Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (5 page)

“I don't know,” the nurse said, leaning over him, “but by any chance did you see a light at the end of a tunnel?”

But this is about the farmer's wife and the farmer. They were both very nice people and the daughter, who was with them, seemed very pleasant as well. The wife was my patient; she seemed like the kind of woman who became nervous when she wasn't cleaning. Sixty-four years old, according to the chart. She was overweight, of course, old Germanic stock, but otherwise healthy. Here with chest pain on a sleepy Sunday afternoon. So far I had seen mostly ankle sprains and mosquito bites.

“How would you describe the pain?” I asked and she paused for a moment, stumped.

People work very hard at describing their pain and can sometimes come up with strange, creative results. “It's a sort of rushing, gurgling pain.” “It's a whooshing pain.” “It's a kind of dry, sparkly pain.” Other people don't have any kind of vocabulary to describe how they feel; they grope around even longer and come up with the (not uncommon) response, “It's a hurtin' kind of pain,” which of course takes you nowhere but is the best that they can do.

“Well,” she replied, “it's not really pain…” She groped for the right word while one hand hovered over her left chest. Finally she came up with a “pushing feeling.” I stood wondering what this really meant when she made it easier by saying, “Sometimes it's like an elephant sitting on my chest.”

“Sometimes?” I said.

“Like if I'm vacuuming or something. If I sit down it goes away.”

“Do you have any pain now?”

“No, not now. I feel better. I think I can just go home. The pain's gone.”

On the patient's right was her husband, on her left was, I presumed, her adult daughter. They stood humbly in the background, husband with his arms folded, daughter with hands clasped as they waited on the story.

“How long have you been having this elephant stuff?”

“About, well, for about a month now.”

The husband came forward. “You didn't tell me anything about this.”

Actually, it became clear, it was more like six months. At first the pain just came with exertion, but recently it had come on even with rest. She had been in to see her gynecologist two days ago and had mentioned it to him. He called another doctor, who wanted to put her in the hospital right away, but she really didn't feel that bad, she thought, and she hadn't had any pain for the last week or so (deny, deny), so she decided to go home. That was Friday. Today she had begun to feel the pain again, so she thought maybe she should come in just to make sure everything was okay.

“Everything was okay.” That was the key. She didn't want to know what was wrong. She wanted me to tell her that everything was okay.

I finished the history and examined her. In her favor: she didn't smoke, drink heavily or have a strong family history of heart disease. On the other hand, she had never had her cholesterol checked and she had been overweight for years. Nothing on exam. Normal heart, normal lungs. Pulses normal throughout. Even so, the symptoms were classic. The patient had unstable angina, most likely due to coronary artery disease.

“I'm going to put you in the hospital,” I told her.

She started. “You haven't even done any blood tests.”

“It doesn't matter what the blood tests show,” I said. “You have a very good chance of having heart disease, significant heart disease. You need to be in the hospital.”

“There is no way,” she said. “I have laundry at home in the dryer.”

As I rolled my eyes, the husband came forward. “Now, Mother,” he said. “Don't argue.” He laid his hand on her shoulder and gave her a gentle shake. “You've got to listen to the doctor.”

“You know if I leave it all night it'll do nothing but wrinkle.” She turned back to me. “What if the tests are all normal?”

“The tests can be all normal and you can still have heart disease. Even if they
are
normal, I will recommend that you stay.”

She looked around at her daughter and then at her husband. “That's impossible. Who's going to feed the cat?”

“I'll feed Binky,” the husband said.

“You don't even know where I put the cat food.”

“Mom,” the daughter said kindly, “shut up.”

The woman shook her head. Her face was set, but I could see she felt that by being ill she was betraying the two people beside her. They were her life.

Carolyn was standing behind the daughter with the ECG machine. “Hel-
lo
,” she said loudly. “You know, when someone has chest pain it is important to get an ECG, and we're not going TO get an ECG until you all move out of the way.”

I took the woman's hand in mind and said, “You're going to be fine, dear. You are going to be very okay. I promise.”

