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."

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:

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

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 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 **************************************

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.

"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'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."

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 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?"

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?"

"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.

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."

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.

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?"

"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."

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.

I had a massive heart attack at age 44. I kept putting off going to the hospital because I KNEW I couldn't be having one.

A few years earlier I had to have an intense physical for a job. The heart doctor told me at the time, "You have a heart like a mule, you'll never have to worry about a heart attack."

Several years later I started having chest pain one day at work. I discounted heart attack right away because of what I had been told.

I have always been a person with a cast iron stomach - I could eat road kill and the tire that killed it with no problems. My chest started hurting so bad I thought that maybe I finally was getting heartburn or something. It hurt so bad I couldn't believe that other people would just chew a Tums and go on their way.

I got home from work that evening and it kept hurting worse and worse. By then I had pain shooting down my arms. I told myself that I would just go to bed and if I still hurt in the morning, I would go see my doctor.

I woke up at 3:00 AM in incredible pain. I sat up and found myself soaking wet. I immediately threw up with no warning and just made it to the bathroom where I had a terrible episode of diarrhea. I went back to bed and tried to go back to sleep, but the pain in my arms and especially in my palms was so bad I couldn't go to sleep.

All of a sudden I got very dizzy and started to black out.

Then it finally hit me - I was having a heart attack and was actually dying.

I called a friend who lives a few blocks away and asked her to come and get me and take me to the emergency room. She told me I should call 911, but I told her I didn't want flashing lights and sirens and all the fuss all over some bad pizza (which I had for lunch that day).

She came and picked me up. This was a hot August night - 95 degrees and steamy, but as Susan was driving me to the hospital I was shivering with cold. Luckily, Susan had an old dog blanket in the back of her car - I wrapped up in that and was still freezing. I couldn't stop my teeth from chattering.

Susan had quit smoking a year before this. I told her, "I know you don't want me smoking in your car - but I'm sure this is the last cigarette I'll ever have. If I die I won't smoke anymore and if I live I'll have to quit smoking.

I was smoking that last cigarette as I went through the Emergency Room doors.

I went to the desk and told them I was having chest pains. They asked me how bad the pain was on a scale of 1 to 10. I told them it was about 25.

They rushed me back, tore my clothes off me and started pumping morphine into me. A minute later a doctor was bending over me and said, "Sir, I'm going to be blunt with you. You are having a massive heart attack."

I asked him, "Will I live?" He replied, "I don't know. We are going to rush you into the Cath lab and try to save you. If you had waited another 30 minutes - you would already be dead."

I wasn't scared when he told me I was having a heart attack - but I was absolutely terrified when he told me about the 30 minutes, especially since I had put off coming to the hospital all day.

They did the angioplasty and through my morphine haze I asked again, "Will I live?"

The heart surgeon said, "If you make it through the next 24 hours - you might." He told me I had what they call the "Widow Maker" - a Left Anterior Descending blockage.

I asked him, "Why did I have a heart attack? I am in perfect health, I have low blood pressure, I have low cholesterol, I have no family history of heart disease."

He replied, "I can tell you in three words. Two packs of Kools a day."

I said, "That's more than three words, but I get your drift." He replied, "If you live through this you must NEVER smoke again - or you'll die, it's that simple."

Later, I overheard a couple of the nurses talking outside the ICU room. One of them said, "That was a record - we got him in within 10 minutes of him coming through the doors."

Needless to say - that cigarette coming through the emergency room doors was my last.

What was really weird about all this is that when I was first hit with the morphine just before they wheeled me into the cath lab, I had the distinct impression of being surrounded by a group of very tall figures. I couldn't really see who they were, but I could definitely feel them all around me. Because I was so zoned (and scared) I dismissed it from my mind.

I never told anyone about it, because it sounded crazy. It wasn't until several weeks later, when I was home from the hospital (after 6 days in Intensive Care and 14 days in the Cardiac ward) that my sister told me something that sent icy chills up and down my spine.

She said that Susan had called her about 3:30 AM and told her about my heart attack. She lived on the far East side and had a bit of a distance to travel to get to the hospital I was in. She said she was praying the whole way. My younger brother had died tragically a year before this. My sister said in her prayers she asked my brother Steve to put in a good word for me. She said all of a sudden she heard his voice saying, "Don't worry - he's being protected." She said she could see me laying in a hospital bed and that there were 6 tall shining winged figures surrounding my bed holding large shining swords. She said she was instantly filled with a sense of relief and confidence that I was going to live.

While I have always been a fairly religious and spiritual person - I never really gave a lot of credence to "guardian angels" protecting us. When my sister told me about the vision she saw and when I remembered sensing a group of figures standing around my hospital bed - It scared the beejeebies out of me.

I realized that angels must be real and that they must have saved my life.

Think what you want - maybe it was a drug-indiced hallucination, but if it was, how did my sister see it from 20 miles away?

To this day, I thank God every single day for saving my life.

I still firmly believe that something or someone stepped in and saved me. For what reason, I don't know yet - maybe it was just to spare my parents the agony of losing two sons within a year. Whatever the reason, I try to live each day as a gift from God - which it truly is.

