Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

The Heart of the Matter

The Heart of the Matter I became an emergency physician for many reasons, including my love of immediate problem-solving and my interest in episodic patient care. But by definition, my role as an initial caregiver means that I rarely know the endings to the stories, many of them joyful, some tragic. One patient was different. As I went on my shift in the emergency department, I found it quiet. There were a few patients left over from the night shift, and three new patients waiting to be seen. As I was preparing to review a case with a resident, I received a call from the radiologist. These early-morning calls usually meant that the radiologists had found a discrepancy with the previous night's reading. “We were reviewing a CT scan from last night,” she began, “which was ordered to rule out a pulmonary embolism, and there appears to be an unusual additional finding. The patient may have an anomalous right coronary artery that seems to be traveling between the pulmonary vessels and aorta.” I realized the implications of this information—sudden cardiac death has many causes, one of which is the coronary arteries having an abnormal anatomical location. It is estimated that 15% of young people who experience sudden death from cardiac causes are found to have a coronary artery anomaly.1 It is the second most common cardiac cause of sudden death in young athletes. I looked over the patient's medical record from the night before. She was 22 with a history of three recent visits to the ED for asthma. On the latest one, the team suspected these repetitive asthmatic attacks might be a manifestation of a pulmonary embolism, hence the chest CT. They appropriately read the scan as negative for clot, treated her wheezing, and discharged her to home with prednisone and β-agonists. My next call went to the cardiologist on staff, who agreed with the radiologist and recommended a coronary CT scan or an angiogram to determine the actual anatomy. He impressed me with the urgency of doing this. If the coronary artery really was located between the aorta and the pulmonary vessels, the patient could have a cardiac arrest with the slightest exertion or rapid heart rate. Since she was also taking β-agonists for significant asthma (on one of her visits to the ED, she was even hypoxic), we realized that her heart rate was already exaggerated. The cardiologist gave me other advice and then, of course, recommended she see him at his clinic as soon as possible. This was the moment I dreaded. There was one additional piece of information that was not yet discussed: The patient was uninsured. Normally, that is not something I like to divulge, but given her likely path of multiple expensive imaging examinations, ultimate surgical correction, and a lengthy hospitalization, the cost of her treatment would undoubtedly be in the hundreds of thousands of dollars. As an emergency physician, I cannot refer to specialists unless there is a life-threatening problem. This case certainly qualified as life-threatening, but just as death could be the next week or day or hour, it could also be years and years away. The ultimate decision for whether she would be treated would rest with the medical and hospital team assigned to make these decisions. The cardiologist and I agreed that we needed to at least determine whether she had this anatomical problem, and then the remainder of her course could be discussed by others. I was also the person who had to call the patient and tell her the news. In 30 years of practicing emergency medicine, I have had my share of giving bad news to patients, telling relatives of the death of loved ones, explaining medical problems, and grieving with families. In fact, I have even written about how to tell bad news to patients and family, but I have yet to master this process over the phone—it is cold and sterile and difficult—I hate it, yet I had to do it. The ED was beginning to fill up with new patients, and I needed to reveal to her the diagnosis. You can rehearse this message a hundred times, but there is no way to anticipate the patient's response. “Hello, Ms Jones. This is Dr Honigman calling from the ED at the university. How are you feeling this morning?” “My wheezing is better, but I am tired.” “Are you having any chest pain?” “No.” “That's good. I need to talk to you about the CT scan that you had last night, when the doctors thought that you had a clot in your lungs. The radiologists reviewed that scan again this morning and found a possible problem.” “What kind of problem?” I tried to stay calm and reassuring, but I knew the next sentence would be difficult. “It's not a certainty, but there is a concern that one of your heart arteries may not be in the right place. The biggest worry would be that heavy work or a rapid heart rate might cause the heart muscle to block that artery and cut off blood flow to your heart.” There was a pause—it felt like hours! “What do you mean?” was all she could say in a trembling voice. I imagined her heart rate rising as we spoke. I explained the anatomy of her coronaries as best as I could. “There are 2 main arteries around the heart. One of them is perfectly normal, but the other one looks like it may not be in the right anatomical location. The good news is that if you really have this, it can be fixed. The bad news is that you cannot strain too much while working or exercising. It is also not a good idea to take too much of your inhaler, because that can cause your heart rate to get too fast, which can also cause the artery to lose flow. Do you understand this so far?” “Yes, but I work as a stocker at a warehouse, and I lift heavy boxes all the time. Do I have to stop? What about my asthma? The inhalers are the only thing that help with it.” She began to cry. I explained to her that the cardiologist had agreed to see her in the next few days but that she had to stay home from work, had to use only her steroids and to minimize the use of inhalers, and had to come back to the ED for any chest pain. We talked about the risk of sudden death, as I thought it was vital that she understand the full implications of this problem; she needed to be diligent in her follow-up. We also discussed her lack of insurance and the possible implications. I assured her that we would do our best to care for her heart condition. I hung up, relieved that I had spoken to her, but feeling drained. That was difficult, but now came the task of ensuring that an uninsured patient with a major medical problem could get seen in our system. The funds available for uninsured patients in my state are extremely limited. At my hospital as at others, we have to be very judicious with these funds in order to provide service to the neediest and most critically ill patients. As an emergency physician, I am confronted by this issue on a daily basis, but rarely by a case as dramatic as this one. This patient was seen a few days later in the cardiology clinic, and then she was in different hands. Her medical plight aroused the compassion of the entire team—cardiologists, surgeons, and intensivists. She ultimately had her coronaries surgically corrected and received excellent care in the intensive care unit. On a recent evening shift, 2 years after my episode with this young patient, the resident began telling me of a woman in room 12 with vomiting and diarrhea. “She has quite a remarkable past history for someone so young,” said the resident matter-of-factly, but before she could tell me more, she was interrupted to provide care to someone else. I walked into room 12 to find a woman dozing in bed. I woke her and introduced myself as Dr Honigman, the attending physician. She opened her eyes and said, “What did you say your name was?” “Dr Honigman,” I repeated. Tears started streaming down her face. Now, I must admit I do not usually have this effect on my patients, so I asked, “Why are you crying?” “You saved my life!” she replied. She then told me who she was and brought back that conversation 2 years before, the follow-up visits to our clinics, subsequent surgery, and her health since that time. I was speechless and touched. All I could do was hold her hand for several minutes, cry a few tears of joy, and tell her I was happy to finally meet her and delighted to see her well. We talked for a few more minutes, and I found out that despite a rocky surgical recovery, she recently got a new job (with health insurance coverage!) and that aside from this “gastroenteritis,” she was doing fine. Before she left I gave her a hug (as part of her discharge plan) and wished her the best. On this particular occasion, I was gratified by finding out the positive outcome for this patient, which reinforced all of the reasons that I became a physician. But I was well aware of what would have happened had the real heroes not performed in an exemplary fashion: the radiologist who made the discovery of the anomalous artery; the cardiology team who agreed to see the patient and operate on her heart; and the hospital that agreed to provide her with definitive surgical care. She would have undoubtedly been a statistic in the “sudden cardiac arrest” registry. During this time of health care reform discussions, it is worrying that life-saving events for patients such as Ms Jones may become more difficult as health care costs increase and the number of uninsured patients rises. Yet doing the “right thing” for our patients must always be our guiding light as we debate the solutions to our health care problems. References 1. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA. 1996;276(3):199-204Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

