I tried not to sound too tired or annoyed, even though I was answering the phone from my bed and looking forward to ending my day. It was about 10:00 p.m. on a Friday night, and my two daughters (one about to turn two years old and the other ten weeks old) had just fallen asleep.
“Hi Jim, it’s Ed.” One of the family practitioners who participates in our group, Ed had two things to tell me. The first was that he had traded call weekends with one of our other colleagues, and he was therefore on call for the weekend. I wasn’t prepared for the second.
“Fred Cartwright was admitted to Marin General tonight after a cardiac arrest.”
My turn had come. During my training, gray-haired mentors had warned me that someday I would evaluate someone having symptoms that would lead to heart attack and would miss the diagnosis. Herb, the family practitioner whose practice I took over eight years ago, decided after his first such miss that he would never let it happen again, so in the days before managed care, he bought a treadmill and gave every patient in his practice an exercise treadmill test when they turned 40. I sold that treadmill last year.
Ed gave me the Marin General emergency-room phone number and hung up. After I sat on the bed for about 30 seconds sinking under the weight of my plummeting ego and spirits, I called the hospital. Dr. Kahn, the ER physician who helped resuscitate Fred, could tell I was anxious and didn’t waste words. Fred had severe chest pain while hiking down Mount Tamalpais that evening and called 911. In the ambulance, his heart went into ventricular fibrillation, a state of uncoordinated electrical chaos in which the heart muscle quivers uselessly instead of contracting and pumping blood. Thirty minutes of advanced cardiac life support (ACLS), including electrical shocks and multiple medications, didn’t accomplish anything until someone had the inspiration to give him amiodarone, a rhythm-stabilizing medication that is not in the standard ACLS ventricular fibrillation protocol but was the one thing that got Fred’s heart beating again.
Now that he had a pulse and blood pressure, Fred needed to have the cause of his heart attack, a blocked coronary artery, fixed. Dr. Sklar, the cardiologist on duty, took Fred to the “cath lab,” where, using x-rays to guide him, he threaded a catheter into Fred’s coronary circulation and injected the dye that showed the complete occlusion of Fred’s left anterior descending coronary artery (LAD). The worst artery to close off during a myocardial infarction (MI, or heart attack), the LAD feeds the heart’s front (anterior) wall, most of which is the wall of the left ventricle, the main pump that sends oxygen-containing blood though the aorta to the entire body. Kill that area and a lot of things can go wrong. Jim Schneid, one of the clinical faculty at the Maine Dartmouth Family Practice Residency and a man who can give a spontaneous lecture on any medical topic, taught me the elegant FARTS pneumonic (which I have changed to RAFTS for my students) to help residents memorize the life-threatening complications of an anterior MI:
Failure — when the left ventricle becomes too weak to pump enough blood forward, fluid backs up into the lungs.
Arrhythmia — an abnormal heart rhythm, of which ventricular fibrillation is an example.
Rupture — the damaged anterior wall can burst open, a catastrophic occurrence that is almost always fatal.
Thromboembolism — the dead wall doesn’t move much, so the adjacent blood sits around and forms a clot, which the heart can then launch through a carotid artery into the brain circulation, where it can clot off a large cerebral artery and cause a stroke.
Shock — the weakened ventricle cannot pump enough blood to sustain the body’s vital organs.
Dr. Sklar was still working on Fred as Dr. Kahn was speaking to me, so all I knew was that Fred had suffered a big heart attack and had relied on CPR techniques to circulate his blood for half an hour. This was not good news. CPR is not a good substitute for a normal circulation. I knew that Fred might never wake up.
