First Do No Harm

by L Jan Eira

  “We’ve noticed a few patients, usually pretty young, in their forties or fifties, who come in with chest pains, rule out for a heart attack, but die for no apparent reason. Like Mr. Roper,” continued Heather.

  “We’ve had three between the two of us over the last couple of months. Roper is number four,” interjected Julie.

  “Weird, huh? Get me their charts; I’ll see if there are any common denominators,” dismissed Jack.

  “They all become agitated; the monitors suddenly show tachycardias, for no good reason,” continued Julie not wishing to be dismissed so easily. Heather remained silent with a concerned look on her face.

  “This may be nothing or just a coincidence, Dr. Norris. But there seems to be an epidemic of cardiac arrests in otherwise healthy relatively young male patients,” said Heather.

  “Okay, I promise to look into this. Get me the charts. Put them on my desk,” Jack remarked in a fatherly, calming and soothing voice trying to reassure the women.

  “Thanks,” they said as they prepared to leave the room.

  “Ladies, before you go. These are the medical students for the month, Pete, Taylor and Chris. This is Julie and that’s Heather. They are the best nurses in the world,” said Jack making the introductions.

  “Good to meet you, guys. Welcome to Memorial. Dr. Norris, I bet you say those nice things about all the nurses in the hospital,” said Heather. The nurses exited the small room, smiling.

  “These gals are like mother hens.” Jack turned to the medical students. “That’s a good thing. They really watch over their patients. Nurses like this are to be respected. They will save your ass many times throughout your career. Oh, and they like chocolate. They all love chocolate. Are you taking notes? These are great clinical pearls.”

  The four men rose and walked out of the nurse’s station. Rounds continued uneventfully afterwards. Jack assigned each student a patient to review and discuss the next day.

  “Read up on your patient, boys. I’m starting each of you with only one patient, so no excuses. Read up on their problems and be ready to talk about differential diagnoses, pathophysiology, clinical findings, and management options and so on. Okay?”

  *****

  Six weeks ago

  August 16

  1:20 PM

  The ambulance drove rapidly, slowing down at red lights, but not stopping completely. The emergency lights and siren signaled something dreadful was going on inside the emergency vehicle. Mr. Floyd Sullivan had called 911 when he developed pain in the middle of his chest while at work. He was only thirty-nine, although he looked much older. There was no history of heart trouble in his family and Floyd stopped smoking three years earlier. The paramedics had started an intravenous line and a bag of five percent dextrose in water was hanging, slowly dripping into his vein. A clear plastic cannula delivered two liters per minute of oxygen into his nostrils, the tubing hanging over his ears. The cardiac monitor indicated a steady heart rhythm at eighty-two beats per minute. Occasionally, a skipped beat, referred to as premature ventricular contraction or PVC, disrupted the steady and regular beeping sounds. The patient seemed stable but a rapid transfer to the hospital was nonetheless customary. No words were spoken during the twelve-minute ride to Newton Memorial Hospital.

  “What ya got?” asked a nurse as they arrived at the emergency department’s ambulance bay.

  “Chest pains, gone after two sublingual nitros. IV with D5W. Monitor with normal sinus rhythm and frequent PVCs,” answered the paramedic, giving a brief report as the team rushed the stretcher with the scared patient into the depths of the emergency department.

  “Okay, put him in room three,” commanded the nurse, totally disregarding the patient who quietly listened to the entire conversation of medical lingo, clearly not understanding much of it.

  With this, the paramedics wheeled the stretcher to the appropriate room where another nurse and technician greeted the team.

  “This is Sully. His full name is Floyd Sullivan. He had chest pain relieved by nitro. Monitor shows frequent unifocal PVCs.” The paramedic repeated the report to the receiving nurse while the team slid the patient from the stretcher to the hospital bed. The heart monitor leads were exchanged, replacing the ambulance gear with like hospital equipment. These multiple steps were accomplished in less than fifteen seconds, as if by a well-oiled machine. It was easy to imagine that this process was skillfully repeated numerous times each shift and was now attained without conscious effort by the emergency workers.