The Heart of the Matter

JAMA , Volume 302 (24) – Dec 23, 2009

Loading next page...
 
/lp/american-medical-association/the-heart-of-the-matter-Pr6rNAZFhU

References (1)

Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2009.1808
Publisher site
See Article on Publisher Site

Abstract

I became an emergency physician for many reasons, including my love of immediate problem-solving and my interest in episodic patient care. But by definition, my role as an initial caregiver means that I rarely know the endings to the stories, many of them joyful, some tragic. One patient was different. As I went on my shift in the emergency department, I found it quiet. There were a few patients left over from the night shift, and three new patients waiting to be seen. As I was preparing to review a case with a resident, I received a call from the radiologist. These early-morning calls usually meant that the radiologists had found a discrepancy with the previous night's reading. “We were reviewing a CT scan from last night,” she began, “which was ordered to rule out a pulmonary embolism, and there appears to be an unusual additional finding. The patient may have an anomalous right coronary artery that seems to be traveling between the pulmonary vessels and aorta.” I realized the implications of this information—sudden cardiac death has many causes, one of which is the coronary arteries having an abnormal anatomical location. It is estimated that 15% of young people who experience sudden death from cardiac causes are found to have a coronary artery anomaly.1 It is the second most common cardiac cause of sudden death in young athletes. I looked over the patient's medical record from the night before. She was 22 with a history of three recent visits to the ED for asthma. On the latest one, the team suspected these repetitive asthmatic attacks might be a manifestation of a pulmonary embolism, hence the chest CT. They appropriately read the scan as negative for clot, treated her wheezing, and discharged her to home with prednisone and β-agonists. My next call went to the cardiologist on staff, who agreed with the radiologist and recommended a coronary CT scan or an angiogram to determine the actual anatomy. He impressed me with the urgency of doing this. If the coronary artery really was located between the aorta and the pulmonary vessels, the patient could have a cardiac arrest with the slightest exertion or rapid heart rate. Since she was also taking β-agonists for significant asthma (on one of her visits to the ED, she was even hypoxic), we realized that her heart rate was already exaggerated. The cardiologist gave me other advice and then, of course, recommended she see him at his clinic as soon as possible. This was the moment I dreaded. There was one additional piece of information that was not yet discussed: The patient was uninsured. Normally, that is not something I like to divulge, but given her likely path of multiple expensive imaging examinations, ultimate surgical correction, and a lengthy hospitalization, the cost of her treatment would undoubtedly be in the hundreds of thousands of dollars. As an emergency physician, I cannot refer to specialists unless there is a life-threatening problem. This case certainly qualified as life-threatening, but just as death could be the next week or day or hour, it could also be years and years away. The ultimate decision for whether she would be treated would rest with the medical and hospital team assigned to make these decisions. The cardiologist and I agreed that we needed to at least determine whether she had this anatomical problem, and then the remainder of her course could be discussed by others. I was also the person who had to call the patient and tell her the news. In 30 years of practicing emergency medicine, I have had my share of giving bad news to patients, telling relatives of the death of loved ones, explaining medical problems, and grieving with families. In fact, I have even written about how to tell bad news to patients and family, but I have yet to master this process over the phone—it is cold and sterile and difficult—I hate it, yet I had to do it. The ED was beginning to fill up with new patients, and I needed to reveal to her the diagnosis. You can rehearse this message a hundred times, but there is no way to anticipate the patient's response. “Hello, Ms Jones. This is Dr Honigman calling from the ED at the university. How are you feeling this morning?” “My wheezing is better, but I am tired.” “Are you having any chest pain?” “No.” “That's good. I need to talk to you about the CT scan that you had last night, when the doctors thought that you had a clot in your lungs. The radiologists reviewed that scan again this morning and found a possible problem.” “What kind of problem?” I tried to stay calm and reassuring, but I knew the next sentence would be difficult. “It's not a certainty, but there is a concern that one of your heart arteries may not be in the right