By BirdStrike M.D.
I’m sitting in my apartment on the West Coast starving, listening to my stomach growl, waiting for my pizza to be delivered. It is taking unacceptably long. I’m going back and forth on how little I can tip the pizza delivery man without feeling too guilty to actually enjoy the pizza if and when it ever arrives. There’s a knock on the door. Thank God, I think to myself, it’s about time.
I open the door, “Pizza’s here,” says the pizza man. “You’re the best doctor in the world!”
“What?” I say. “Yeah, the doorman says you RULE! He said if I ever need to get checked out, to go see you. He says, ‘You da man!’”
“Oh, that’s just Tony the doorman,” I say shaking my head. “Don’t listen to him. He says that all the time.”
I pick up a chart in the ER, back when there still were things called “charts”, and it says: “Tony ***** 37-year-old male. Chief Complaint: Back Pain.” I walk in the room and it is Tony the doorman of my apartment building, nervous, sweaty and pacing the room, with his jet-black hair slicked back and his gut as huge as always.
“Tony! How are you doing? Good to see you. What brings you in here, today?”
“Doc. You gotta’ do somethin’. My back’s killin’ me. I’m dyin’ here,” he says in his tough-guy accent, as he nervously paces the room.
“Where does it hurt?” I ask.
“Right here,” he says, pointing to his upper back, “right between da shoulder blades.”
“When did it start?” I ask.
“Just a couple hours ago. I didn’t do nuttin’. I was just sittin’ there and it hit me like a ton of bricks. I didn’t fall, lift anything heavy or hurt myself at all. I’m dyin’ here doc. You gotta help me. I need something for this pain,” says Tony.
“What does it feel like?” I ask.
“It feels like someone’s got a sledge-hammer on my back. Seriously, man. I’m dyin’ here. Come on. Do something doc. Make this pain go away. I need something for this pain. Please.”
“Is there anything that makes it any better? Anything that makes it hurt worse?” I ask.
“Nope,” he says.
“Does the pain move? Does it radiate?” I ask.
“No,” he says, “it’s just right there in da middle of my back?”
“By chance, is it a ‘tearing pain’ right between your shoulder blades?” I ask.
“Not really,” he says, “it just hurts!”
My gut is telling me that something is not as it appears. I have the nurse give Tony a dose of Morphine while I continue to get the history. Tony proceeds to tell me that he doesn’t drink, smoke or use any illegal or prescription drugs. Also, he reports no significant medical problems, and no significant family history. He also denies any history of chronic pain of any kind. His physical exam is completely normal including his vital signs with equal blood pressures in both arms.
“Alright, Tony, the nurse is going to give you another dose of the pain medication. We’re going to get a chest x-ray and see what that shows. I’ll be back in a few minutes,” I tell him. My gut is telling me, that there is something Tony is not telling me, but my brain is telling me that if Tony’s upper midline back pain is from a thoracic aortic dissection, and he dies from it, I’ll never forgive myself.
“Doc, it’s starting to hurt right here,” Tony says, pointing to his chest.
Bingo, I tell myself, it’s IS a dissection. I order a CT of the chest with IV contrast, d-dimer, basic labs and cardiac enzymes. Wait! His EKG? Did we do an EKG? I ask myself. I honestly can’t remember at this point. I could have sworn I looked at one and it was normal. They wheel him off to CT and I go pull up his chest x-ray. It’s normal; painfully normal. I walk over to the CT suite to look at the images as they load onto the screen and to take another look at his chart to see whether or not I had looked at an EKG. There it is, on the chart. It is in fact, completely, stone-cold normal. I breathe a slight sigh of relief. I watch as the cross sections load on the computer screen. His aorta looks as normal as can be. I’m not a radiologist, but I can usually spot a big tearing aortic dissection on a well done CT scan, and this one looks perfect. Of course it does.
I turn the corner to the main ED, and I’m hit with the all too familiar sound and smell of ambulance sirens and exhaust blasting through the double doors, monitor alarms frantically beeping, patients crying, doctors and nurses sighing.
