His Failing Heart

JVD is an anachronym for jugular venous distention, a phenomenon I observed Friday for the very first time outside a classroom. It's one sign of a failing heart, a heart that has virtually worn itself out pumping against the unrelenting resistance of untreated high blood pressure. Besides the accumulation of fluid in the lungs -- pulmonary edema -- which leads to shortness of breath, with heart failure the jugular vein becomes distended and you can literally see the pulse throbbing away, driving the rhythm of circulation like a drummer's foot on the bass pedal. Boom, boom, boom.

For clarity's sake, we aren't talking oxygenated blood here, the bright purplish juice of life that shoots out the left ventricle into the aorta. Nor is JVD the same thing as an aortic aneurysm. You've heard of those, I'm sure. An expansion of the artery in all directions forming a cul-de-sac typically (though not exclusively) in the gut with two openings, an entrance and an exit, instead of just one. As long as it stays intact, blood can make its way from the heart to the toes and back again. If it begins to leak or worse, if it blows, you get a STAT ticket to the surgical suite.  

The blood carried by the jugular vein is deoxygenated -- it's already given up its cargo of oxygen molecules in the name of everything that constitutes daily life. On its way to the lungs for more, however, it runs into a problem. Heart failure starts out with an overworked left ventricle but as it progresses, the right ventricle slowly turns into an anatomic approximation of a child's balloon that has been inflated a few times too many. Having lost much of its elasticity, the right ventricle can't pump as well and back pressure builds in the veins above it; naturally, they distend with the volume of blood waiting in the queue.

I'd read about JVD, but reading is one thing, seeing it up close, is another. I watched my resident turn our patient's neck to the left in order to tighten the skin on the right, then watched wide-eyed as his neck bulged outward every half-second. I'd been talking with him for fifteen minutes -- how could I have missed seeing it before? As must have been the case with my entering classmates when they were in my shoes, my mind raced through a litany of possible explanations, while I waited for the end of the day when we'd finally have a free moment to recap. I was glad my first best guess was the correct one.

Yesterday, going over material for board exams, I thought about my patient's physiology, why he was short of breath, why he gained excess weight in water only to lose it when he took his diuretic medication, why just sitting there talking with me was an effort. He was a good teacher who taught his lessons well. But I also thought about him, his experience, what it meant for him to retain his driver's license, why he was so determined to hold tight to his independence and live like there was no tomorrow. Why he continued to have heart. Despite his failing heart.

(GNU Free Documentation Image via Wikipedia)