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 …?
What if that man had given a damn about his own health or the well-being of his daughter?
Not your fault, WC.
Thanks.
From a medical perspective, I know that.
Still doesn’t always make the human side of medicine any easier.
Rupture of an MI indicates an MI that is usually a week to ten days old. Could have been early as 3 days, but that’s unlikely. You guys were a week late, putting you firmly in “you can lead a horse” territory.
So sorry for all involved.
[...] A Broken Heart | WhiteCoat's Call Room http://www.epmonthly.com/whitecoat/2009/08/a-broken-heart – view page – cached 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 — From the page [...]
A somber start to the week.
My husband had an MI at 47 years of age. He also c/o intermittent chest pain for actually several weeks prior. He was seen by a cardiologist and given tests, all of which came back normal. Finally, the chest pain became constant but it was two days before he told me.
He ended up having a quadruple bypass. He’s doing very well now, but those lifestyle changes are slow to take root. He’s 49 now, thank God.
That is indeed a sad story, and my condolences to you, your staff, and the daughter.
But as someone knowing I am going to die, his death doesn’t sound that bad. He was able to control his life, in spite of an MI, up to the last few hours, and at that point he did suffer, but it was only a short time. If he’d had his way, he might have died at home, which he might have preferred. It’s hard to say whether the morphine and other relief you offered outweighs the loss of calling the shots for yourself, but of course, at the point the decision to go to the hospital was made, no one could know the final outcome. If he had been treatable, you might have restored him to several more years of quality life.
I’m not afraid of death. I’m terribly worried about pain and suffering, and hope that I will be able to go quickly when my time comes. I’ve seen too much suffering that comes with a lingering death.
I pray that God will let me pass away peacefully in my sleep with no warning, and if not, that He will give me the grace and strength of character to endure whatever my final lot is.
Wow, this one got me. If it was a factual account, heart-breaking, if fiction, excellent writing WC.
Definitely factual. I even saved the two copies of his chest x-rays. One with a normal sized-heart and one with a slightly larger heart. Still wonder “what if” some days.
Careful WC, I’m sure Matt will be by soon to quote you as an expert who disagrees with the care you provided since you wonder “what if”.
But from another pit doc – there are times medicine just sucks. This is one of those. Sorry that happened to you man.
Emblematic of why healthcare is so outrageous and expensive in this country with reletively poor outcomes. We are willing risk and spend to send a helicopter crew to try and save a guy who is not too concerned about himself and has a poor prognosis.
Agreed. If you asked him if he wanted the helicoper or to die, he probably would’ve said die.
Who are we to judge.
True that his prognosis was poor in retrospect, but we had no idea of his impending cardiac rupture while he was in the ED.
Another part of the problem – where do we draw the line between someone who is triaged as a “red” and someone triaged as a “black”?
I hope to die peacefully in my sleep like Uncle Jim, not screaming in terror like the passengers in his car.
Incredibly sad for all involved. Sure, he didn’t take care of his health, and he’s to blame for not seeking medical help sooner. But, he sounds like a man who didn’t want to be a burden or bother to anyone. He wanted to live his life the way he always had. That makes it sadder for his daughter, who’s now alone. I hope she finds peace.
Excellent storytelling, WC. The emotions jumped off the screen.
Great story. Tragic.
Wait … the story’s not over until Counselor Matt weighs in.
I am so sorry. I witnessed a massive coronary and talk about helpless!! When people are stubborn about what they feel and what they will do about it,oy!
This friend had a history of a triple bypass. He never said he didn’t feel good but, looking back, I should have known. At lunch, he stood up and said he felt sick. Ashen, he turned and fell to the floor. CPR…useless. Dead as he hit the floor.
Maybe on the way to the ER, he told her he loved her and was sorry. Hopefully, she will learn that info and be able to forgive herself.
Long time reader.
