The Patient Was…

The patient was in his late sixties, a physician, a colleague, and a friend.

We shared office space for several years and while we had separate medical practices and different patients, we freely exchanged ideas, advice and confidences.

Early one morning, when I was already in my consultation room preparing for the day, my colleague popped his head in and said, simply, “Good morning, Henry. I had a heart attack last night.”

I looked up from the records I was reviewing, trying to process what I had just heard. My friend appeared alright, and I thought for a moment that perhaps he was joking about some minor incident. But the serious look on his face quickly disabused me of that notion.

“Come with me,” I said, leading the way into my examination room. “Take off your things and tell me exactly what happened.”

“I was on my way to medical meeting in midtown,” he said. “And as I was crossing 57th Street I felt a heavy pressure in my chest. I wanted to stop right there, but I was in the middle of the street, so I crossed to the sidewalk. The pain was pretty severe; it was also hard to breathe, and I was nauseated and sweating.”

So far, his description was typical of the symptoms of an episode of severe cardiac ischemia, where a portion of the heart muscle, or myocardium, is deprived of oxygen-carrying blood. The usual cause is obstruction to the flow of blood through the coronary arteries, the vessels supplying the myocardium. If the lack of adequate blood supply persists too long, a part of the heart muscle can actually die. That is a heart attack or, in medical terms, a myocardial infarction.

“I was thinking of calling for an ambulance,” the doctor continued, “but the pain began to subside. So, I waited a little while longer and then went on to the meeting. I didn‘t feel great all night, but I figured it could wait until today.”

By this time, he was lying on my examination table. Blood pressure, heart rate and rhythm, and breathing rate were unremarkable. His heart sounded normal when I listened with my stethoscope and his lungs were perfectly clear, suggesting no buildup of fluid from weakened heart muscle allowing backflow of blood into his chest. I was quite reassured.

His electrocardiogram, a recording of the electrical activity of his heart, told a different story, however. There was clear and unmistakable evidence of significant damage to a portion of his heart muscle called the inferior wall.

“Well,” I said, “you were right, my friend. You did have a heart attack. But, fortunately, it’s limited to the inferior wall, and you know those tend to be less serious than injury to other areas of the heart. I want to get you over to the hospital and admit you to the CCU.”

A  CCU, or Coronary Care Unit, is a specialized area of the hospital where cardiac patients are monitored and treated. It’s like an ICU, or Intensive Care Unit, but only for heart patients.

“I’m not going,” said my colleague.

“What do you mean you’re not going?” I said. “You have to go.”

“No, I’m not going,” he repeated.

“Why won’t you go?” I countered, amazed that he would refuse the obvious advice.

“Those young doctors will kill me,” he said, deadly serious.

“What are you talking about?” I said. “Who is going to kill you?”

“ It’s July,” he said. “There are new medical interns, residents, and cardiology fellows in the hospital. They don’t know what they’re doing, and they’re going to kill me with the tests and drugs they order.”

“That’s ridiculous,” I replied. They’re all supervised by experienced people.”

“Well, the supervisors aren’t there all the time,” was his answer.

“Look, I’ll make sure nobody orders anything without consulting me.”

“You can’t guarantee that,” he said. “You’re not there all the time.”

This was becoming really frustrating. It was reassuring that the damage to his heart was localized to one area, and the overall prognosis after injury to that portion of the heart was generally pretty good. But there was one fairly common complication to an inferior wall infarction that worried me: a condition called heart block.

Heart block refers to an interruption of the electric signals that normally travel from the upper part of the heart to the pumping muscles of the lower heart chambers, or ventricles. The electric signals control the heartbeat by triggering the heart muscles to contract. If the signals are blocked, the heart muscles don’t contract normally and don’t pump adequate amounts of blood around the body. Complete blockage of the electric signals can be fatal.

I confronted my colleague with this reality directly and emphatically. “Look, you know that you can develop complete heart block from your infarction. And you can die from it. If you are in the hospital, we can monitor your heart rhythm continuously. If you develop heart block we can insert a temporary pacemaker wire, and make your heart beat normally.”

”Just what I’m afraid of,” he said. “Those young doctors will try to put the pacemaker in and they’ll screw it up and kill me.”

“I’ll do it,” I said. “I’ll personally put in the pacemaker wire. And you know the electric signal blockage is almost always temporary in these cases, so we can remove the pacemaker wire in a few days.”

“No,” he said, with finality. “I’m going home.”

“Well, I’m coming over to see you twice a day to check on you,” I said. He smiled.

He went home and for the next few days I visited him every morning before office hours and early every evening. I carried my portable electrocardiograph machine and recorded his heart rhythm each time. And sure enough, as predicted and feared, he began to show signs of developing heart block. At first, each of the signals from the upper heart was simply slightly delayed in reaching the pumping muscles of the lower heart chambers. Then, the delay grew longer, following which some of the signals did not get through at all.

With each progression of signal interruption, I warned him of impending complete heart block, reiterating that it could be fatal, and that we could prevent it by putting in a temporary pacemaker wire in the hospital. He refused each entreaty.

One evening, a few days into the episode, his electrocardiogram finally showed complete heart block. His heart rate dropped to almost zero, as the pumping muscles used up their own intrinsic ability to generate a few beats.

My patient, my friend, my colleague passed away, peacefully.