  The paramedics said goodbye to the patient, wished him well and left.

  “How are you feeling now, Sully?” asked the nurse.

  “The chest pain is back a little bit. It’s not as bad as it was at work,” answered the patient. The technician started to hook the patient up to an EKG machine in order to produce the required electrocardiogram.

  “Hold still while I do this. If you move, the signal doesn’t come out right and the doctors make me do this all over again,” said the technician. Sully complied.

  “Dr. Norris,” yelled the nurse to the passing young doctor. He was leading the group of medical students and young doctors in training back upstairs having been summoned earlier to render an opinion about a rhythm strip that turned out to be artifact and harmless. The team was eager to return and finish rounds on the fifth floor before Grand Rounds, a weekly conference at the hospital delivered by an outside guest speaker. Today’s topic, Sudden Cardiac Arrest in Patients with No Structural Heart Disease, to be delivered by Dr. Anton Damato, a famous electrophysiologist, promised to be a great learning opportunity.

  “What’s up Lorrie?” answer Jack making a sudden stop and entering room three. The others followed him into the small room.

  “This is Mr. Floyd Sullivan. He goes by Sully. He had some chest pains, which were relieved by nitro, but returned. He is having frequent PVCs. Can you look at him for me?” inquired Lorrie Nunez, the head nurse in the emergency department.

  “For you, anything,” smiled Jack as he took the chart. He shook the patient’s hand. “I’m Dr. Norris. What does the pain feel like?” he asked spying the electrocardiogram on the bedside table. A few seconds later, he picked up the EKG printout and handed it to Dr. Kathryn Mansfield, a first year cardiology fellow. Kathy accepted the tracing and stared at it inquisitively.

  “It’s like a fire on the inside of my chest, doc,” answered the patient calmly.

  “What does the EKG show, Kathy?” asked Jack turning to the young doctor.

  “Lots of PVCs, otherwise normal,” answered the cardiology fellow who, by now, had passed the electrocardiogram to one of the students. The three medical students now analyzed the tracing, as they listened to the exchange.

  “Can you say anything else about the PVCs?” persisted Jack looking directly at Kathy.

  “Remember, I’m just a plumber; I’m not an electrician,” she replied, indicating she was much more comfortable dealing with issues involving the coronary arterial blood flow than with electrical matters, such as PVCs.

  “Fair enough. But I want you to be able to recognize this pattern. The PVC has a tall R-wave in lead two and left bundle branch type morphology. This means it’s coming from the front of the heart, the area called the right ventricular outflow tract or RVOT. The prognosis with these is excellent; they tend to occur with stress,” said Jack confidently.

  Turning to the patient who had a worried look on his face, Jack continued: “The skipped beats you may be feeling are not worrisome and your pain does not sound like it is from your heart. We’re going to do some tests to be sure, but I’m not too worried at this point, okay? We’ll give you some medicines to help your pain go away.”

  Jack smiled, as he looked Sully in the eyes, providing him with much needed reassurance. Placing his hand on Taylor’s shoulder, Jack continued: “This doctor is going to stay with you and get you admitted to the hospital for observation. We’ll know more by tomorrow morning. This is Dr. Taylor Twelly.” This sai
d, Jack turned to Taylor: “Do your thing and call me when you’re done so we can go over the orders. The rest of us will go finish rounds upstairs.” Both men nodded. As Taylor grabbed all the paperwork and sat on a chair right next to the patient’s bed, the others exited the room.

  *****

  Six weeks ago

  August 17

  10:42 AM

  The doctors entered Sully’s room, smiling as they did.

  “How was your night, Mr. Sullivan?” asked Taylor.

  “Not bad. No more pain. That medication you gave me really worked.” Sully seemed happy and satisfied. “Am I going home today, doc? Please say yes.”

  Giving the impression that he disregarded the patient’s question, Taylor turned to the group of doctors.

