Tuesday, January 23, 2007

Famous Last Words...

He came in at 1 in the morning, and I triaged him. His chief complaint: "Well, my chest kind of hurts, and my girlfriend made me come in." His girlfriend sat next to him, appearing fretful and unhappy. The patient was a 37 year old who appeared to be in general good health.

I was tired. It had been a long shift so far, having been spent sticking IVs into dehydrated babies suffering from GI bugs that have been particularly vicious this year. I was shipping demented elderly people to the floor at a record pace, and the nurses in MedSurg were threatening to form a lynch mob. I was 9 hours into a 12-hour shift that I worked because my opposite has decided to break his leg skiing.

But medical emergencies don't care how tired or busy I am. My triage assessment had to be thorough, and that meant that I had to elicit as much information as possible in order to find out what was really going on. I've been doing this long enough to suspect when a patient was not giving me the whole story, and I could tell that this guy was not being very candid about what was going on. Generally speaking, when a patient evades the questions it is likely that either the patient was doing something he should not have been doing, or he is in denial of an emergent problem. So we went through the sparring ritual at triage, with me probing and he evading while his girlfriend fretted on.

The training that has been pounded into my brain took over as I attempted to classify the patient's chest pain. Is this a heart attack, a pulmonary embolism, a bad gall bladder, gastroesophageal reflux, an anxiety attack, or what? I'm trying to get as much information from the guy as I can, but he is not helping.

The patient's vital signs were stable. He was not sweaty, he was not clutching his chest, and he did not appear anxious. Finally, agitated with her boyriend's evasiveness, the girlfriend could stand nor more. She interrupted him and told me: "His brother had a heart attack when he was 35, and his dad had one when he was 36."

This guy was 37.


In that instant, the lesser possibilities were automatically disqualified and I began to operate on the assumption that this patient was having a heart attack.

Now let me acquaint the reader with a big fat truth. If you have a heart attack, it may not necessarily feel like your textbook heart attack. You know, the elephant on the chest, the sweating, the horrible left-sided chest pain that radiates down the left arm and up into the left jaw. People are all unique. While that's a beautiful altruism, the fact also makes my job a lot more challenging.

I had one patient whose only symptom was a severe case of the hiccups. He was having an acute myocardial infarction (MI). I had another MI patient who simply fainted. I had yet another who had pain in both elbows. Diabetic patients often feel no pain at all (called a "silent MI"). These seemingly innocuous manifestations and vague complaints are why thorough patient assessment will always be at the top of the Challenge-O-Meter.

This is also, of course, is why ER nurses tend to jump all over a patient and stick monitor leads and IV lines in them in a hurry any time someone verbalizes symptoms that trigger our alarms- which is exactly what I did to my patient within 0.5 seconds of his girlfriend's statement.

In the Museum of Famous Last Words, three words are at the center exhibit. Here they are:

"It's probably nothing."

(Hah. I bet you thought it was "Hey, watch this." Those actually run a close second.)

And guess what the patient snapped at his girlfriend when she interjected?

"Stop it! It's probably nothing."

But with his familial history, my suspicion index was going bonkers and I was not about to be caught flatfooted if it turned out to be something. So I unceremoniously took the patient back to a cardiac room (dragging a bewildered ER Tech with me) had the patient strip out of his shirt, and slapped the blood pressure cuff, pulse oximeter, and the cardiac monitor leads on him. The patient shot his girlfriend a "see what you did?" look, but cooperated.

Now, a note on the 5-lead cardiac monitor: In terms of monitoring heart rhythm, the 5-lead monitor is great. But for diagnostics, it's like taking a picture of the Grand Canyon using the camera on your cell phone. It's informative, but not precise. So I ordered the tech to do a 12-lead.

The plot thickened.

The patient had some suspicious aberrations in his inferior-septal EKG tracings. That means that the electrical impulses that travel through the part of his heart containing the SA node (the natural pacemaker) and the AV node (which regulates the ventricular contraction) were not traveling as they should. The artery that supplies these parts of the heart may be occluded, and if that part of the heart dies, the result is a "negative patient outcome" (i.e., death). Furthermore, if that region is affected, the patient may not show classic signs of cardiac injury. Isn't that encouraging?

I know that alot of this is arcane to the reader who is not well-versed in heart attacks. Suffice it to say that I was not reassured in any way after looking at the EKG. Could it be that he was having a heart attack? Maybe. But then again, maybe not. But again the old adage applied: when in doubt, assume that the patient was having a heart attack. I was not reassured at all when I showed the MD the 12-lead, and he became immediately suspicious and got on the phone to the on-call cardiologist right now. Meanwhile, I stuck an IV into him and drew blood for more tests. I tossed 325mg of aspirin down his throat. I put him on 4 liters of oxygen.

