic rendition, like you mentioned, at the bottom of each artwork is the life lesson or the spiritual lesson or the lesson from the universe. I've encountered these several emotions, you know, through my work as an interventional cardiologist who has dealt with, you know, families who've lost loved ones from heart attacks, but also other cardiac emergencies. Also the broken heart syndrome. I mean, broken heart syndrome is very real. You know, we published about broken heart syndrome. And, you know, I think the other thing that I want to sort of talk about during this conversation, which I feel is extremely relevant to the book, particularly gets more, more relevant, is the times that we're living in. And that's the times of the pandemic where, you know, unfortunately in the United States, you know, we've lost so many lives. I mean, the loss is profound and it has happened in, in such a concentrated time. I think it's going to take us many years to to completely grapple with the profound loss that we've, we've suffered as a society, you know. I'm not only saying, you know, personal loss in terms of life, but also like loss of job and loss of relationships and, you know, just loss of our sense of normalcy. So many, many losses, you know. Not every loss is, you know, a personal loss. There are other losses too. But it's a compendium of losses, and I think for all of us it has just hit us home, uh, and, and hit us deep within as to what we truly value and cherish as, as people, as humans, as persons. So the broken heart syndrome, as I was mentioning earlier, is real. And we saw an uptick in the incidence of broken heart syndrome. We thought that this was a cluster, but then we wanted to investigate and study it in a systematic fashion to see if this was truly a cluster or if there was an association with the pandemic and what was happening with people's lives in the pandemic. And we found that there was a 4.5 to 5-fold increase in the incidence of broken heart syndrome compared with, you know, the pre-pandemic controls that we looked at from the year So I think the book, you know, for me spiritually, I'm a spiritual person. It came at a time where I did not foresee that we would be in the pandemic. And then the pandemic just hit. I think the book was released on Valentine's Day in 2020. And in Ohio, the first case was diagnosed mid-March. And that's where, you know, I think the US really started reacting to what was happening to the rest of the world.

Yes, it's, it's a bit prescient then that your book came out when it did. Do you happen to have a copy nearby?

I do not have a copy nearby.

Okay, because I do. Because I thought for our viewers, a poem would be a nice touch. So it looks like I'm elected to read it. And I, you know, there are several that I, that I chose, I looked at and I thought would be appropriate. I've chosen Conversations. So I'll go ahead and read it. And then I want to just talk about the interpretation or the, as it's called underneath the artwork, it's the lesson. Long conversations were forgotten. Emotions became irrelevant. I was expeditiously deposed in the wrong Basket. Amazing line. Without consideration or benevolence. I was the most important person once. In the blink of an eye, my existence became irrelevant. Change is the only constant. The lesson is now permanent. It wasn't just an eye contact. The innermost feelings were bared transparent. I was barely an attractive stop in a fast highway that couldn't sustain resplendence. Where does this come from?

It comes from— I'll share the underlying essence of the words, which I think you're trying to get at. It comes from having had an intimate connection with someone, someone whom you've considered special, and then having lost that someone suddenly, rather acutely. The narrator is trying to comprehend what he or she just experienced, as in one of the other poems I've mentioned, a tête-à-tête. Or was it, you know, more spiritual and carried more meaning? Because if latter was true for that particular individual, that's a profound loss. Like, if you've spiritually connected with someone whom you've lost rather acutely. Now, it may not be true for the other person that the narrator, you know, felt that emotion for. If you've lost that person rather acutely, you know, it could be an emotion which could be extremely, extremely hard to grapple with. You know, it's the kind of emotion that is, you know, very dangerous from a physical, mental, emotional point of view. you know, from a health standpoint also.

Unless it's contextualized.

Yes, I completely agree with you. Does that answer your question?

It does. And I'm just gonna read the lesson that appears with the poem, and that is, intense emotions, feelings are normal, and it's not unreasonable to experience anger. It's contextualizing these feelings as part of the human experience. And to me, it's about what must go through your soul, even in the cath lab, you know, day to day, of course, in interactions with people, but even at that most sacred moment where The lives of other individuals are literally in your hands.

Yes, it's, you know, fortunately, knock on wood, it's, you know, like I was mentioning at the beginning of the show, with great advancement in technology, and obviously with evolution of skills for the field as a general, we've gotten very, very good at handling very complex cases. But every now and then you will have cases which are extremely complex. And, you know, a subset, I'm I'm avoiding the medical verbiage or you know the medical jargon, but I'm going to give you an example. So heart attack with what we call as cardiogenic shock is a patient subset which is which still in 2021 the mortality is 50%. Turns out we haven't been able to budge this number in the past decade. If you look at the literature, which is now a decade old or even more than that, you will find that the mortality has remained at a static 50% for patients who present with heart attack and are in cardiogenic shock. That's an extremely sick patient subset, and as an interventional cardiologist. You will encounter those patients every now and then. When you lose those patients, whether you lose them on the CATS table or whether you lose them in the ICU, it's tough. It's extremely tough. You keep questioning your clinical decision-making and you keep questioning what else could you have done differently. It's taxing on you. Like I said earlier, you carry, you sort of rerun, for me at least, and I'm sure The same is true for every proceduralist, interventionalist. At least it's true for the colleagues who I work with, is that we rerun scene by scene and frame by frame what exactly happened. It's etched in our minds, and we keep rerunning every single step. We keep rewinding and figuring out the question that we ask ourselves is, was there any point in time during several minutes or several hours that we would have done anything differently? You know, different wire, a different catheter, you know, more expeditious, more finesse with our skills, you know, in terms of instituting advanced therapies early on. Not having to take the patient to the cath lab to begin with. As great as it may look, and it actually looks very great, I mean, it's a great visual for people seeing primary angioplasty and stenting in patients who come in with a heart attack. It's a great visual. I mean, even when we go back and see these films, we're just amazed and in awe. Not of ourselves, but of the abilities that as a field we've been able to offer to our patients.

