The Patient Was…

The patient was a 92-year-old man with chronic, stable heart disease and severe symptoms of an enlarged prostate gland.

The prostate gland is a part of the male reproductive system and is located just below the opening of the urinary bladder in the male pelvic region. The prostate surrounds the urethra which is the tube that carries urine from the bladder to the outside. The chief function of the gland is to contribute to the formation of semen.

The prostate gland is normally about the size of a walnut. But as men grow older, the prostate gland tends to grow larger. As it does, it interferes with the emptying of the urinary bladder and the flow of urine through the urethra tube. Common symptoms of prostate enlargement include a frequent urge to urinate, often waking men several times a night, and slow urinary flow. If the interference with urine flow is severe, the bladder cannot empty, and it becomes a medical emergency.

When the passage of urine is blocked, patients require what is called a bladder catheterization, in which a flexible tube (catheter) is passed from the outside into the urethra, through the portion narrowed by the enlarged prostate, into the bladder itself. Urine then flows through the catheter and the bladder can empty.

Men with enlarged prostate glands are subject to infections of the urinary tract. And every time a catheter is passed into the urethra to relieve obstruction to the flow of urine, the possibility of infection increases. Leaving a catheter or other drainage tube in the bladder as a permanent solution to impaired urine flow is rarely done because of the specter of infections.

The patient was having increasing difficulties in passing urine due to a very enlarged prostate gland. He had undergone bladder catheterizations on many occasions and had had several infections of his urinary tract. He clearly needed some sort of permanent relief, and prostate surgery was the only realistic option at the time.

Because of his age and heart disease, the risk of surgery was not inconsequential. His family was rightfully concerned about the risk, as I was, but there seemed to be no better alternative. I discussed the benefits and risks with the patient and his family, and they all agreed to an operation. I told the family that I would be in the hospital during the operation and could be summoned at once if a problem arose. The surgeon and the anesthesiologist knew the patient’s condition; we all agreed to go ahead.

The family was gathered in the patient’s room when the hospital escorts came to transport him to the operating room. They all looked very worried, as they had every right to be. They said goodbyes as if they feared they would not see the patient again.

About an hour into the procedure, I heard my name called over the hospital paging system. It summoned me to operating room “Stat,” meaning immediately, without delay. I rushed to the OR, where the nurses held a sterile gown open for me to slip into as I entered the room.

The surgeon was standing at the operating table but looking toward the anesthesiologist who was staring at the cardiac monitor which was displaying the patient’s heart rhythm. Monitor screens in those days were small, but with a normal heart rate and rhythm a few successive beats could be displayed at once. What the monitor was showing, however, was a chaotic series of irregular beats, moving rapidly across the screen.

“I’m not sure what the rhythm is,” the anesthesiologist said, anxiously. “But his oxygenation and blood pressure are okay.”

I looked at the monitor screen and, at first, I couldn’t figure out what I was seeing, either. But with the patient’s oxygen and pressure readings at a good level, some of the more dire possibilities were momentarily ruled out, and we had a moment to figure out what was happening.

Observing the monitor for a few more seconds, I realized that what I was seeing on the screen was a common heart irregularity called atrial fibrillation. (People nowadays are more familiar with the term, and its abbreviated name A FIB, due to television commercials.) Once we realized that was the abnormality, we knew we had a bit of time to work with.

One of the oldest drugs still in current use is digitalis, a drug derived from the Foxglove plant and used for cardiac patients for over 200 years. A refined form of it, lanoxin, is useful for a few cardiac conditions, including atrial fibrillation where it slows the heart rate. Occasionally, if the atrial fibrillation appears suddenly, due perhaps to an unusual stress like an operation, the drug may restore the heart’s regular rhythm.

I injected some of the drug through an intravenous line into the patient’s vein.

We agreed to stop the surgery and transport the patient back to his room. We had a larger cardiac monitor attached to the patient, so the heart rhythm could be more easily observed. The monitor also beeped loudly with every heartbeat, so while the rhythm was still rapid and irregular, the beeping was noisy and chaotic.

When the patient arrived back in his room, his family became alarmed. They knew it was too soon for the surgery to be finished, so something must have happened. The patient was still only semi-responsive because of the anesthesia. And the heart monitor seemed to be going crazy, with the rapid and irregular signals of the heartbeat visible on the screen and the beeping going off with each one.

I arrived in the room just after the patient. “Everything is under control,” I said, but the family looked dubious. My stethoscope was around my neck, but before I put it in my ears I simply put my hand on the patient’s chest.

At that very instant, as I touched the patient, the drug that I had injected in the operating room kicked in. The monitor, which everybody had been fixed on, suddenly showed a normal, regular heartbeat, and the beeper dutifully announced each restored beat. There was an audible gasp in the room. It was as if they had witnessed a miracle.

In the room along with the family was one of the urology resident physicians. I looked over at him, nodded just to indicate things were now stable, but he looked as awed as the patient’s family. When I left the room, after assuring the family that the patient was now stable and would be all right, the urology resident followed me out into the hall.

“How did you do that?” he asked.

I thought he was kidding and knew that I had given the lanoxin medication in the operating room. So, to keep the joke going, I said, “You know, as a cardiologist, I use so much lanoxin it’s all over my hands. So, when I touched the patient’s  chest, the medication on my hands got right into him.”

The look on his face told me that he believed every word. I thought: How could a doctor, any doctor, even a non-cardiologist, be so ignorant, so naïve, as to  believe such a preposterous story?

I was embarrassed to explain the true explanation to him. His ignorance and gullibility would be too apparent, and I did not want to be there when it happened.

I hope he never told another physician what he thought he had seen.

I never told him the truth and never told a colleague the story.