12.31.2007

obesity. viagra. heart attack. thrombolytics.

Last night in the ER...
....was very busy. And "busy" in a good way. Lots of codes and respiratory distress. Not so much "weak and dizzy" and "TMD (todo me duele)". The kind of night that reminds you why you chose emergency medicine as a specialty, and not primary care.

Anyhoo, there was this one guy...
A 36 yo morbidly obese Samoan man with a past medical history of diabetes, hypertension, and has lots of 'bad habits', was brought in by paramedics complaining of chest pain which started 10 minutes prior to the 911 call. He was sitting on the sofa watching reruns on TV when he suddenly felt a tightening in his chest. He got up to get a cup of water, and the pain got worse. Then he felt weak and lightheaded so he sat down on the nearest chair. He then called for his wife, and she took one look at him and called 911.

In the field EMS established a very tiny finger IV (because 'his veins could not be accessed secondary to excessive adipose tissue.' i.e. he was too fat). They gave him an aspirin, and after he denied using Viagra, a nitroglycerin sublingual. Immediately thereafter his blood pressure dropped from 150s systolic to low 80s. He became very diaphoretic (lots of sweating), and short of breath.

Upon ED arrival the patient was alert and oriented, but very agitated sitting upright on the gurney, in moderate/severe respiratory distress. He weighed about 450 pounds, and was extremely diaphoretic, and c/o worsening SOB. EKG could not be obtained by the paramedics because the stickers wouldn't stick to the body for all the sweat. Also, the patient was so agitated and anxious that a good reading couldn't be obtained even when the EKG leads were held in place by assistants.

In the ED we attempted to obtain an EKG...for over 20 minutes. We cannot make a diagnosis of acute MI requiring thrombolytics if we cannot obtain an EKG. Afterall, there are other deadly causes of chestpain, some of which absolutely cannot be treated with thrombolytics (or else you kill the patient). It's one thing for someone to die. It's another thing to kill them. So we worked to obtain that EKG...over, and over, and over, and over again.

During this time we worked to establish a better IV with ultrasound guidance. We worked to improve his oxygenation (from 90% on face mask to 95% on non-rebreather). We asked basic questions (allergies, past medical history, medications, *viagra use*). His bloodpressure continued to register in the low 80s (82/64 - narrow pulse pressure, with a heartrate of 120). Are you sure you don't take Viagra (or other 'viagra-like' drugs)? we asked again. He adamantly denies.

I'm so nervous at this point. Here I have a very sick patient, who I think I'm going to have to intubate. He's 450 pounds. His blood pressure sucks. And we can't get a frikin EKG. Agreed, he's likely having an MI...but what if it's an aortic dissection (which could be dissecting up to the origin of the cardiac vessels...causing the MI). On CXR it's possible that his mediastinum is widened. What if he has cardiac tamponade? (the cardiac silhouette is enlarged) I feel stuck without the EKG!!

Finally we get a very crappy EKG. The QRS complexes are very wide, and there are diffuse ST segment elevations. Hmmm....hyperkalemia? Pericarditis? Massive MI? Maybe....TCA toxicity? I give bicarb and fax the EKG to the cardiologist at home after explaining to her the clinical history. She agrees that it is consistent with hyperkalemia. We call the lab..."hey, we so *need* the results of the chemistry ASAP!! please!!" And push more bicarb. He seems to get a bit better. The QRS complexes narrow a bit. He admits to a questionable history of renal disease.

35 minutes have passed. Out of the window of thrombolytics. Now I'm going to have to justify to administrators (and those who wear suits) why I didn't push the thrombolytics in less than 30 minutes. For those that don't know, thrombolytics are very powerful clot busting drugs that have lots of potential deadly side effects. Afterall, they make the blood so "thin" and remove the ability of the blood to clot...and destroy existing clots...that brain bleeds and GI bleeds are not uncommon. And, again, if this guy had an aortic dissection or cardiac tamponade...or pericardities even...I'd kill him with this drug. My biggest source of stress was trying to mentally justify *not* giving this drug in 30 minutes or less (so my chart won't go to 'peer review', or whatever)...which is crazy being that I'm the doctor taking care of him, and arbitrary 'rules' shouldn't apply to individual patients. I should just focus on practicing best medicine, and not doing things simply to make it easier to 'explain' and 'justify' (to non-involved non-physicians analyzing *my* patient thru their retrospectoscopes) my actions after-the-fact. So I hesitate for a second, but proceed doing what I feel is good medicine...and continue trying to obtain EKG #2.

