Fortunately, the cath lab nurses and technician had heard the call for the emergency response team and had not left the hospital. They were at the ready. Like a well-trained orchestra, everyone did their job. We learned that our patient was Father Karl, a popular seventy-year-old priest whose church and followers were about a thirty-minute drive from the hospital. Father Karl had been dutifully visiting his hospitalized parishioners, offering prayers of healing. We knew none of his medical history. We had no idea how long he had been pitched up against the elevator door. We didn’t know on which floor he had entered the elevator, nor why it stopped on our cardiac floor. We only knew he was cold and clammy and pulseless when he rolled forward from the elevator. His pupils were fixed and dilated, a very bad sign of impending death and/or brain damage. This was in an era long before we knew about cooling to protect the brain.
With ongoing CPR, we performed a catheterization procedure to find the cause of his cardiac arrest in hopes of reversing it. The procedure involves inserting a catheter (tube) into a large vein that runs directly to the heart. Dye is then injected into the arteries of the heart to find the problem. The large main artery on the front of the heart was occluded by a clot. That was the cause of his heart attack—that main artery is colloquially known as the “widow maker” because when it’s blocked, there’s big trouble.
While visualizing the catheterization procedure on the video monitor, I was able to reach his blocked artery with the catheter and slide a wire, and then a balloon, across the soft clot. I dilated the balloon to open up the artery, and then deflated it. Blood flow in the vessel was restored. This was at a time before stent devices, which these days are left in the opened arteries to keep them open, but the flow through his artery continued to look strong after the balloon procedure. He was still without a heartbeat. Another shock with the paddles, now to a heart getting adequate blood flow, was followed by return of a more normal heart rhythm, and then a weak but definite pulse. We boosted his blood pressure with another type of device, this one inserted into his aorta (the main artery leaving the heart), and with multiple medications.
I was told that people were in the waiting area, wanting to know about Father Karl’s condition. I arrived there, my scrubs soaked with Father Karl’s blood and sweat. Some of my own sweat, I presume, as well. I was greeted by a sea of black and white, a roomful of priests and nuns, every seat taken. They had heard about their beloved Father Karl and had come to see him and to pray. They all stood up as I arrived.
I told them that the good news was that Father Karl was alive, at the moment, and in our CCU with a heartbeat and a blood pressure. The blood pressure, of course, was being helped by many medications and the intra-aortic device. The bad news was we had no idea whether Father Karl’s brain had survived this dramatic insult. We didn’t know if he had been out for sixty seconds or five minutes before the elevator doors opened and we started CPR. The loyal legion said that they would pray for Father Karl and for the physicians. One after another expressed profound gratitude for what we had already done.
A mere four weeks later, after a full recovery, Father Karl addressed his congregation. He expressed gratitude to God and, graciously, to his physicians.
I, too, was very grateful. Grateful that a kind and revered man who had just been bringing good wishes and prayers to patients had the good fortune of having his potentially fatal heart attack in a hospital. More precisely, in a hospital elevator, which opened to the hospital floor where I was standing waiting for that elevator. The same hospital floor where the cardiac cath lab and CCU were located, and where I and others, trained and experienced in just this type of cardiac emergency, were still at work on a weekend day. Grateful that after literally falling at my feet, as if delivered to me, his heart finally responded to our treatment. Treatment that would have been impossible to receive in such a timely fashion had he collapsed almost anywhere else that day. Grateful that the prayers he said for our patients earlier that day were repaid many times over by the prayers of his community who had gathered in our waiting room that afternoon, and subsequently in his church during the harrowing days that followed.
As the saying goes, timing is everything. I will always be grateful for Father Karl’s timing.
Date of event: February 2013
An Unlikely Discovery by the Unlikeliest Person
Ryan Jones, MD
Claudette Dalton, MD
Gilbert Upchurch Jr., MD
Editor’s note: This remarkable story is separately told by three different caregivers, each from their unique vantage points. The roles of the medical student (Dr. Jones), teacher (Dr. Dalton), and surgeon (Dr. Upchurch) were each essential—without any one of them, the miracle would never have happened.
