It was one of the first cases of the evening. I had all the time in the world in the ED to do the work up. But if the patient needed admission, we were approaching the holidays when it would be really difficult to get specialists to stop their charge out the door to get entangled in a difficult case. Everyone would be trying to put things off or temporize and see the case later. But one look at this patient and it was clear that he did not want to wait.
He was 93-years-old and in relatively good health. His records showed that he had had stable angina for decades treated with stents and various medications. But tonight he complained that his chest pain was now severe and intractable. Initial EKGs were unchanged from previous ones and his initial labs were borderline negative. Rather than wait four hours for another set of enzymes I took a chance and called the interventional cardiologist of record that I had seen coming down the hallway as I came in the hospital.
The cardiologist answered right away. After hearing the story he remembered the patient well as a kindly old man with a dry sense of humor. He recalled that the man had no risk factors other than age and bad genetics. He even recalled his cath results from several years back. Multiple lesions had been stented, but multiple other lesions that were either in bad locations or were not ready for stents at that time.
“What do you want me to do?” I said. “I can get another set of enzymes in four hours, but by then it will be after midnight. Who’s on call for the cath lab?” I asked already knowing the answer.
“I am,” he said after a long sigh. He was a reasonable man and usually easy to work with on shifts, but he didn’t like taking calls after midnight. I even recalled once giving him a rather long patient presentation followed by a long silent pause. He had fallen back to sleep. There was a long pause tonight as well.
Finally he said, “I’m here. Let’s take him to the cath lab now and see if there is anything I can do.”
“I’m sure he and his family will appreciate it,” I said. “I’ll let him know and get things prepared on this end if you want to go ahead and notify your cath team.” It seemed like everything was going smoothly. About an hour or so later I got a call from him.
“I can’t do anything for this guy,” he said without any introduction. “He has lesions all over the place. Some of them are in areas that I can’t get to with a stent. The lesions that were mild a few years ago are really bad now. But oddly enough his distal vessels are still relatively clear.”
“You’re not suggesting bypass grafts on a 93-year-old are you?” I wasn’t sure I understood his implication and I wanted to be absolutely clear.
“Hey, I’m just saying I can’t help him,” he said defensively. “He can either live where he is or consider this alternative. That’s all I’m saying.”
“Wait, wait, wait,” I said with a cynical chuckle. “Do you know if any of the CV surgeons will do a multi-vessel bypass graft on a 93-year-old. Otherwise this is a false choice.”
“Call Dr. Morris. He’s on call. He’s usually game for any work that really needs to be done. But call him now if you really want to get this done. I know he’s planning to leave town for the holidays. I doubt if anyone else on the schedule would touch a case like this.”
I was feverishly tapping the table with my thumb as I searched for the best of all the bad alternatives for this patient. It was a habit that drove my wife mad.
“Are we good?” he said trying to sign off.
“Yeah, yeah, yeah,” I said absent-mindedly. I thought that the case had been worked up appropriately and had gone well so far. He had been transferred to the treating physician in a timely manner. So why was this case landing back in my lap for disposition? I was just ruminating on this when I saw the patient being pushed back into the ER by the orderly.
“I thought the patient was admitted to the cardiologist for cath,” I said to the charge nurse. “Why is he back here?”
“The cath lab took him so quick that we didn’t have time to admit him,” he said. “Now they are saying that he is your patient for disposition. They told us you were admitting him to the CV surgeons for bypass grafting.”
“No, no, no,” I protested. “That’s just a consideration. The patient hasn’t even heard of this. And no surgeon has accepted him. Heck, I haven’t even presented him to the CV surgeon on call.”
“I guess that means you want me to call the CV surgeon on call?” He gave me a shrug that said ‘I have no dog in this fight.’
“Let me go talk to the patient and we’ll see.”
“Don’t dilly dally on this,” he warned. “The clock is ticking. The Fellow might still be in house. After that, it’ll be the second year or event the intern doing the work up. And you know what that means.”
“Ok, ok, I’m on it,” I said impatiently.
When I entered the room I could see that the old man was still in some distress. His face was pale and he was gently rubbing his chest. He gave me a wan smile.
“They say they can’t help me,” he said seeming to probe my reaction.
“No… he said he couldn’t put in any more stents. He seems to think that you would benefit from bypass grafting,” I said waiting for his reaction. But his expression seemed to suggest that he didn’t know what I was saying. “He seems to think you could benefit from surgery.”
“What do you think, doc?” he said as if he was speaking to his son.
“It wouldn’t be without risk,” I said shading the truth. “But it might help.”
“I can’t go on like this,” he said.
“Ok,” I responded without breaking from his trusting gaze.
I made the call to the Fellow, who said that he would schedule the surgery for the next morning and send the intern down for the pre-op workup. It was, he explained, coming up on the holidays and would be the last case of the day. And just like that, the case was scheduled for the next morning.
I explained the plan to the man and his family. Both seemed relieved and yet still a little apprehensive about the risk presented by his age and the drastic measures we had suggested. I tried to reassure them and told them I would try to make him comfortable. As I came in for my next night’s shift, I stopped by the surgical ICU to check on him.
The surgery had gone well, but he was requiring multiple pressors. An attempt at early extubation had resulted in aspiration and potentially aspiration pneumonia. And now his virtual obtundation suggested multiple ischemic strokes. I spoke with the family briefly who seemed to hold out hope of eventual total recovery. But I knew that each day his mental status waned spelled a bad outcome.
The next day I stopped by again hoping to see improvement, but the team had seen no improvement and was pressuring his elderly wife to make him a DNR and consider taking him home to be on hospice. On the way out of the unit I ran into the patient’s cardiologist.
“Why didn’t you call me?” he asked trying to politely disguise his frustration. “I could have told you he wouldn’t tolerate a big surgery like that. The family told me that he was almost pain free the morning of the operation. But they were already prepping him for surgery. What was the rush?”
“The holidays?” I said with a frustrated shrug.
“Yeah,” he said with a shake of his head. “Merry Christmas.”