I am a 4th year medical student and I had to share a similar experience. Some time ago, I was on my rural rotation in a town just large enough for a hospital with a small 2 room ER. This was my first month as a fourth year and I was living in the hospital for that month.
A ~70 yo patient arrived by private vehicle with right sided weakness, hemineglect, unable to speak. He was still responsive to his name and could follow some basic instructions. He kept looking at me in the eyes and pulling at my stethoscope while I assessed him like he was trying to tell me something. The radiology and lab techs had to come from home which took about 10 minutes. During the time I learned that the patient was on coumadin and had a recent adjustment upwards on his dosage.
CT showed a big left sided intracranial hemorrhage and his INR was ~7 (normal = 1). When he got back to the room he became more and more unresponsive until painful stimuli wouldn’t even arouse him. It was the first time I saw a patient decline so quickly before my eyes. We had him airlifted out to a larger center with a neurosurgeon on call. He died shortly after arriving to the larger hospital, just in time for his family to arrive by car.
My “What ifs?” are plentiful. What if we reversed his INR sooner based on clinical suspicion? What if we had tech’s in the hospital at the time and got the results back just a little earlier? I’m 99% sure the outcome would have been the same, but that 1% of doubt is hard. Especially after interacting with him and his wife.
nothing would matter, yet we spend millions of dollars as if it did.
sweating + sallow + chest pain = ekg first, worry about physical (let alone rectal) exam way, way later.
Things like lines, labs, EKG, and physical exam in our shop tend to happen in parallel, not in series, but maybe that’s just us.
Social history and informed consent for rectal examination before getting an ECG in a sick lookin’ old smoker with chest pain? A helicopter bounceback? A pericardiocentesis after thrombolytics?
That is a weird case.
In the ERs I rotated through, EKGs weren’t instantaneous. it usually took 5-10 minutes for the EKG tech to arrive and perform the EKG. in the meantime, someone (usually me as an MS3/4) would get some more of the history and physical.
it wouldn’t surprise if that happened here…place the EKG order and continue the workup while you wait for it to happen.
I have had too many of these cases to count, some still haunt me. Last one being 2 weeks ago. My condolences WC.
On another note, who is this other “cynic” dood.
I don’t think you are the only cynic
This post had my heart going. We are so lucky where I am. I had a dear friend that had a MI at 42, he was cathed and saved right there at one hospital. Three blockages. He said the pain was the worst kind of pain you can possibly imagine. I’m sorry this was a hard one for all, WC.
Your comment reminds me of this:
http://www-rohan.sdsu.edu/dept/press/2001pi4/marcus.html
The EKG was probably being set up at the time. Rectal exam is actually a great idea if you’re planning on giving heparin or tPA, which I’m sure WhiteCoat was. All that stuff happens at the same time, monitors are not instantaneous and neither are EKGs.
Only on the l’il test with the l’il boxes is ‘the next best step’ a) EKG or b) rectal as if it happens one after the other.
Well written.
You’re sure WC was planning on giving heparin or tPA before he even saw the ECG? Really?
Personally, I prefer to see the ECG first.
wow! that was some story. sad, and compelling.
Sad. Reminded me of the death of Arthur “Killer” Kane, of the New York Dolls. From Wikipedia: “On July 13, 2004, just 22 days after the reunion concert, Kane thought he had caught the flu in London, and checked himself in to a Los Angeles emergency room, complaining of fatigue. He was quickly diagnosed with leukemia, and died within two hours.” So he walked into the ED and died two hours later of cancer. Memorably covered in the film “New York Doll” (on IMDB at http://www.imdb.com/title/tt0436629/).
TGT
wow. tears. i can imagine the anxiety.
sending empathy
I remember the first patient that I had that actually “died” in the back of my rig. Not dead on arrival, but actually started alive and ended up dead. 93 yo female. We couldn’t get the pacer to keep capture. Not far enough down to start ACLS per protocol, but to far up to work as a code. I wondered for a month if there was something I could have done different….