Carolyn shouldered the daughter out of the way, scowling at the family and at me. Carolyn was one of my favorite nurses. She was a brusque, no-nonsense kind of person—worse than me, even. On a bad day she could generate more patient complaints than anyone I knew, mostly by being crusty and blunt. (One patient referred to her as the “ER Gestapo.”) But she was always there, always working, technically brilliant. If you ever needed an IV on a crashing patient or a deft hand with drugs, it was Carolyn who could deliver.

Now at the bedside, she pulled out a packet of ECG leads and began stripping them off one by one and sticking them on the woman's arms, legs and chest. Carolyn had been doing this for—how long? Fifteen years, maybe twenty. She stood over the woman applying electrode leads with infinite grace; no hesitations, no wasted motions. This is where trouble always starts on the TV shows about medicine; actors just can't quite get the rhythm down. The TV doctors fumble with their gloves, whereas the real doctors pull them on, one, two, with no wasted motion and a snap of a cuff as punctuation. There is magic to these practice moves—they have been worn smooth like a stone polished by water.

I crossed over and stood behind Carolyn, watching the wavering baseline finally settle out on the ECG. Heart rate 92; normal ECG.

“That's good, isn't it?” the woman said.

“Very good,” I said and went back to squeeze her hand again. “You're going to be fine.”

I turned, studying the ECG printout as I walked away. I had taken exactly two steps when Carolyn said sharply,
“Doctor!”

I had several complicated thoughts as I paused, one foot still in the air.
Doctor!
Carolyn and I had been on a first-name basis for a long time. There were only two reasons why she would call me “Doctor!” One: she was angry at me. (This is a dead giveaway to watch your step. Nurses can make the word
Doctor
sound positively scatological.) Two: she was frightened. Now I was pretty sure she wasn't angry at me, which meant she was frightened. But of what? I mean, I was just there two seconds ago. I hadn't even walked three steps away.

I backtracked. “What's the matter?”

In the narrow moment when I had turned to walk away, all the color had drained out of the patient's face. She was now stark white, bloodless, her lips pressed thin in a rictus of pain.

“Hurts,” was all she said. Her hand was on her chest.

What the hell had happened?

Carolyn raised her arms to shoo the family away. “You folks need to go out into the waiting room.”

They both stood for a moment, husband to the right, daughter to the left, looking down at her.

“We'll have you back in a little bit. Just give us a few minutes here.”

The husband reached out and squeezed his wife's hand, clucking at her. “You be good now,” he said with a worried smile. “They're going to take good care of you.” The wife responded with a grimace.

As soon as they had pushed through the doors to the waiting room, I barked at Carolyn. “We need another ECG.” I leaned over the woman. “Are you having chest pain now?”

She nodded.

“What's the pain like?”

“Heavy, heavy like an elephant.” She grabbed my hand, looking up at me. “I'm afraid,” she said. She squeezed my hand tightly. “Please don't let me die.”

I bent over for a quick listen to her chest. “Don't be ridiculous,” I told her. I rechecked her pulses: radial, femoral, dorsalis, pedis. They were all present but fainter now, threadier. “Is this the same kind of pain you've been getting over the last few months?” I gazed up at the monitor, not waiting for her answer. Her heart rate had increased from the initial 80 to 112. I recycled the blood pressure cuff by poking at one of the monitor buttons. In a moment the numbers flashed up. Blood pressure 90/40. It had dropped precipitously since her arrival.

“We've got a little problem here,” I said to Carolyn, who rolled her eyes; she was miles ahead of me.

The patient tugged at my hand. I looked down. “Please,” she whispered. “They need me.”

I barely heard her. I was watching Carolyn reapply the ECG leads across her chest, pulling the woman's flaccid breasts out of the way. Once again the screen faded to light and the baseline bucked and shivered before settling into place. This was a whole new ECG; it was difficult to imagine that it was related at all to the one we had just taken five minutes ago. This woman was having a heart attack of major proportions, a massive anterior wall infarction. The whole front wall of her heart had been deprived of blood—blood-carrying oxygen—because a clot had formed in one of the heart's major arteries. She must have been teetering on the verge of this for months; hence the angina. Her arteries had been narrowed with cholesterol and miscellaneous debris. Whenever she increased the oxygen demand on her heart, she would get ischemic pain because there was not enough blood flow. Now the inevitable clot had formed, blocking the entire artery. As a result, half of her heart was dying. It had all happened in a moment.

