It started out like any other night. My wife took a shower, put on a T-shirt and some sweatpants, and walked downstairs to let the dogs out one final time for the evening. I heard her close the front door as I laid in bed watching the news. It’s odd how one look can change things. She walked back upstairs and stood in the hall for a few moments. I looked over. She turned her head so that the light from the television illuminated her face. Her gaze locked onto mine and I knew there was a problem.
“There’s something wrong,” she says.
“What do you mean?” I ask, sitting bolt upright in bed.
“I think I’m having a heart attack.”
I jump up and have her lay down on the bed. Her skin feels diaphoretic. Or maybe it is the moisturizer from the shower. Her pulse is strong, but racing. Maybe it’s just a panic attack. I palpate for a few more seconds and can feel the irregularity in the beats. Great. She’s in atrial fibrillation. But why?
We happen to have an EKG machine in the basement that she used to keep in her medical office. I run downstairs to grab it. When I came back to the room with the machine under my arm, she is sitting upright in bed with her hand on her carotid pulse.
“Lay back down for a minute so I can get an EKG.”
“I’m feeling a lot of chest pressure.”
“It will just be a minute, and then we’ll be on our way.”
Unfortunately, as I begin placing the EKG leads, they pop right off. Moisturizer on her skin didn’t help matters. Or maybe it’s diaphoresis. I go to the closet to get a towel to dry her skin. When I return and reach over her, she sits up in the bed, grabs me by the shirt, and says, “Get me to the hospital or I. AM. GOING. TO. DIE.”
Words like that coming from the most important person in your life tend to have a way of snapping you out of “doctor” mode. Still, I hesitate. On one hand, it would be helpful to have an EKG so that we know whether or not she is having a STEMI. On the other hand, it is obvious that we’re not going to be able to get an EKG done before we leave.
“Call an ambulance,” she says.
The station is six to eight miles away. “Forget it. By the time an ambulance gets here, we’ll be more than halfway to the hospital.”
We quickly wake our oldest daughter and tell her what is happening as we walk out the door. During the ride, we hold hands. I unconsciously put my finger on her wrist to monitor her pulse.
“Stop checking my pulse, dammit. You’re making me more nervous.”
“Okay, well stop tapping your foot on the floor. I don’t have red lights and a siren.”
I pull up to the front entrance of the hospital. I am tempted to drive around to the ambulance bay, but think that the sight of some random person in pajamas with his hair sticking every which way pounding on the ambulance bay doors would probably prompt a call to police rather than a call for a stretcher. Yeah, if I was working a shift and saw someone like that, it would be a mime routine of “Go around the front” closely followed by “Someone call security.” No way are they opening the ambulance bay doors in that scenario.
“Make sure you tell them that you’re having chest pain,” I tell her as I help her into a wheelchair under the hospital canopy. “Don’t downplay this. You hear me?”
“Of course, I’ll tell them I’m having chest pain. I AM having chest pain.”
I quickly park the car and jog inside. By then, she is in the triage room, and the nurse is having the same problems I was having getting the EKG electrodes to stay in place.
“Sorry, I just took a shower and used moisturizer.”
The nurse goes to get some wipes to remove the moisturizer. I look at my wife and give her a smirk. She is not amused.
Soon, the EKG is making the all-too-familiar whirring noise and begins spitting out a piece of red graph paper. The machine is out of her line of view, so in my peripheral vision I see my wife staring at me, waiting for some type of facial expression. She’s in rapid atrial fibrillation with a rate of 170. Fortunately, no ST changes. I try to keep a poker face. She is even less amused.
The nurse interrupts. “Let’s just get you back to a room.”
The nurse escorts her back to room in a wheelchair. I help her change into a gown.
You know that whole patient satisfaction suggestion where people are happy if they are seen within 30 minutes? Don’t believe it. When you think you’re having an emergency, ten minutes seems waaaay too long to wait.
I can’t help pacing back and forth. I check her pulse a couple times. It is still racing. She is still sweaty—or moisturized—it doesn’t matter which at this point. She is still having chest pain, too. Five more minutes elapse. That’s it. I begin digging through unlocked drawers trying to find leads so that I can hook her up to the cardiac monitor myself. Then maybe the beeping from the monitor alarms will get someone in the room. All I find are extra gowns, urinals, and some random alcohol pads. I consider going to go to the counter to ask for the leads, but then think how that would also probably prompt a call for security.
So we sit in the room holding hands and try to watch “Ridiculousness” on television. I intermittently check her radial pulse. Still racing.
“Stop it, already, will you?”
“Sorry. I just hope they don’t have to cardiovert you.”