  “His cardiac markers were negative times three. His stress test was negative for cardiac ischemia or infarction and his LV function is normal. Protonix stopped his chest pain completely. I think he can go home,” said Taylor feeling confident, but awaiting for approval from Jack nonetheless.

  Jack turned to the patient.

  “Your pain was not due to your heart, as we suspected. Your cardiac markers were normal. These blood tests tell us you did not have any heart injury. You had indigestion. Take the Protonix and follow up with your regular doctor.” Sully gave thumbs up and an even bigger smile than he had mustered before.

  “Thanks, doctors. You people are great. I’ll call my wife to come pick me up,” replied Sully still smiling.

  Taylor and Sully shook hands. As the group exited the patient’s room, Taylor stayed behind and said: “Give me a few minutes to do the paperwork and write you up a prescription. We may have some Protonix samples to give you.” He left the room.

  The team continued with rounds. The morning routine remained without incident. A few patients were discharged and as many admitted, each assigned to a medical student and a resident doctor.

  After rounds were over, it was 12:34 p.m. Stomachs growling, it was lunchtime. The team walked downstairs to the cafeteria.

  “Who’s going to make Starbucks rounds today? It’s on me,” asked Jack looking for volunteers. Before one came forward, the pagers beeped rapidly and in unity, followed by an excited voice: “Code Blue, emergency department; Code Blue, emergency department.” The young doctors proceeded to the location of the cardiac arrest immediately.

  To their dismay, they saw that the man receiving CPR by the emergency department staff was Mr. Floyd Sullivan, whom they had just discharged in great condition just a few hours before. Disheartened, the cardiology team added their services to the ongoing efforts. The patient was intubated and ventilation was attained via a bag, which was being squeezed periodically, delivering oxygen through a tube directly into the dying man’s lungs. Chest compressions were rhythmically delivered to the singsong: “One-one thousand, two-one thousand, three—”

  None of them asked the question they all had on their mind: What the hell just happened? This guy was well a couple of hours ago. Despite all efforts, the code was unsuccessful and Sully was pronounced dead.

  Nothing was said. The team would discuss the case later, entertaining different theories about what might have happened. For now, they all stood at the bedside, in silence, flabbergasted, defeated and sad. The worse was yet to come—to explain all this to Mrs. Sullivan.

  An autopsy would later reveal that the patient died from an acute aortic dissection. This is an emergency condition that can lead to a quick demise due to intra-abdominal internal hemorrhage. The second the walls of Sully’s main artery split apart then burst, he was a dead man. How he died was easy to explain. What remained mysterious was why this would happen to a healthy man like Mr. Sullivan. He had none of the risk factors associated with this clinical entity.

  *****

  Five weeks ago

  August 26

  12:28 PM

  Joe McIntyre was happy to be out. The last five days had been frightful, but now that he was leaving the hospital, he could breathe a sigh of relief. In fact, as he exited the front door, he did.

  “I’m too young for this shit,” he thought, still in disbelief that at age forty-two he had a heart attack. His father had his at fifty-four but unfortunately, the heart attack had suddenly stolen his life. Joe still remembered how his dad dropped to the floor, lifeless, like a sack of potatoes, while scolding him about smoking. Though Joe’s father smoked for years, he had always forbidden Joe and his brother to take up the nasty habit. He sometimes would go on a rampage about how bad smoking was while puffing on a cigarette. The advice had been mostly fruitless and in vain. The warnings had been ignored.

  The guilt was inevitable. Joe had been told many times that his father’s demise was not his fault. He was not responsible in any way. Nevertheless, he had never forgiven himself. Yet, despite it all, Joe had taken up smoking having succumbed to peer pressure. Joe smoked one and a half to two packs of cigarettes a day. Despite nicotine being a stimulant, smoking gave him the feeling of calmness he had grown to enjoy and require. The nicotine abuse had been the major factor predisposing Joe to coronary artery disease. The arteries that feed his heart muscle had clogged up with plaque to about half the vessel’s diameter. The blood could still flow unimpeded through the blockage and gave him no symptoms whatsoever. No symptoms until the morning of his heart attack.