The technology.

The technology, exactly. It's a great visual, but when you have these sick patient subsets, it turns not to be a great visual. And you have to remember Remember, put yourself in the skin and shoes of that particular individual who's laying on the CATS table in an extremely vulnerable position, you know, between life and death, and you're the only person in between that, in between those 2 occurrences. If you think of it that way, and I actually, I almost always think of it that way, you know, like I've said, I'm a spiritual person, and when I'm taking these cases on, you know, the only conversation I'm having with me is I'm actually constantly praying within. So even though externally I'm giving orders to the team who's, you know, helping me with these cases, you know, whether it's, you know, I need this medication, I need this drug, okay, give me this balloon or give me this stent. My inner work has allowed me to constantly pray till the case is done. You know, we're all humans and, you know, I think, you know, for me that has been a source of great strength to tackle and take these cases on. And but, you know, still like I said, Every now and then you would have these cases where the outcome is not good. It affects you as a human. It affects you as a person. It affects you as a physician. It affects you and affects you tremendously. There's a deep sense of loss and there's a deep sense of failure. You know, I'm sure you can relate to this, Dr. Polmaro, that as physicians we are, you know, like my colleague Dr. Hedrick, who's a senior interventionalist, he says we're creatures of habit and our habit is to succeed. So we really get attuned to success and when we meet with failure, it's a very tough emotion to grapple with and you struggle with it. And, you know, like I said at the beginning of the show, it sort of— the cath lab humbles you. The cath lab will humble you. For me, the only way to deal with these emotions is in the form of poetry. And, you know, this compendium or this anthology was put together, you know, when I was transitioning between jobs because I had written but not had the time to actually collate them together. But when I was transitioning jobs, you know, I had some downtime where I thought I could put that to use and put this compendium together.

Can we talk a little bit more about the artwork?

You know, once the poems were written and the emotions were expressed, you know, like I alluded to before, I wanted the words to carry a spiritual meaning and to carry a spiritual message because, you know, in and of itself is not a casual read. It's a pretty heavy read even though it's a collection of 30 poems.

It is. You know, beyond admiring the craft, the message is very deep. I mean, it's for me, I don't know how this is going to resonate with you, but it's right up there with Joni Mitchell lyrics.

Boy, that's, that's a terrific compliment. Thank you for that.

Oh, good. You got that one.

Yeah, no, thank you. So I really wanted the book to carry a spiritual message because I still believe, and when I was putting it together, I believed that the book will find its reader. And it's again coming from a spiritual place in my heart that the words will find people who need them the most at that particular time in their life. So I did want each poem to have a message. a deeper spiritual message from the universe, and I thought that I would convey that with, with art. And so I was looking for an artist. I still follow Ram Dass, the late Richard Alpert. He— I think so, there was an Ojai, California artist who had teamed up with the Love Serve Remember Foundation from Ram Dass and had tried to sort of give an artistic perspective to his teachings. So I really liked his work. And I reached out to him on Instagram, and you know he really liked the idea. He thought that this was novel. He had never done you know something of this sort, so he was really interested. And then I think what happened was, I think he got more work, or he you know he sort of underestimated the amount of time he would require on another project, and then he came back to me saying, "Look, I'm extremely sorry. I know you've been waiting on me, but I don't think this is going to happen because you know I'm really engaged." in another project and I said, you know, I said that's— I was disappointed, no question, but I also said that things happen for a reason and I wanted to, you know, I said, you know, that's fine, don't worry about it, I'll find someone else. And then I went back to the publisher and said, look, the artist really does not have the bandwidth to finish this work, so why don't, you know, we work together to sort of get some illustrations? And then I think a few weeks down the line he contacted me again and said, look, you know, I think I've found someone for you. who would be perfect for this. And it turns out that it was, you know, his wife, and they were going through separation and divorce. And, you know, she had come to know about this work, and because of what was happening, unfortunately happening, you know, in their lives, she felt an instant connection to this work because the profound theme is that of loss. And, you know, she said that she would really love to do this. She's Biana Novas. On the book, on the front page, sort of referenced her name, and if anyone wants to look her up, feel free to. I think she does some incredible artwork. So what she did was beyond my expectations, quite frankly. So she sat down with each poem and she meditated on each poem. So she read it and then she meditated on it. After she was done with her meditative practice on that particular poem, whatever pattern came to her from within, she drew. And she used earthen natural colors to draw these paintings. And so that was the process of the artwork. And then she, I think she converted these watercolor paintings or these earthen color paintings. I don't want to get the technicalities wrong because I know as a technician, if you get the technicalities wrong, that really upsets the other technician. So I want to respect the technician in her. You know, we sat together and sort of came up with the universal messages that we wanted each artwork and each poem to convey.

So underneath the artwork is a lesson, and that was a collaborative effort then, that the lesson under the artwork?

Yes, so the lesson out of the artwork is a collaborative lesson. It was collaborative work and what we came up together, you know, as artists, you know, me being the poet and she being the person who drew the artwork.

I want to thank you for spending time with us today. I'm very taken as to how you and I came to know each other. Thank you again. This is— it's really a terrific bit of work, and all that you do is really so contributory. So thank you.

Oh, thanks again, David. Thank you, Dr. Perlmutter.

Well, I hope you enjoyed our time together today. We went to a very special place, and I'm glad we did. You know, it's not all about facts and figures and how much of this and that we should be eating. It's about meaning in life as well. And so grateful to have had this opportunity. Thanks again for joining me on The Empowering Neurologist, and we will be back soon. Bye for now.