“This time I’m not kidding.”
After another 15 minutes, my wife gives me that look again. I have to do something. So I commit one of the cardinal sins in emergency medicine: I poke my head out the door to see what is happening. Unfortunately, it is late at night, so there is only one doctor working, and I can tell it is a busy night. The doc sees me looking out the window, grabs the chart and EKG, and walks towards the room. Younger fellow. Calm demeanor. Nods his head and smiles a lot.
“I’m not sure why it happened, but she’s in atrial fibrillation, and she has never been in atrial fibrillation before. She was complaining of chest pain. It seems better now. She also had some shortness of breath.”
I am about to run through a differential diagnosis, but stop myself short. He’s the doctor now, not me. But I still can’t help thinking about the differential diagnosis. Pulmonary embolism? Hyperthyroid? Some undiagnosed valve abnormality? High blood pressure? She received an iron infusion a few days prior, but that shouldn’t be causing symptoms now.
The physician performs a brief exam. He gets a little more history, and then has the nurse start an IV line. He orders Cardizem for rate control.
As the monitor comes online, a rapid blipping noise echoes through the room with each heartbeat.
“Great,” my wife sighs as she hears her heart rate.
Then the rate alarm goes off.
“Wonderful,” she sighs again and slowly shakes her head.
Two nurses are assigned to the room. One starts the IV as the other gets medications from the pharmacy. After receiving two doses of Cardizem, my wife’s heart rate drops to 130, but she remains in atrial fibrillation. I ask whether or not we should be cardioverting her since she is still having chest pain. My wife shoots me a scowl.
“No, we don’t do cardioversion in the emergency department,” the nurse notes. “The cardiologist will do it upstairs when he sees her.”
My wife shoots me a bigger scowl. She is making it blatantly obvious that she doesn’t like the thought of electrical intervention. I shrug my shoulders.
Four hours elapse before we move from the emergency department to the telemetry floor, and it is 3 o’clock in the morning. I sit in the chair holding my wife’s hand as she closes her eyes. She gets about a half hour of sleep. I get a little sleep as well—maybe an hour. We wake up by a nurse checking on her, then by a lab technician drawing the next set of cardiac enzymes. Shortly afterwards, a tech comes by to check vital signs. Then someone knocks and asks if we want a newspaper. Then one of the clergy comes to see if we want to attend mass. With every knock at the door, I find it more and more ironic that people want to be admitted to the hospital so they can “get some rest.”
The cardiologist comes by at about 7 a.m. My wife’s heart rate is in the 150s. He orders another dose of Cardizem and begins to discuss cardioversion. As he does so, I can see the look on my wife’s face drop.
He steps out of the room to answer a page. Suddenly, my wife raises her eyebrows.
“It stopped,” she says. “My rhythm is normal. I can feel it.”
A repeat EKG confirms that she is indeed back in sinus rhythm.
The next several hours are filled with tests. They have discovered that we are both physicians. Actually, my wife told them that I was an ER doc. They discuss the results with both of us. An echocardiogram is normal. Her TSH is normal. A D-dimer is also normal. We had a couple glasses of wine with dinner that evening, but that wasn’t out of the ordinary. Could it have been “holiday heart” syndrome? Unlikely. There were a few reports of the new intravenous iron solution she had received precipitating atrial fibrillation. We contacted the manufacturer and made another report. The cardiologist recommends that she start taking Cardizem and see him in the office the following week. She never fills the prescription. We have some difficulties sleeping the evening we returned home (and I hide the moisturizer just in case), but things quickly return to normal.
The thing that my wife remembers most about this experience was that I kept her calm by remaining calm myself. She also remembers trying not to offend me as I was attempting to get the EKG. She noted how few people performed a thorough examination on her. She didn’t recall anyone touching her thyroid or feeling to see if her legs were swollen or tender. What I remember most about the experience was that all I wanted was to know what the hell was wrong with my wife and what was going to be done about it. Actually, I knew what was wrong. I just wanted someone to fix the problem. I didn’t care about much else.
I try to incorporate better explanations into my own practice now. The funny thing is that I find many times (not all the time, though) patients don’t necessarily want a slew of tests. Often, they just want someone in a white coat to tell them that everything is OK, that they probably don’t have cancer or a heart attack, or that their child isn’t going to die from a fever. Communicating these thoughts often makes the patient feel better, but having recently been in the same situation, it also makes me feel better to know that I’ve been able to address their concerns.
Fast forward a couple of weeks. In the mail is a form letter from some company called “Press Ganey” asking us to rate our experience. My only question: “Honey? Where do the kids keep the glitter for their art projects?”
Write In, Be Heard
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