The Patient Was…

The patient was an elderly man whose father, a friend and colleague of mine, had admitted him to the hospital because of chest pain suggesting cardiac ischemia, meaning inadequate delivery of oxygen-supplying blood to the heart muscle.

The patient was of Eastern- European origin and, although having been in the United States for some time, neither spoke nor understood any English at all. His son, an excellent specialist in Internal Medicine, was not at the hospital but had ordered the appropriate nitroglycerine medication to dilate the patient’s blood vessels, thereby allowing the restoration of adequate amounts of oxygen-carrying blood to meet the needs of his father’s heart.

Nitroglycerine medication?  Yes, when diluted and modified, the chemical you know as TNT and used in explosives is a time-honored, standard treatment for cardiac ischemia. By effects on both veins (blood vessels carrying blood toward the heart) and arteries (blood vessels carrying blood away from the heart and to the tissues of the body), nitroglycerine restores the balance of supply and demand for oxygen in the heart muscle. Most heart medications affect either the demand side or the supply side of the “oxygen supply-demand equation”; almost uniquely, nitroglycerine both reduces the demand for oxygen and increases the supply of oxygen in the heart muscle.

Nitroglycerine can be administered to a patient in many ways, including intravenously, orally (by mouth), by absorption through the skin, and sublingually (under the tongue). The sublingual route is most commonly used when a rapid effect is needed, since the drug is quickly absorbed into the blood stream from under the tongue. Nitroglycerine tablets are very tiny, and patients can easily carry them around and use them pretty much whenever they want and wherever they are.

While some patients with ischemic chest pain respond to a single sublingual nitroglycerine tablet, others may not. Standard instructions for its use recommend that one nitroglycerine tablet should be placed under the tongue and, if there is no relief of chest pain within five minutes, then successive doses should be given every five minutes until three doses have been administered in a fifteen-minute period. If no relief of chest pain occurs after that period of time, further measures need to be taken. Excessive dosing of nitroglycerine can have very serious side effects.

The patient in this instance had never been given nitroglycerine before and was unfamiliar with its use. His physician–son had instructed the nurse to give him the medication and to repeat it every five minutes if the pain was not relieved. Apparently, the doctor assumed that the nurse knew that if, after three doses of nitroglycerine given five minutes apart the pain was not relieved, that something else would need to be done.

The nurse, who was a recent nursing school graduate and new to the hospital staff, either did not know this dose restriction or assumed that the physician would have specified the three-tablet limit and was choosing to override the usual directions because the patient was his father. At any rate, the nurse dutifully checked on the patient every five minutes, and seeing him in obvious continuing distress, kept giving him nitroglycerine tablets.

She did not realize that the patient was unfamiliar with the sublingual placement of nitroglycerine. And since she couldn’t verbally explain that the tiny tablets she showed him each time should be placed under his tongue for relief of his chest pain, she held each between her thumb and index finger and pointed to his chest.  Then, she handed him the little pill and left the room. After numerous repetitions of this sequence of events, and the patient still in pain, the nurse finally called the patient’s son who then called me and requested my assistance at the bedside.

When a patient is unable to give or receive oral information it might be considered good news or bad news, a blessing or a curse. The good news is that time is saved; all the difficulties and distractions of getting pertinent information are avoided, and one can move to the next step in managing the medical problem. The bad news, of course, is that vital information that could change the course of events is unavailable.

Having been forewarned that there was to be no verbal communication with him, I approached the patient’s bedside prepared to immediately carry out a physical examination. It was obvious that he was in considerable distress, not surprising since he had had constant chest pain for at least an hour. Wanting to listen to his heart, I put my stethoscope in my ears and unbuttoned the pajama top he was wearing.

And there they were!

Eleven tiny nitroglycerine tablets neatly lined up on his chest. I picked one up, gently opened his mouth, and placed the tablet under his tongue. He stared at me, uncomprehendingly. And then, after about a minute, his grimace turned slowly into a smile, he breathed a deep sigh of relief, took and squeezed my hand.

The whole experience was the result of miscommunication, which can be dangerous in many settings, especially in medicine. The nurse was certain that the patient understood her pantomime through which she indicated the tablets were for his chest. He understood it all too literally.

George Bernard Shaw said that the single biggest problem in communication is the illusion that it has taken place. I hark back to the iconic scene in the movie Cool Hand Luke, where the sadistic prison-farm captain beats Paul Newman with a truncheon while calmly intoning, “What we have here is a failure to communicate.”

Fortunately, the failure to communicate in this medical encounter had a happier ending than Paul Newman’s.