“Tony, all of your tests came back perfectly normal. I honestly cannot tell you what is causing this pain, at this point,” I explain. I know exactly what’s causing this pain, I think to myself. “It’s probably nothing serious. Most likely it is musculoskeletal back pain or some acid reflux causing esophageal spasms. I think we’ve ruled out most of the ‘bad stuff’, however, it is concerning that this pain is so severe, especially since it is in your chest. The chance of this being a heart attack is extremely low, statistically, but I’d like to keep you in the hospital overnight. It’s just a precaution. You’re only 37 years old, you really don’t have much in the way of risk factors for heart disease, but you know what, I’d just feel better if we watched you overnight. Is that alright?”
“Doc. I need some more of that pain medicine,” says Tony.
Just then Melba, an old battle-axe ER nurse who I would shutter to ever run into in a dark alley, decides upon herself to start doing another EKG.
“Melba, we don’t need another EKG. Why are you doing another EKG? The first one was completely normal. We’re just going to give him some aspirin, nitro-paste, another dose of morphine and get him admitted. Cancel the repeat EKG. Okay? Stop,” I bark at her. Ignoring me completely, she shoots me with a glance from her evil Melba eyes and peels the EKG off the machine and flings it at me. I look at it: T O M B S T O N E S . Uh-oh. We went from a totally normal EKG, to a massive acute myocardial infarction, in a 37-year-old male with no practically no risk factors. Wow. Tony is dying.
“Tony, you alright?” I ask, as his face drains white. “Melba, put the pads on him,” I order. His eyes drift off, and his head slumps to the side. Tony’s dead. “Oh, sh–! V-Fib. Get the pads on him now! Gimme the paddles now! Charging. Everyone clear?!”
After 10 seconds of V-fib, and with a massive jolt of electricity directly through his heart, he is now back in normal rhythm. Tony’s alive. Thank God.
Off to the cath-lab goes Tony and there I stand scratching my head thinking, how in the world could I have been so wrong about this guy? I had him pegged as wanting nothing but morphine and he’s burning up myocardium. Geez. I could have seen myself sending this guy home with little or no work up. A 37-year old male? Back pain? No cardiac risk factors? Acute MI with a normal EKG on presentation? Holy crap! I almost missed it. If I had sent him home, he’d be dead!
A few weeks later, I’m practically falling asleep while walking into my apartment lobby at 8 am after the first of several night shifts. There’s Tony, back at his doorman post. I duck down and head toward the stairs trying to sneak by unnoticed, feeling like a complete idiot at having almost misdiagnosed his heart attack. “Doc! Get over here! Now!” screams Tony. I stop. I’m busted.
Tony runs over and surprises me with a M A S S I V E chest bump with his huge gut almost knocking me over and then follows it up with a huge bear hug. “You saved my life. You saved my life! You’re the best doctor in the world. I was having a heart attack. Can you believe it?! I was having a HEART ATTACK!”
“No, I can’t, I mean uh, yes actually I knew it from the minute you walked in the door. Yes. Thanks. I’m glad you are not dea….I mean I’m glad you are doing so well,” I say.
“I’m gonna tell everyone you da’ man! I’m gonna send EVERYONE to the ER to see you, doc!” he yells.
“No, please don’t do that….I’m mean, thanks, but I’m an ER doctor, and I don’t really have my own office, and you know it’s really busy there and we don’t need any more patients. Uh, I mean…you know what I mean, don’t you? But thanks, really, I’m glad everything turned out all right,” I stammer.
“I’ve never felt better in my life. Thanks again, doc,” he says.
Tony worked the door at my apartment for two years after that and suffered no ill effects from his heart attack. Then one day Tony didn’t show up to work. No one seemed to know if he quit, moved, got fired, or where he went. But for those 2 years Tony the doorman told every single relative of mine, pizza man, friend, paper boy, mail man, or random stranger in the lobby that I saved his life and that I was the best doctor in the world. I couldn’t believe it. I thought he would do it for a few weeks and forget about it, but he never did. Every chance he got for the 2 years that he worked there, he would loudly and proudly announce to everyone he could, that I saved his life. As you can probably imagine, it is not rare to save a life in the ER. However, to actually have someone go out of their way to thank the ER doctor and nurse who saved that life is rare. For whatever reason, Tony did his absolute best to say thanks not only for himself, but for everyone else that either just didn’t think to say it, or was too busy, sick, tired or stressed to do so. I don’t know where Tony the doorman is today, or if I’ll ever see him again, but if I do there’s one thing I’d like to tell him: “Tony, thanks for saying thanks.”
This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional. Any opinions expressed here are of the author alone and not those of epmontly or WhiteCoat.