An elderly female with previous coronary artery disease, diabetes, and hypertension called EMS for chest pain. Then she has a syncopal event in front of her husband.
Medics arrived and found the patient in ventricular tachycardia. They cardioverted her back to sinus rhythm, but she was still hypotensive. EMS transports her as a sudden cardiac arrest to a STEMI facility.
The patient is taken directly to cath lab which had already been activated due to the EMS report of a “code STEMI.”
During the angiogram, the patient remained unstable, went in and out of ventricular tachycardia, and remained markedly hypotensive, requiring fluid resuscitation and pressors. The angiogram showed severe three vessel disease.
Cardiologists couldn’t get the patient stable despite pressors, IV fluids, multiple defibrillations, and ACLS drugs.
Then the cardiology fellow notes that the patient’s abdomen seemed to be distended – moreso since the case started. They directed the cardiac catheter down the aorta and injected dye while doing cineangiography. It showed contrast material going into the patient’s peritoneal cavity.
Shortly afterwards, while making arrangements for the patient to be taken to surgery, she died on the table.
The rest of the history came out when the husband was informed of his wife’s death. The night before, the patient had been seen at a different hospital for evaluation of abdominal pain. They diagnosed her with “obstipation” and sent her home.
Some of you are probably wondering how cardiologists missed the ruptured abdominal aneurysm when they inserted the catheter into the groin and advanced it up the aorta into her heart. Radial access is all the rage these days, so initial access was through the arm and not through the leg. Therefore, the catheter didn’t pass through the lower aorta.
So why was the patient in ventricular tachycardia? The cardiologists surmised that the hypotension led to low cardiac perfusion, which, in the setting of severe CAD, caused chest pain, cardiac ischemia, and the arrhythmias.
The patient probably wouldn’t have survived surgical repair of her aneurysm, but one of the down sides to that holy grail of a short door to balloon time is that it is more difficult to obtain a complete history.
Ironic that sometimes hospital boards and/or administrators care more about their numbers than they do about the actual patients. When hospital boards or administrators pressure medical staff to meet unreasonably high standards for “door to balloon times,” perhaps lawyers need to start looking at the administrators and board members for reckless decisions that result in adverse patient outcomes.
This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.