Whenever I hear someone tell me about chest pain - I am like a madman. I won't let them alone until they promise me they will go seek immediate attention.

Please learn from my experience - if you get chest pain, if you feel faint, if you get pain in your arms or your jaw, if you feel a hard to describe sense of unease - don't do what I did, don't take any chances. Go directly to the nearest emergency room and seek help. It may save your life. You may not be as lucky or as blessed as I was.

Tokra, you have an awesome testimony! Thank you for sharing that with everyone.

I wish I had a nickel for every patient who drove himself/herself to the hospital when they experienced the symptoms you have described. I'd be living on my own private island in French Polynesia right now.

Note to all and sundry: if you are having chest pain, nausea, sweating, weakness, palpitations, or shortness of breath- or any combination of one or more of those symptoms- CALL 911. DO NOT DRIVE YOURSELF TO THE HOSPITAL.

This may seem silly to someone who only lives five or ten minutes away from a hospital. But if you have those symptoms, it indicates that your heart is already being starved of oxygen (Myocardial Ischemia). If your heart is ischemic, you may be only seconds away from that heart muscle actually dying (Myocardial Infarct).

Not minutes, people; seconds. All it takes to convert your chest pain from ischemia to infarct is a shift of that clot by a distance that could fit easily on the head of a pin.

If that happens while you are driving yourself to the ER, you will not only be hurting yourself. You will also harm anyone standing in the path of your vehicle as you lose control. It's happened. I encountered such a person on one of my days off when he rear-ended me at an intersection. I got out to give him a piece of my mind and ended up performing CPR. On my day off. Don't drive yourself!

And don't get a friend or loved one to drive you, either. You may avoid hitting another car when your heart stops, but your friend will be a little distracted by your agonal breathing and will have to live with the guilt forever. Don't do that to your friend or loved one.

Medic units are trained to give care within minutes of the call and to transport you to the ER safely, continuing progressive care for you all the way there. They exist for this reason. USE THEM.

Oh, and two more good reasons to let EMS take you to my ER:

1: The Medic Unit doesn't get caught at red lights;

2: Traffic will get out of the way of the Medic Unit.

So you can travel quickly to the ER while passing the corpses who chose to drive themselves and died on the way.

Triple bypass about a year ago, 1.5 years post-double-stenting. What I've learned:

Be sure and keep your internist in the loop; my cardiologist didn't. My problem WILL RECUR SOON if I don't get my blood lipids into line, and my cardiologist apparently had LITTLE interest in exploring that; three of them refused to give me standing labs instead of CoQ10-zapping statins and beta blockers so I could get everything where it should be. It took me one month to do that. I am now seeing Dr. Joe Prendergast in Redwood City CA and taking Byetta (synthesized from Gila monster saliva) to stimulate regrowth of pancreatic beta cells, etc., which is helping me lose the weight I've been struggling to lose and helping to get/keep my lipids in line, along with very low carb and high-value fish oil. Dr. P. has NO END-STAGE RENAL DISEASE in his diabetic patient population (so no dialysis down the line, bone loss and early death from cardiovascular, etc.) High triglycerides and high cholesterol are LINKED together: I was at 1252 trigs at stenting, only 550-750 just before bypass, and total cholesterol was 297 at both of those readings; when I cut carbs to the bone, my trigs dropped to 220 (still high) and the total cholesterol went to 157, with similar better numbers for the other lipid values.

Get on the 'net and learn about your own condition, don't take any wooden nickels (statins, beta blockers), and check out a book from Thomas Smith in Loveland CO about how he cured his own diabetes by driving the so-called "good" (junk) oils out of his system with flaxseed and fish oil, etc. You can find him on the 'net if you look for him. His book is reasonably priced, low-tech, and he is way ahead of the Big Boys.

Oh, Byetta (alone) has gotten my fasting blood sugars (first thing in the a.m.) way down into the normal range (which numbers they've just elevated in order NOT to have to treat you early enough to avoid bypass at $63,500 patient cost -- insurance companies get a big break). (sneer)

Byetta is FDA-approved, apparently; you'll be hearing more about it, but I wouldn't wait. It's an incretin-mimetic.)
Dr. P. also uses D3 at therapeutic levels to remove calcified plaque and reverse osteoporosis. He has quite a personal story; you can find him on the web, also. I've never met a nicer doc and he has a big, thriving practice on the outskirts of Stanford U. Hospital and is HIGHLY published.

Oh, my MI signs: catch in the intake breathing had been there a few years disappeared right after stenting, dull ache between the shoulder blades on exertion, and also up into the jawline on both sides, EXTREME fatigue, strong burning sensation across the diaphragm and up under both armpits. Thankfully, I had little to no heart muscle damage both events, but I also learned of a woman who had heart muscle repair (cellular level); she can be found on the web if you explore the Linus Pauling approach to cleaning your arteries. Apparently, of thousands of items tested, only vitamin C effected heart muscle cell repair, and she has a testimonial to that effect on the net.

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