A 45-year-old man who gives seminars teaching people how to get more enjoyment from sex, Fred had been my patient for about five years. In April of 1999, he came to me complaining of occasional chest pains, which did not have the classic features of angina pectoris, the pain that comes from not getting enough blood to the heart muscle. Although the heart is located in the left side of the chest, the brain doesn’t know that, so we don’t experience heart pain where the heart is. Our brains most often “refer” heart pain to the center of the chest as a dull or squeezing sensation that can radiate to the neck, jaw, and both arms (but more often the left). Fred’s discomfort did not radiate, nor did it occur during his often heavy exertion. It was not associated with the shortness of breath, nausea, or sweating typical of heart pain. He did not have a history of high cholesterol, high-blood pressure, diabetes, nor tobacco use, all of which increase one’s risk for developing blocked coronary arteries. He did have one alarming feature in his medical history: his father had died in his early 50s of a heart attack. That led me to have my office staff call our local cardiologist’s office to schedule Fred for an exercise treadmill test.
I didn’t see him for over a year after that, not until the Friday of his heart attack. He called me that morning and told me that for three days he had been having almost constant discomfort in his upper body, sometimes a tightness in his upper chest, without any nausea nor sweating and unrelated to activity. Angina does not usually cause constant symptoms enduring for days, but he was anxious, and he had that family history, so I told him to come in to the office; I didn’t have any openings, but I would squeeze him in between my scheduled patients. He had not kept his appointment for the treadmill last year. People who feel healthy and who somewhere deep inside don’t want to find out that something is wrong with them sometimes avoid getting diagnostic tests. I haven’t yet asked Fred if that’s why he didn’t go.
When he came in, he complained of pain in his upper back and shoulders and a tingling in the fingertips of both hands. He still did not have discomfort under the sternum nor involvement of the neck, jaw, nor arms. I measured his blood pressure at 106 over 70 and his pulse at 72, normal numbers within his usual range. His physical examination, including his heart, lungs, abdomen, and the pulses in his feet, was normal. I did an electrocardiogram (EKG), because if someone has had low blood flow to the heart for three days, the EKG usually will show some sign of muscle injury or low blood flow or perhaps previous injury to the heart. Fred’s EKG was normal.
At this point, I had two options: admit Fred to the coronary-care unit with a diagnosis of possible unstable angina or let him go enjoy his weekend seminars. This is a decision I make for patients with chest pain almost every day. Fred had that family history, but frankly, I see patients like him all the time and send them home, and that’s what I did with Fred. Actually, he sent himself home when my medical assistant relayed the news that his EKG was normal before I had a chance to talk to him. I did call him at home about an hour later, and he was feeling better. He said he would get on that treadmill as soon as we could schedule it.
Instead, he wound up on the cath-lab table. Upon finding the blocked artery, Dr. Sklar injected a clot-busting medication and restored the blood flow to the severely damaged anterior wall. He then placed a cylindrical stent through the catheter to keep the narrowed artery open.
While the cardiologist performed these heroics, which have become routine in the past few years, I got to stare at the repeating reticular blue-and-white flower patterns on our bedspread, retreating into a zone where impending grief and guilt dominated and squelched all other thoughts. My wife Terry came to my side, saying all the right things, but when someone presents you the opportunity to save their life and you fail, it feels terrible, even when you’re not to blame. In Fred’s case, I had concluded that his symptoms would not threaten his life. I was wrong. It didn’t matter at that moment whether I was reasonable and wrong, nor how many times I had been right before. I would grieve for Fred if he didn’t wake up, and I would have to live with my decision forever. Regardless of whether I could justify my decision to myself or to a jury, Fred’s family and friends would always see me as the one who could have prevented this tragedy but didn’t.
Given all of this, sleep was out of the question, so I went downstairs to let Terry go to bed. I turned on the TV and observed the talking heads reading me the 11 o’clock news, but of course I wasn’t interested. Some time passed, and I called the hospital. Fred had not awakened, but he had tolerated the procedure without complications and had stable vital signs. His heart was okay, and we didn’t know about his brain, which was about as good news as I could have expected. I took my dry mouth and aching abdomen upstairs and conked out.