I stared up at the blood pressure reading on the screen, shaken by how low it was. We had to do something right away to open that blood vessel back up. Nitroglycerin is what I usually use first, but that drug would be a disaster with this blood pressure. Heparin, a venerable blood thinner, was also high on the list, but heparin only prevents clots from forming. It does not break up clots that have already formed. Lastly there was TPA. “TPA,” I said aloud, relishing each letter. Tissue plasminogen activator, the “clot buster” drug. It was new then; I had only given it a couple of times before, but I had never given it to someone who looked like she needed it more.

I waved at Carolyn. “We need to get a loading dose of TPA up from the pharmacy.”

“No joke,” Carolyn said. She looked around the ER. “Where's Bill?” she asked at large. Bill was the tech; he needed to run to the pharmacy for us to get the drug.

“He's sleeping,” the unit clerk sang out.

“Well, for Christ's sake wake him up.”

I had my fingers on the woman's wrist, counting out her thready pulse, my own hands already slippery with sweat, my pulse racing ahead of hers. “Don't let me die,” she had said. Never a good sign.

I thought of another possibility, an outside chance. This could also be a dissection, a tear in the lining of the blood vessel. Sometimes aortic dissections can present with ECG findings just like that of an acute anterior MI, but you give them TPA and it's a disaster. The patient usually hemorrhages to death (not that their chances are that great to begin with). I shook myself, remembering that her pulses were good, rare in a dissection, and her symptoms were classic for a heart attack, not a dissection. If I pursued this line of thinking, I might end up wasting the precious time we needed to treat her MI.

I barked at Carolyn. “Let's get some heparin going.
Now
.”

Carolyn put one hand on my shoulder and whispered, “Chill out.” Then she leaned over the woman to start an IV. I watched in awe as, one-handed, she flicked the cap off the hub of the IV and slipped it, almost without even looking down, into a tiny vein on the back of this woman's hand. God love her.

I leaned over to the patient and said, as calmly as I could, “Ma'am, it looks like this pain is coming from your heart. We are going to give you several medicines. One of them is a new medicine that seems to work very well when someone has had a heart attack. It's called TPA, tissue plasminogen activator.”

She gazed at me blankly and then finally raised a weak hand. “Whatever you need to do.”

TPA was what we needed to do. This was the dawning of a new era in medicine, the era of “clot busting” drugs: streptokinase and, of course, TPA, the first effective drug therapy for heart attacks. Not a few years before, all we had to treat heart attack victims was painkillers and attentive nursing. Now there was a real treatment—inject these drugs and there was a chance the heart attack would
go away
with minimal damage to the heart. Cardiologists and ER doctors were falling all over themselves to get the TPA to any patient in whom there was even a remote possibility that it would help. (And the drug company that manufactured the drug, and sold it for $2,200 a pop, was falling all over itself to get the drug to the doctors.)

TPA works by breaking up—“lysing” in medicalese—blood clots after they are formed. Heparin, TPA's alter ego, prevents clots from forming but can't break them up after they are formed. TPA “lyses” clots that form in the main arteries of the heart, allowing the blood flow to return to normal and thereby salvaging heart muscle. Not surprisingly, this action also produces, as its worst side effect, uncontrolled bleeding. Patients can bleed from anywhere into anywhere, but the most serious side effect is bleeding into the brain. This happens a little less than 1 percent of the time, but when it does, the results can be devastating. GI bleed, stroke, death. Always in medicine there is the risk/benefit trade-off. Nothing comes for free. But in this woman's case benefit surely outweighed the risk. Surely, I thought uncertainly, surely.

When TPA does work, the results can be unexpected. The first sign is a collection of panic-inducing cardiac arrhythmias. My heart, a couple of times, has leaped through its own hoops as I tried to keep track, second by second, of the barrage of abnormal rhythms, one right after another, that finally, spontaneously and without warning, arrived at the heart's distinctive and most welcome normal sinus rhythm. The first patient I went through this with looked up at me and said, drum roll,
ta da,
“My chest pain is
gone
.”