A stoic man in his early 60s walked up to the registration window and even the registration clerk could tell that something wasn’t right. He looked sallow and was a little sweaty. The clerk asked him what was wrong and he calmly said “chest pain.”
He was whisked back to a treatment room to begin the standard chest pain protocols. We could still smell the remnants of that last drag he took off his cigarette before walking in the hospital doors and flicking the cigarette butt onto the parking lot. A pack of Pall Malls abutted his heart in his left front shirt pocket.
As we questioned him, we learned that he had been having the pain on and off for more than a week. Only that morning did the pain become constant. He sat at home for 9 hours going about his business and hoping that the pain would go away.
It didn’t.
He didn’t like going to doctors. In fact, he hadn’t seen a doctor in more than 20 years. Wouldn’t have come that day had his daughter not nagged him so much about it. He came to the hospital more to stop her from nagging than he did because of the pain. The pains actually felt like “gas” and he was burping a lot.
His physical exam didn’t tell us much. I told him I needed to check a rectal exam for bleeding. His daughter stood up to excuse herself.
“Ain’t no doctor done that in more than 60 years, and you ain’t going to be the first. There’s no blood there.”
“But if it’s an ulcer or intestinal bleeding, I may have difficulty diagnosing it.”
“There’s no blood there,” he repeated.
Our hopes that the pain was just some indigestion were short-lived. The EKG showed that he was having the “big one.” Significant ST elevation in all the anterior leads.
As I walked into the room to inform them about the diagnosis, the patient was leaning back on the bed with his eyes closed and his daughter was chomping on her thumb nail.
“It looks like you’re having a heart attack,” I said calmly.
His daughter immediately started crying. “I told you that you should have come in sooner.”
“Don’t worry about me,” he replied. “Only the good die young.”
“We’re the only ones left. We have to take care of each other.”
I interrupted.
“We don’t have the ability to do a cardiac catheterization here, so we’ll need to fly you to the closest cardiology center.”
Tears streamed down the daughter’s face. The patient just laid his head back and closed his eyes.
I spoke with the cardiologist on call at the referral center. Normally the arrival time for the helicopter is about 30 minutes. This time, the helicopter was out on another run, so it wouldn’t even get to our hospital for another 60 minutes.
Sixty long minutes.
The cardiologist suggested that we give thrombolytics.
“You realize that the pain has been stuttering all week and that it has been constant for the past 9+ hours, right?”
“Thrombolytics are OK. They will save some muscle even if they are given a little late.”
Nothing else we were doing was helping the pain. The patient just sat there with his eyes closed. I couldn’t tell whether the beads of sweat on his forehead were because of his pain or because he was scared. We gave him morphine several times, but the pain didn’t improve. We gave him beta blockers. Still no improvement. Nitroglycerin … nothing. OK, we’ll give the thrombolytics. What can they hurt?
I went about seeing other patients in the ED, but poked my head in the room frequently to see how the patient was doing.
“Pain’s still a seven, doc,” he said.
Fifteen minutes later the pain was still at a “seven.” A repeat EKG still showed the “tombstone” pattern in the anterior leads.
“Let’s start the thrombolytics,” I said.
As the labs trickled back, we got several phone calls for critical lab values.
“His CPK is 3150.”
Ten minutes later we learned that his MB fraction came in just shy of triple digits when it should be less than five.
Five minutes after that, the phone rang again.
“Leg me guess, troponin is also elevated,” I said without even saying “hello.”
“Yup – 73 with upper limit of normal being 0.3.”
I looked through the curtains and the patient mentioned that his left shoulder was starting to hurt. Great. He’s having an MI and a dissection or something. We gave him some more morphine and repeated a CXR and EKG. No change.
Forty minutes had come and gone. Still no helicopter. The daughter was at the desk asking what was taking so long. Good question. We called the transport team connection center.
“They’re five minutes out.”
Five long minutes.
We could hear the helicopter circling the hospital. I was one of several people who breathed a sigh of relief.
The team strode into the room and hooked the patient up to their monitor. One of the nurses raised his eyebrows as the blips showed up on his monitor screen.
“We’ve thrown everything at him and nothing’s helped,” I mentioned.
“Guess not,” he said.
Another five minutes and the security guard was escorting the transport team back up to the helicopter pad with their new cargo.
As they rolled by, I quipped “No backseat driving up there, you hear?”
The patient didn’t say anything in response. He still looked pasty two hours into this visit.
We heard the helicopter lift off the pad. Thirty seconds later, it sounded like the helicopter came back down and landed again.
The security guard called us on his portable phone. “We need the doctor up here now.”
I ran up several flights of stairs and burst onto the helicopter pad. The side door to the helicopter was open and the nurse was doing CPR. I ran over to the patient. No pulse.
“Get him back downstairs now!” I yelled over the helicopter engine.
Then I heard a scream from below the helicopter pad. I looked down to see the patient’s daughter standing in the middle of the street next to her running car. The driver’s door was open and she was blocking traffic.