Fred woke up the next morning, a bit confused and full of questions about the previous day’s events, including his visit to my office. Relieved at the news of Fred’s mental competence, I discussed that visit with the cardiologist on duty. “That’s why one in five people with coronary-artery disease present with sudden death as their first symptom,” he reminded me. “It’s very tough sometimes. Fortunately he was in an ambulance when he had his cardiac arrest."
Reviewing everything brought me to the conclusion that, although I hadn’t made any glaring errors, I had not done something that I’m sure I will never forget to do again under similar circumstances. I should have told Fred to take an 81-milligram aspirin right then, and once daily thereafter, and I should have given him a prescription for nitroglycerin to put under his tongue if he got tightness in his chest. Aspirin poisons platelets, the blood elements that start the clotting process, and nitroglycerin dilates the coronary arteries. These might have helped prevent the clot that occluded Fred’s left anterior descending artery; we’ll never know. From now on, until I have the negative treadmill result in hand, everyone who raises the slightest suspicion will get those two things before they leave my office. Arid I’m sure he would have if he hadn’t left my office before I spoke to him after his EKG. But these things happen, and one has to be thorough.
For a moment, I thought about the difficulty and economics of my job. Insurance companies pay about $45 for me to decide whether people like Fred are having a heart attack, about $20 of which I get to take home before taxes. Enough said. I try not to ruminate on such matters.
Now I had to talk to him. I needed to help him reconstruct the situation, and to do so in a way that he could see it through my eyes as well as his. After understanding that, he would have two issues with me: should he sue me and, if not, should he continue to see me as a patient. The following morning, Sunday, I took the 45-minute drive over the Richmond-San Rafael bridge into the idyllic valleys of Marin County to Marin General.
I found him sitting up in bed, below the cardiac monitor whose familiar spikes and waves gave me the good news that his heart was beating in a normal sinus rhythm. The smooth skin and the slight pink glow in his cheeks suggested a youthfulness that seemed out of place in this setting of beeping machines and plastic tubes blowing oxygen up his nose and pumping medicine into his veins. We exchanged greetings and I pulled up a chair.
“It is very good to see you,” I began.
“I’m glad to be here.” This got the conversation going in the direction of how he was feeling, and we talked about that for a few minutes. Then came the inevitable questions. “So what happened in your office on Friday? I remember calling and coming in, but I don’t have a clear picture of what happened after that.”
I told him, hoping he would not take me through his processing of whether he should blame me for what happened, and fortunately he did not. He thanked me for coming and I left, relieved that he was doing so well and had thus far spared me any hostility.
When I saw his name on my schedule eight days later, I knew this would be my day before the jury. His wife Sara’s eyes met mine as I entered the exam room. Both of their faces wore the polite smiles that pleasant people put on before having unpleasant discussions. Fred introduced Sara to me, and we then began retracing the steps Fred and I had covered the day of his heart attack, emphasizing the exact descriptions of his symptoms. “I see patients every day with chest pain, and I have to decide who has to go into the hospital. If I admitted all patients with your symptoms, there would be about a thousand who would go in without having heart-related problems for every one like you, and we can’t do that.”
“I didn’t have chest pain,” Fred pointed out in mild protest.
“That’s part of my point,” I countered. “Your symptoms in the neck and shoulders did not point to the heart as the source.” We then moved on to the evening’s events and the phone call I received. “I can’t compare it to yours, but that was one of the most difficult nights of my life,” I confessed. “You came to me with a life-threatening problem, and I didn’t make the diagnosis. I understand that now you have to decide if you have enough confidence in me to continue seeing me as your physician. I would certainly understand if you didn’t. I can’t tell you how grateful I am that Fred is alive and well.”
That closed my testimony, and Sara responded. “You said what we needed to hear.” I felt my blood pressure drop about 30 points. Fred told me he would have to think it over, and I told him he was welcome to come back. A month later, he did.
“It’s really been an amazing experience,” he told me. “Sara, my family, and you had to go through it and have expressed so many great things to me, but I don’t remember anything about the heart attack, and now I feel just as well as I did before.” Too bad heart attacks aren’t like that for everybody.