With every minute that passed waiting for lab results, the patient became more and more impatient. And he was still not communicating his symptoms. We found out that the patient was again having chest pain only because his girlfriend came out and told us. When she did, the MD and I rushed in. I did another 12-lead EKG and as it spit out the results, the top of the page had this:

************************************* ACUTE MI **************************************

I was not reassured.

The cardiologist arrived and reviewed both EKG results with the MD, and then strode into the patient's room and informed him that he was going to be admitted to the CCU and would be going to the Cath Lab for angiography.

"Oh, no I'm not! I have to be at a meeting in the morning."

"Sir, you are having a heart attack."

"I feel fine. You don't understand- I have to be at this meeting. My business depends on it. It's not an option."

"No, sir, you don't understand." The MD countered. If we don't fix this problem right now, you will probably miss your meeting anyway because you will be dead.

The patient opened his mouth to say something to the MD, thought otherwise, and then turned on his girlfriend. "Thanks a lot! None of this would have happened if you'd have just SHUT UP!"

"I don't want you to die," she answered weakly.

"I'm not going to die! I'm FINE!" The patient turned on the ER MD. "You can't keep me here if I don't want to be here."

"That's true."

"I don't want to be here. Take this stuff off of me NOW. I'm leaving."

The girlfriend stood and declared, "If you leave you'll be walking home, because I won't drive you."

"FINE!" the patient roared. I caught the girlfriend's attention and motioned her out of the room and into the waiting area. She turned to me with tears in her eyes.

"I don't believe him! He's in total denial of this. How can he be so stupid?"

"I can't explain his attitude; but I can say that bringing him in was a wise choice on your part. Right now, the most important thing is to keep him calm. Getting angry is the worst thing he could do. How well do you know him?"

"I've been with him for a little over a year."

"Is he under any stress?"

The woman threw her arms up and said, "Oh, yeah! He works two jobs: He owns his own construction company but he's also the top loan officer for a mortgage company. He's their Golden Goose. He works constantly, and he never lets up." She paused, then added: "He has a lot riding on that meeting. Could he really die if he goes home?"

"Yes, he could."

"If he could possibly die, can't you keep him without his consent?"

"Not in this case, no."

"I have to talk him out of leaving," she concluded. I put both hands up.

"No, ma'am. Right now, we need to get him calm. Can I offer a suggestion?"

"Sure. I'm all out of ideas with him."

"Just have a seat in the waiting room for a little while. Let me get you something to drink. Getting away from the room will help both of you to calm down right now. Do you agree?"


I heard commotion in the treatment area, and a lot of feet. I excused myself and rushed to the patient's room to find him ashen, sweaty, and limp. His monitor showed a disorganized and slow rhythm. He was in full heart block, meaning that the connection between his SA node and AV node had been completely severed by the injury to his heart.

Oh, crap.

I joined the rest of the code team and slapped the pacer pads onto the patient, hooking it up to the defibrillator. The MD ordered sedation, which another nurse was in the process of giving. As the patient slipped out of consciousness, he slurred, "Stop it. I'm fine."

The MD looked at me and rolled his eyes. "Famous last words."

After the patient was unconscious, we managed to "capture" his heart and pace its rhythm. His vital signs began to stabilize, and we all started to breathe again. I prepared the patient for transfer to the Cath lab and gave report to the receiving nurse.

As the Cath lab team pushed the stretcher down the hall, I turned and found the girlfriend beside me.

"I'm sorry I couldn't come get you sooner," I said. "Are you going to be okay?"

She sighed. "Yeah. I'm glad it happened this way. Is that wrong?"

"Well, for what it's worth, I would rather he did it here than at home."

The woman paused and then asked: "Is it my fault that he got upset and his heart attack got worse?" She lowered her head and looked at the floor.

I turned to face her and told her, "Look at me." When she met my gaze, I continued: "Consider the possibilities. What if you had not brought him here? Upset or not, it's likely that if he was not here, he might be dead right now. So you tell me: was bringing him in worth making him upset?"
"Yes," She replied. She began to cry. "He's never snapped at me before like that."

"I can't give you an answer for why he did," I said, handing her a box of Kleenex. "You know him better than I do. But I've seen alot of people who come in with heart attacks who refuse to believe it even when they can hardly breathe and the staff is swarming them. It is a frightening thing to face, and people respond to the prospect of mortality in their own ways."

I then asked, "Would you like to go to the Catheter Lab waiting room and wait for him there?"

"I'll go there. How long will it take?"

"Maybe a half hour to an hour. I'll call over so the team will be expecting you, and I'll have one of our Techs walk you over there. I have to finish charting, so I'll say goodnight now."

She extended her hand. "Thank you. You all were very good with him."

"It's our pleasure. Try to get some rest, Okay?"


I found an available Tech to escort the woman to the Cath Lab and turned to the arduous business of documentation so that I could run the chart over to Cath Lab quickly. As I sat down, I looked up at my watch: two hours more, and I would be off. I stretched, yawned a long and obnoxious yawn, and set to work.