Part 1. The student
In all honesty, I was just trying to pass my exam. Once a week or so for the first two years of medical school, my fellow students and I donned our short white coats and had contact with patients as part of our Clinical Performance Development course. The contact ranged from watching trained physicians interview and examine patients, to doing the same ourselves under the supervision of our physician teachers. On the day that led to this essay, I was at the end of my third year of medical school, feeling fairly relaxed because the “worst” of my difficult rotations were behind me. I was generally comfortable with my skills in obtaining a medical history from a patient and performing a physical examination, and the exercise that day was designed to test those skills in preparation for the national licensing examination I would take in the near future.
The exercise consisted of a series of volunteer pretend “patients,” each with a different faux condition, from whom we students were expected to extract the relevant information to lead us to the diagnosis the actors were pretending to have. It was a little like a game—these pretend patients revealed only the information we students elicited by careful questioning. After the questioning, we went through the motions of a physical examination directed at where we thought the problem might be, based on our interview with the patient, and then we summarized our treatment plan to both the patient and a physician proctor for the exam. Once we finished the case, we moved on to the next.
When I walked into Jim’s room, I had just finished a previous case where I thought I could have done better. I belatedly realized questions I should have asked and was kicking myself for the mistakes. Nonetheless, I told myself to let it go and focus on the next patient, Jim, a seventy-five-year-old retired engineer. Fortunately, Jim’s story was fairly straightforward. He conveyed risk factors in his history for an abdominal aortic aneurysm (an abnormal and potentially dangerous bulge in the aorta, the main artery in the body that courses from the heart through the chest and abdomen), and he reported symptoms that could be explained by a large abdominal mass or aneurysm. When it came time for the physical examination, I knew the abdomen would be my primary focus.
The physical exam of the abdomen is an important part of a physician’s education, of course, but I was just focusing on making sure I got all the steps right so the preceptor observing me on closed circuit TV from another room would see I knew what I was doing. In this case, I was going through the motions of looking for an abdominal mass or an abdominal aortic aneurysm. The latter, in particular, can be detected by feeling a pulsating (“beating”) mass in the abdomen or by hearing a bruit, a sound from turbulent blood flow, with a stethoscope. With Jim, I wasn’t expecting to find anything, of course—he was a pretend patient! I vividly recall the Whoa! moment when I thought I felt a pulsating mass in Jim’s abdomen, right where the aorta should be. I took a step back from the exam table and collected my thoughts. Then, listening to his abdomen, I thought I heard a bruit, adding weight to my diagnosis of an abdominal aortic aneurysm. A real one!
It seemed odd to me that Jim would be volunteering for this case. I thought he must be a “ringer,” a patient with an actual disease thrown into the test setting to se
e if the students would detect a real condition—in this case, a very serious one. Rumor had it that sometimes national examiners do that for the licensing tests, but this was just a clinical skills course as part of medical school—highly unlikely to have a patient with a real disease volunteering to play the part for the students in this setting. I was so taken aback by what I felt and heard that I “broke character” for a moment and addressed Jim as a potential real patient rather than a pretend patient. After all, he was reporting to have symptoms—I needed to be sure that what he was saying wasn’t true, because the symptoms he was describing would have raised concern for leakage from the aneurysm or impending rupture, a highly fatal complication.
“Do you know you might have an abdominal aortic aneurysm?”
But Jim stayed in character. “What’s an aneurysm?” he asked, even though his job that day was to portray a patient with an abdominal aortic aneurysm and he had been fully prepped in the condition he was “pretending” to have. Later, I learned that all the symptoms Jim had complained about to me were, indeed, pretend, just part of the test. In fact, he never had any symptoms. It turns out that many patients with real abdominal aortic aneurysms don’t have symptoms, sometimes until it’s too late.