As we 'encourage' the patient to 'just "hold still for one minute," he starts blaming himself for being "so fat", not following his doctors advice...and how he deserves to die. He feels this is the end...

...all doctors know, it's never good when a patient says "I'm going to die." Especially when they're circling the drain.

Suddenly the monitor flickers, the heartrate speeds up, and the patient mumbles, "I don't feel well." Then he becomes altered. The monitors reveal v-tach...so I shock him. He wakes up with the shock. The monitor reveals sinus tach, and he's yells "what tha hell?!"" I breathe a sigh of relief. "Sir, I'm sorry, I had to shock you...your heart started having trouble."

Then it happens again. This time I warn him...."it looks like your heart is doing that thing again...I'm going to have to shock you again, I'm sorry."

"Bring it on Doc!!" he yells.

EKG #2 is obtained (finally)....and seems clear now that he's having an MI. So we get the 'thrombolytic box' out....and fax the 2nd EKG to the cardiologist. She agrees that thrombolytics may help (especially since everything we've been doing so far hasn't helped much....and the patient seems to be getting worse - with the whole v-tach/shock thing). I do a bedside ultrasound and there is no cardiac tamponade, and the heart motion....well, the heart is moving.

I suggest trying to get him to the cath lab instead of thrombolytics since this guy is in cardiogenic shock....and only a cath *may* save him. I was informed by the cardiologist that the cath table can only accommodate up to 350 pounds, so our patient couldn't go for cath. Thrombolytics are the only option for treatment of MI at this point. I ask her to come in to see the patient. She agrees. While she makes her way to the hospital, we obtain consent...and push the thrombolytics....

...30 seconds after the lytics are pushed into the IV, the patient becomes altered, agitated, and his breathing seems (more) labored. I think to myself, I'm just going to intubate him. All of his agitation isn't good for our treatment, but it's also not good for his heart. Additionally, he's nearly 500 pounds so a controlled intubation is preferable. I anticipate a very difficult airway because of his size, the severity of his medical problem, and the fact that he's in cardiogenic shock with frothy sputum coming up his airway.

I intubate him (despite the fat, and thru the pink froth). RT (respiratory therapy) secures the tube. And just then, he's in v-tach again. Before we charge the paddles he deteriorates into asystole. WTF? We'd already given the thrombolytics so I was hoping that this was the 'reperfusion rhythm.' But. It. Wasn't.

We started ACLS...and coded this guy. We got him back....kinda.

The cardiologist comes in and we agree the guy was in bad shape when he arrived. And the fact that he couldn't go to cath lab because of his weight....and the fact that (we later found out) he wasn't honest about his viagra use...and his multiple medical problems, bad habits, etc. made a bleak situation, worse.

In typical fashion, we coded this guy every 45 minutes or so...until he got a CCU bed (maybe 90 minutes later).

He made it to the CCU....and eventually started bleeding from every orifice (including his eyes and ears). It's like he was crying blood. That's what thrombolytics will do. Like most full arrests, he didn't live to hospital discharge.

Most doctors have memorable patients they think about for a long time after their encounter with them. This guy was one of mine.

131 comments:

wealthandtaste said...

Howdy,

Love the blog. I had a similar patient during my clinicals as a paramedic student. On arrival had a HR in the 40's with no palpable BP, gave 1mg atropine to no effect, put on TCP pads with good capture but now he's hypoxic and altered and not enjoying the amperage. After we got a 12 lead showing a massive inferior MI + reciprocal changes his LOC deteriorated even more and I was forced to RSI him. We dropped him off in the ER, he went off to the cath lab (Hx of 13 MI's + EIGHT stents!) and subsequently expired. It's weird to think that the last thing he ever saw before the etomidate hit was my face, poor guy didn't even get to see anyone good looking!

Good post.

wealthandtaste, nremtp

exigence said...