“What is happening?”
I pointed to my ears and shook my head.
“WHAT … IS … HAPPENING?”
I shrugged my shoulders and mouthed the words “I don’t know” then ran back down to the ED.
“The patient’s coding,” I told the nurses. They pulled out the crash cart and rolled it into the room that they had just finished cleaning.
The patient had complained of severe shoulder pain just before the helicopter lifted off. They gave him some more morphine. Immediately afterwards, the patient vomited and went unconscious.
Despite all the stress, the code went very smoothly. The patient was in pulseless electrical activity. Running through the differential list, we opened up the IV fluids and I even performed a pericardiocentesis.
It worked!
The patient regained a pulse … for a few seconds. Then he was right back into PEA.
A repeat pericardiocentesis did nothing.
After 25 minutes of trying to cheat death, we resigned ourselves to the fact that death had won.
Time of death: 4:50 PM.
The patient’s daughter was devastated. She blamed herself for not getting her father to the hospital sooner. Now there was no one left but her.
The transport team was equally devastated. They blamed themselves for not getting to the hospital sooner. If only they hadn’t been delayed on the other call. In reality, the only difference it would have made is which helipad the patient would have died upon.
The staff in the ED was crushed. It’s sad when any patient dies, but for someone to walk into your department, interact with you for a while, and then die … words can’t describe the empty feelings you experience.
What if …?
“Hey, you remember that patient …,” the coroner said to me about 3 weeks later.
“Which patient?” I asked with a blank stare.
“You know, the guy who died in the helicopter.”
“Sure. Patients like that are tough to forget.”
“Well his autopsy showed that he ruptured the entire wall of his left ventricle. There’s nothing anyone could have done to save him.”
Still doesn’t make the feelings go away.
What if …?
Healthcare Roundup 8/27/09
Thursday, August 27th, 2009Want to get more stressed out than an ED physician? Take a job as an immigration judge. According to this San Jose Mercury News article, immigration judges decided 1600 cases last year compared with federal judges who have 350 cases on their agenda at any given time. There’s a push for the immigration judges to hear even more cases to erase backlogs. One judge who retired last year said that “the bean counters have taken over” and that his stress disappeared quickly once he retired.
A NY Times article compares health care in the US to health care in Japan. Why are Japanese patients so much healthier at a lower cost?
A Canadian patient with depression, alcoholism and hypertension who did not have a primary care physician dies after waiting for three days on an emergency department stretcher. The Quebec coroner wants to know why.
Newest drugs of abuse: ADHD medications. ADHD medication prescriptions increased from 4 million to 8 million bewteen 1998 and 2005. The number of calls to poison control centers about teens abusing ADHD drugs such as methylphenidate increased by 76%. Kids are using these medications to lose weight and to get high – sometimes grinding the pills and snorting them, sometimes dissolving the pills in water and injecting them.
Scary that the House of God has been around for 30 years. This NY Times article gives an interesting look at the author Stephen Bergman (AKA Samuel Shem) and the fallout from his book.
Violence in the ED continues:
A young jail inmate was brought to the ED and became upset. When the nurse told her not to swear, the inmate slapped her in the face, spit in her eyes and tried to hit her several additional times. Now she’s facing another 6 years in the Greybar Motel.
A Washington State ED had a shootout between a head injured man and police. The police confiscated two handguns but missed the third gun. When the patient pulled the gun out, police shot him dead.
Lots of articles about health care for illegal immigrants lately
One article mentions several cases about care provided to illegal immigrants under EMTALA laws
Another article states that illegal immigrants “underconsume” health care – representing only 10% of the population but consuming “only” 8% of the health care services (i.e. only about $120-$160 billion per year).
Then President Obama goes on record saying that illegal immigrants won’t receive free health care, but he also states that they’re not going to be covered under the federal health plan. That apparently leaves hospitals stuck paying for any treatment rendered to illegal immigrants. Fair?
Here’s the “spin” on costs of care for illegal immigrants – literally. American citizens on hemodialysis automatically qualify for Medicare and to pay for their dialysis treatment. Illegal immigrants aren’t eligible for Medicare, though. This article shows how Las Vegas’ University Medical Center spends more than $2 million per month providing just dialysis services to illegal immigrants alone. Costs for each emergency visit run between $11,000 and $18,000 and are almost 4 times higher when done through the emergency department.
One way to decrease the number of ambulance diversions is for paramedics to refuse the diversion. Such a policy in Tulsa and Oklahoma City reduced ambulance diversions to zero for the past four months.
The Department of Veterans Affairs is apparently facing numerous lawsuits for such things as infecting veterans with unsanitary equipment, botching 92 out of 116 attempts at prostate cancer treatment, and notifying more than 1,000 veterans that they had Lou Gehrig’s disease when they really didn’t. There are also allegations of coverups and alterations of medical records once the prostate cancer misadventures were discovered. Be interesting to see the outcome of these cases.
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