I reported my findings to my preceptor, Dr. Dalton, as part of my responsibility to present the case as a doctor would when discussing a real patient. Dr. Dalton seemed skeptical of my findings of an abdominal aortic aneurysm in a patient who thought he was pretending to have one. I wondered to myself whether it was even safe for a patient with a real aneurysm to have his belly poked and prodded by student after student, but I assumed everyone knew what they were doing, including Jim, and that my concerns were above my pay grade. Keeping in line with the test protocol, I moved on to my next pretend patient of the day. Each of the students saw eight such volunteers in the same day as part of this testing.
When Jim’s aneurysm was subsequently confirmed by his physicians and the surgical correction performed, there was quite a media storm1-4: “UVA Medical Student Diagnoses Actor with Life-Threatening Condition During Practice Exam.” “Med Student Discovers Real Disease in Fake Patient.” “U-VA Med Student Saves Man’s Life During Training Exam.” “Med Student Saves Life of Elderly Man Acting as Pretend Patient.” I received congratulatory emails from the president of the university, the dean of the medical school, and the CEO of the hospital.
All the fuss took me by surprise, but I enjoyed getting to share the story with so many people. Really, I was just trying to pass my exam. Most meaningful to me, Jim and his wife were extraordinarily grateful, telling everyone I had saved his life. But, as I told the media, Jim and I were both just fortunate to be in the right place at the right time.
1http://www.cbsnews.com/news/uva-medical-student-diagnoses-actor-with-life-threatening-condition-during-practice-exam/
2http://abcnews.go.com/Health/med-student-discovers-real-disease-fake-patient/story?id=21475027
3http://www.washingtonpost.com/blogs/answer-sheet/wp/2014/01/13/u-va-medical-student-saves-mans-life-during-training-exam/
4http://insider.foxnews.com/2014/01/07/uva-med-student-saves-life-elderly-man-who-was-serving-patient-actor
Part 2. The teacher
I have the privilege of supervising medical students who are early in their training and learning to interview and examine patients for the first time. One of our most effective teaching strategies is with “standardized patients” —local residents who portray a patient scenario for medical students to practice their skills—for little or no pay. These “pretend patients” are prepped on how to give consistent histories and behaviors to all the students who examine them. That is no mean feat when you are allowing dozens of students to question, pummel, and fumble through a history and physical exam.
Jim is a retired executive who has volunteered his time for many years to portray patients with various conditions. Jim’s wife also is a standardized patient, and the two of them have a sweet, caring relationship that is a joy to witness. They really enjoy contributing together to medical education in this unique way.
On the day in question, Jim was acting as a patient with a possible leaking abdominal aortic aneurysm. (As an aside, his wife was portraying a depressed patient for the students that day.) The aorta is the main artery in the abdomen, and it sometimes develops a defect that causes it to balloon; this balloon is called an aneurysm. As the ballooning aorta grows bigger, it can leak and even rupture—two very serious and potentially lethal complications. The objective for the students examining Jim was to get a history of underlying risk factors for aneurysms, such as high blood pressure, smoking, and disease in other blood vessels, as well as to obtain a history of belly pain. Then the students were expected to do the proper abdominal exam, focusing on findings that might indicate the presence of an aneurysm, such as a mass that was pulsating, a widened aorta, or an abnormal sound of turbulent blood flow called a “bruit.”
No one expected there to be real physical findings—after all, the stand-ardized patients portray all sorts of diseases that they don’t have and for which they should have no real signs on physical examination. The exercise was to ensure the students asked the right questions in the right way, and went through the motions of the exam correctly. My role was to watch the exam in real time on a closed-circuit TV in another room, and then listen while the student “presented” the patient to me—a test of his or her ability to organize the information and give it back reliably.