  He had gotten up at a quarter to six to the alarm clock, as he had done for the last eight years since he started working at the plant. Soon after getting up from bed, Joe started to feel a squeezing sensation in the middle of his chest, like a vice becoming ever so tight. He also noticed a cold sweat and a bit of nausea. One of his coronary arteries had become occluded by an expanding mass of clot a few seconds earlier, preventing all downstream blood flow. At that occlusion site, the plaque had suddenly cracked, exposing its inner materials to the streaming blood cells. Without blood flow, the front portion of his heart muscle would start to suffer irreparable damage.

  He took an antacid to no avail. By then, his wife, Sheila, noticed his obvious discomfort as he paced the bedroom floor. Joe looked ghastly. She couldn’t say why or how, but he didn’t look like the man she knew for the last twenty-seven years.

  Sheila knew about heart attacks. Her father had one a few years before. In a few seconds, she relived the pain and agony of the moments spent with her father at the time of his event. She knew Joe was having a heart attack. She dialed 911, gave details of the situation, answered some questions and an ambulance was dispatched. Fortunately, Joe had reached Newton Memorial within thirty minutes of chest pain onset, so the degree of heart muscle damage was still insignificant. As the ambulance arrived in the emergency department, he was rushed to the cardiac catheterization laboratory where doctors used a wire to disrupt the clot that had formed in the coronary artery. This was followed by a balloon, which stretched the blockage in the artery allowing normalization of blood flow. This angioplasty procedure was concluded by placing a metal mesh tube, or stent, that would stay in place, forever scaffolding the area, hoping to minimize the risk of re-occlusion. Thanks to the rapid actions by the whole team – from the paramedics at the home to the emergency department staff, cardiologists and catheterization lab personnel –

  blood flow was restored quickly and cardiac markers would later indicate only a small amount of heart damage. Because of some short episodes of rapid heart beating emanating from the site of the small heart attack, the cardiologists had sought an electrophysiology consultation. Jack and his team had evaluated this and opined that the arrhythmia would not require further specific treatment, other than the usual post heart attack management, which was already in place.

  “If you smoke, you pay the piper in the end. On average, smokers live seven to ten years less and with reduced quality of life. Alternatively, you can decide to quit now and enjoy more years of productive life. Your choice! I can’t do it for you, but I will meet you halfway, if you are interested.”

  Dr. Norris was all business, str
aight and to the point. Joe had only met him five days before but had an instantaneous connection to the young doctor. He appreciated his directness. Joe vowed to quit, even if it killed him.

  Armed with a handful of pills and educational booklets on Percutaneous Coronary Interventions, Coronary Risk Factor Modification and How to Live after a Heart Attack, Joe left his hospital room determined to live.

  *****

  9:12 PM

  Joe and Sheila finally sat down to relax. They had supper, consisting of a meal low in sodium, fat and cholesterol. To drink, they had water. Despite the horror of the last few days, the couple had learned many important facts about heart disease and its prevention. Newton Memorial Hospital offered patient and family education for those admitted with heart disease. Joe participated in all the available exercise classes and smoking cessation programs and met with a nutritionist, who provided guidance in what to eat and drink. Sheila was supportive and attended the classes, whenever possible. Today’s evening meal was their first solo attempt to follow the lessons. They were both experiencing feelings of accomplishment. It felt good.

  The dishes were washed and put away. The kitchen table was cleaned and set for the next day. A vase with beautiful fresh flowers in the middle of the table provided balance and esthetics.

  Joe and Sheila curled up on the couch in front of the TV.

  “What do you want to watch? Law and Order, reruns of ER, CSI or—”

  “Hey, let’s look for some health-related educational program,” recommended Joe, interrupting Sheila.

  “Great idea. I’m tired of the same old shows. Here’s the TV Guide,” she replied, handing the small table booklet to Joe.

  Outside, the air was warm. The small winding road in front of the McIntyre residence was silent and empty. The subdivision was either already asleep or getting ready to go to bed.