place. The biggest worry would be that heavy work or a rapid heart rate might cause the heart muscle to block that artery and cut off blood flow to your heart.” There was a pause—it felt like hours! “What do you mean?” was all she could say in a trembling voice. I imagined her heart rate rising as we spoke. I explained the anatomy of her coronaries as best as I could. “There are 2 main arteries around the heart. One of them is perfectly normal, but the other one looks like it may not be in the right anatomical location. The good news is that if you really have this, it can be fixed. The bad news is that you cannot strain too much while working or exercising. It is also not a good idea to take too much of your inhaler, because that can cause your heart rate to get too fast, which can also cause the artery to lose flow. Do you understand this so far?” “Yes, but I work as a stocker at a warehouse, and I lift heavy boxes all the time. Do I have to stop? What about my asthma? The inhalers are the only thing that help with it.” She began to cry. I explained to her that the cardiologist had agreed to see her in the next few days but that she had to stay home from work, had to use only her steroids and to minimize the use of inhalers, and had to come back to the ED for any chest pain. We talked about the risk of sudden death, as I thought it was vital that she understand the full implications of this problem; she needed to be diligent in her follow-up. We also discussed her lack of insurance and the possible implications. I assured her that we would do our best to care for her heart condition. I hung up, relieved that I had spoken to her, but feeling drained. That was difficult, but now came the task of ensuring that an uninsured patient with a major medical problem could get seen in our system. The funds available for uninsured patients in my state are extremely limited. At my hospital as at others, we have to be very judicious with these funds in order to provide service to the neediest and most critically ill patients. As an emergency physician, I am confronted by this issue on a daily basis, but rarely by a case as dramatic as this one. This patient was seen a few days later in the cardiology clinic, and then she was in different hands. Her medical plight aroused the compassion of the entire team—cardiologists, surgeons, and intensivists. She ultimately had her coronaries surgically corrected and received excellent care in the intensive care unit. On a recent evening shift, 2 years after my episode with this young patient, the resident began telling me of a woman in room 12 with vomiting and diarrhea. “She has quite a remarkable past history for someone so young,” said the resident matter-of-factly, but before she could tell me more, she was interrupted to provide care to someone else. I walked into room 12 to find a woman dozing in bed. I woke her and introduced myself as Dr Honigman, the attending physician. She opened her eyes and said, “What did you say your name was?” “Dr Honigman,” I repeated. Tears started streaming down her face. Now, I must admit I do not usually have this effect on my patients, so I asked, “Why are you crying?” “You saved my life!” she replied. She then told me who she was and brought back that conversation 2 years before, the follow-up visits to our clinics, subsequent surgery, and her health since that time. I was speechless and touched. All I could do was hold her hand for several minutes, cry a few tears of joy, and tell her I was happy to finally meet her and delighted to see her well. We talked for a few more minutes, and I found out that despite a rocky surgical recovery, she recently got a new job (with health insurance coverage!) and that aside from this “gastroenteritis,” she was doing fine. Before she left I gave her a hug (as part of her discharge plan) and wished her the best. On this particular occasion, I was gratified by finding out the positive outcome for this patient, which reinforced all of the reasons that I became a physician. But I was well aware of what would have happened had the real heroes not performed in an exemplary fashion: the radiologist who made the discovery of the anomalous artery; the cardiology team who agreed to see the patient and operate on her heart; and the hospital that agreed to provide her with definitive surgical care. She would have undoubtedly been a statistic in the “sudden cardiac arrest” registry. During this time of health care reform discussions, it is worrying that life-saving events for patients such as Ms Jones may become more difficult as health care costs increase and the number of uninsured patients rises. Yet doing the “right thing” for our patients must always be our guiding light as we debate the solutions to our health care problems. References 1. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA. 1996;276(3):199-204Google ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Dec 23, 2009

There are no references for this article.