Intense read; one of the more enjoyable blog posts to come a'rolling via my RSS feeds in quite some time.

Interesting that it's posted now; I'm just now starting the long road (MCAT = 01/26) and was wondering how regularly EM docs have those really "EM patients" instead of TMDers.

Kate said...

yikes.

The Happy Hospitalist said...

It's amazing how patients will lie to you up until the very end. Great story. Also a great indication on how hospitals are not set up to accommidate the morbidly obese. You did everything you could with what you had to work with.

frylime said...

wow.

and you would think that once he realized (or not?) that he was in some major trouble, he would have told you about the viagra...i still have much to learn.

Lisa said...

Great post.

marty said...

Great post. You capture the essence of what happens all too frequently in the ER. Medicine is difficult. Then you add 400lbs, self abuse, incomplete information, frank lying, inadequate resources, litigation fear, and rectrospectoscope bean counter review into the mix it makes EM practice very shitty. There was probably 5-10 other patients with BS complaints probably moaning because they were not getting attention during this time.

I spent 8 years of postgraduate education to endure these nightmares at 2am. WTF. And just how many minutes does that take of your own life?

I hear you man.

Anonymous said...

Excellent post!

Dr. Val said...

Wow. Scary stuff. You did the best you could. :(

halfmd said...

A perfect illustration of the bad things that patients can do to themselves... unchecked obesity, lying about viagra... and you're the one who's going to get in trouble. Have you had to explain yourself to the suits yet?

Toni Brayer MD said...

What an excellent summary of a very difficult situation. You did all you could considering the non-truthful history and comorbidities. Wow!

Anonymous said...

mind posting EKGs 1 & 2?

Stephen said...

Really too bad when you can't get people to just tell the truth, even when it will kill them.

/sigh

janet said...

I am an EM doc too. Sounds like Murphy's law and real life.

I am lucky that I don't feel the presence of the big brother-non-doc-second-guessers looking over my shoulder. I do know that most critically ill patients and their care will be reviewed by my peers and remain acutely aware of the need to document if and why patients don't get thrombolysis w/in 30 minutes, EKG w/in 10minutes, aspirin, etc. PEER review in my hospital is by my PEERS and is not usually stressfull and is mostly interesting and education. Again, I feel blessed. That doesn't mean the job is easy....emergency medicine is an endless challenge and usually interesting.

Thank you for sharing this...it strikes a chord.

ER doctor said...

Thanks for the support everyone. :0) I can certainly say I'm not quite as nervous when a "chest pain patient" come thru the door...afterall, can't be worse than this guy!!

Not that it mattered in the outcome...but this guy consistently lied about his Viagra use. It was his wife that told us...as we brought her into the room to watch the code, that told us..."you know, he did use some of that viagra or cialis stuff today."

I do not have the EKGs here...but I can probably find some online that match this guys (minus the artifact). And, the "men in black" have not approached me regarding this case. I did document, literally 2-3 pages of handwritten notes...and an extensive "why I didn't give thrombolytics within 30 minutes" paragraph or two. Maybe that's enough for them to simply trust that everything was done appropriately...

Our peer-review is supposed to be 'friendly'...but it's not. No one in our group wants their charts to go to peer review. So, hopefully...it won't.

Thanks again for the feedback.

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Steve said...

Perhaps if you had explained to him why you were asking about the viagra use he would have been more honest with you. If you did and neglected to mention it in the post, thats fine, but I'm sure he would have told you if you told him why you needed to know.

Cody said...

There's nothing worse than that feeling you get when a patient tells you they're going to die and you know they're right.

The thing that struck me as the most odd about this story is that you spent so much time on the phone with your cardiologist. Whenever we have a patient that may need a cath the cardios are there in 30-45 min or less.

Pancho Villa said...

This is one of those cases where you learn why we all have a "gut instinct."

(You and) Your (colleagues') perception of the subtleties are why we don't have "How to be a doctor for dummies" or "Doctoring by the numbers: 1-2-3" books. Your attention to detail and perception of the near-imperceptible makes it clear that even rules of thumb aren't infallible. This is why you're a physician. Excellent work!

Tell the suits Pancho Villa will vouch for your performance! :)

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