Ryan Jones was the last student of the day. I had observed and listened to seven others that day and twenty-four others in the three afternoons that week prior to this session. Hence, Ryan was the thirty-second medical student to examine Jim’s belly. Ryan did a nice job on both his history and physical examination and his presentation was also well done. But, when he told me that he had felt a pulsating mass and heard a bruit over the abdominal aorta, I admit to being a little peeved. He’s making that up or imagining it, I thought. I challenged him, and asked if he was saying that to represent what he would have heard in a real patient. “No,” he insisted, “I really felt a mass and heard a bruit!”
Something about Ryan’s quiet assurance got me out of the chair from my viewing booth and down the hall to Jim’s room. He was already dressed and ready to leave but readily agreed to let me examine his abdomen. And there they were—an unmistakable mass and bruit. Geez! I couldn’t believe I almost dismissed Ryan’s findings as imaginary.
By this time, Jim was looking a bit confused. I told him that Ryan had felt and heard something unusual and that I had confirmed it. My advice was to go to see his primary care doctor sooner rather than later and get an abdominal ultrasound. Jim didn’t seem entirely convinced—he felt fine, looked fine, and had taken good care of himself. But he did say I could talk to his wife who was finishing up her “performance” in another examination room. That sweet woman looked her husband in the eyes and started issuing orders—he would be going to see his physician. Clearly, this soft-spoken, rosy-cheeked, seventy-plus tiny lady was in charge of the situation. Impressive, especially considering she must have been emotionally and physically exhausted after play-acting as a depressed patient for thirty-two medical students that week alone! I knew she would make her husband do the right thing.
Indeed, Jim’s wife marched him straight to his doctor, the aneurysm was confirmed and the surgery was done by Dr. Upchurch. Without Ryan’s good exam, his mention of something no one else had heard or felt, and his quiet but confident insistence that it was real, who knows when or if Jim’s aneurysm would have been discovered in time?
Part 3: The surgeon
I see hundreds of patients a year for surgery on diseased blood vessels, referred from fellow surgeons and other physicians all over Virginia and around the country. But, in my more than twenty years performing vascular surgery, seeing and operating on thousands of patients, I have never received a patient referral like this
one, and I doubt I ever will again.
Jim came to me after a medical student named Ryan Jones felt a pulsating mass and heard a “bruit,” which is the sound of abnormal turbulent blood flow, in Jim’s abdomen. Jones’s examination took place as part of our university medical school’s “standardized patient” program, wherein volunteers pretend to have a certain condition to help teach our medical students. Jim was supposed to be just an actor, pretending to have an aneurysm so the students could practice their skills. Ryan Jones must have been imagining the findings, right? None of the other students who examined Jim that day felt or heard anything abnormal. Perhaps it was the power of suggestion—Jones knew what he was looking for so he imagined he found it?
No, this was a real aneurysm in a patient pretending to have one. The mass and the bruit sound were confirmed by Dr. Dalton, his proctor for the day, and the patient was referred to me after an ultrasound confirmed the finding. When I evaluated Jim, I observed a thin, fit, and elderly male, the “classic” appearance of patients with abdominal aortic aneurysms. He had no symptoms whatsoever and he was sure this was some kind of mistake. Both he and his wife were nervous about the diagnosis and the treatment that would be required. Indeed, I confirmed the medical student’s physical examination findings and the diagnosis of an abdominal aortic aneurysm was confirmed by CAT scan (a special type of X-ray).
Surgery has come a long way for this problem in recent years. In the past, we opened up the abdomen with a large incision and performed a lengthy and risky resection (removal) of the aneurysm and replacement with a tube (graft) made of artificial material. Now, in most patients, we are able to fix the ballooning vessel by snaking what we call an “endograft” into the aorta through a small incision in the patient’s groin. The endograft is like the inner tube of a tire—we inflate it within the diseased portion of the aorta and it stabilizes the blood vessel, preventing it from leaking or bursting. I performed this procedure on Jim and he was able to go home the next day without any complications. He was stunned by how this all happened, but he and his wife were very grateful to the medical student, the student’s teacher, and me for preventing what could have been a disastrous outcome had the aneurysm not been detected early.
Miracles We Have Seen Page 5