Cardiac & Resuscitation, Columns

An Inside Look at a Hospital Stay From Chest Pain

Issue 2 and Volume 42.

As a boy, soon after my mom would drop me off at Scranton (Pa.) fire headquarters to ride a shift on the ambulance with my dad, the bell would hit and the fire crews would be sent to a big wreck or two-alarm fire. So, at the age of 13, I was nicknamed “Black Cloud” by the firefighters because s— happened whenever I showed up.

I’ve had people go into anaphylactic shock on a train as I rode it to work, and once a homeless gentleman wandering on the tracks had both of his legs amputated by a train entering San Diego’s main station as I stood there watching.

I call it coincidental, but my friends and the JEMS staff joke that it is “Munchausen by proxy” because they think I cause it.

Munchausen by proxy is actually considered a disorder whereby a person acts as if an individual they’re caring for has a physical or mental illness when the person isn’t really sick, so I call it “Black Cloud Syndrome.”1

cardiac catherization
I always wanted to watch a cardiac catherization but didn’t think I’d ever watch my own.

Cavalcade of Events

Whatever it is, it finally caught up to me in December when I found myself immobilized on a hospital cardiac catheterization table with a team cannulating my femoral artery, anticipating that they might have to open one or more of my coronary arteries.

As a proponent of direct door-to-catheterization lab care, I laid there nervously wondering if I had finally jinxed myself.

I often lecture that many of today’s cardiac arrest patients have their electrical problems controlled by beta-blockers, leading them to code because of a clot that could have been removed by cardiac catheterization. I now found myself in that same situation, thinking I might have suffered an acute myocardial infarction.

Truth be told, I thought this could possibly be my final curtain call. It turns out it wasn’t and I lived to see another day. But I want to share my experience with you because my strange collision of symptoms may present in patients you’re called on to treat some day.

In addition, being forced to lay behind hospital curtains for 3.5 days gave me plenty of time to listen and observe in-hospital care and procedures, with important lessons I want to pass along to you.

How It Started

It started with sharp, stabbing chest pain one evening in late October as I was watching television at home. The substernal pain and dyspnea was sudden and intense and forced me out of my chair and onto my hands and knees on the floor.

I immediately thought, “I’m having a heart attack,” but, like many experienced EMTs and paramedics, I ignored my symptoms as the incident passed. 

I continued to ignore intermittent pain and symptoms for weeks. But the pain kept reappearing and began to affect my life and my work.

So, when I went to my family doctor in early November for treatment of bronchitis, I mentioned my chest pain and symptoms.He became concerned and ordered a 12-lead ECG, which was unremarkable except for a few prolonged PR intervals. He felt that because of the periodic pain, dyspnea and subtle ECG changes, I should see a cardiologist.

He reluctantly allowed me to schedule my appointment for the day after my return from New Zealand where I was participating in the Paramedics Australasia Conference the next week. Another mistake on my part.

hospitalist Robert Lee, MD
I found hospitalist Robert Lee, MD, to be brilliant,
personable, caring and one of the brightest
parts of my stay in the crowded ED.

Compounding Factors

Over the next 10 days, my busy schedule and strange circumstances resulted in me torturing my body and compounding my symptoms.

First, the airline failed to transfer my bags to my 14-hour international flight in San Francisco, so for a few days I missed taking the medications that keep my blood pressure and cholesterol in line.

The fun and excitement of the conference helped me ignore most of my distress. However, while walking eight blocks up and down hills to and from the venue each day, I found myself experiencing more pain and dyspnea.

On the 14-hour flight home I felt palpitations and pain on the right side of my chest.

I went to the cardiologist the next afternoon. My wife went with me to make sure I presented all of the facts to the doctor—it reminded me of the important role family members play on scene when the patient is in distress and not a good historian.

The cardiologist ran a 12-lead ECG and told me I was in atrial fibrillation at a rate of 160. She said that because I was experiencing chest pain and dyspnea, the atrial fibrillation might have been caused by a pulmonary embolism (PE) experienced during my long plane flights.

She explained the findings of a 2012 study that showed that when PE is suspected based on new onset dyspnea, atrial fibrillation significantly decreases the probability of PE because it may mimic its clinical presentation. However, in patients with chest pain alone, atrial fibrillation tends to increase PE probability.2

Because of that, she sent me for a CT scan of my chest and an echocardiogram two days before Thanksgiving. She also said I may have been in atrial fibrillation for more than a week and need to be cardioverted after the holiday. That sure dampened my holiday spirit.

Five days later, I awoke with increased chest pain but no acute dyspnea. Odd, I thought. Where was the dyspnea I previously experienced? I again ignored the pain, but then applied a wrist blood pressure monitor and found my pulse and blood pressure fluctuating in both arms.

I was again in denial and hoped it would pass. But I finally came to my senses and had my wife drive me to the hospital.

I didn’t call for an ambulance. This could have been another fatal mistake on my part. I have to admit that, subconsciously, I really didn’t want to have an engine and ambulance roar into my neighborhood with red lights and siren, alerting my neighbors to my private crisis. I also didn’t relish the idea of having six firefighters rush in with their bunker gear on and rile up our four dogs.

My ED/Hospital Experience

We arrived at the hospital at 3:30 p.m. to find the ED packed. Luckily, my report of chest pain got me fast-tracked ahead of the young guy with an obvious mental disorder who was pacing nervously and approached the triage nurse every time she called out a name, claiming to be that person. It actually relaxed me a bit and brought back fond memories of encountering “unusual” patients, particularly when he kept saying he was “with the CIA” and at the ED to “investigate a double stabbing.”

As an EMS provider, I never really paid attention to the ED noise or the myriad patients in all the curtained areas. But when you’re a patient on the other side of that curtain, you see things from a totally different perspective.

Maddening noise confronts you when you’re in a multi-curtained ED—people moaning, people complaining about being neglected, people asking whether their purse was taken home by their loved ones—all of it at a time when you’re not in the mood to hear any of it.

Once placed in my little curtained cave, the ED physician came in and had a brief interface with me. He never performed a head-to-toe assessment as we do in the field, relegating that to a nurse an hour later.

I tried to strike up a conversation with the ED physician regarding my thoughts on my symptoms and potential causes, noting that my wrist BP monitor presented fluctuating vital signs all afternoon, from bradycardia to tachycardia, and from normotensive to hypotensive, and also my concern that my pain was radiating across my nipple line, not just my substernal area. He totally dismissed me, “Those wrist things don’t work,” and walked out, ordering the staff to run a 12-lead ECG.

This was odd to me because I felt it left the door open to missed assessment points, such as the fact that I had been taking digoxin for the past five days, with a loading dose of four pills, which could contribute to my conversion from atrial fibrillation as well as my bradycardia.

In addition, I had gastric bypass surgery several years ago and have six small, indicative scars on my abdomen, an important aspect to my final diagnosis. But no one noticed these for an hour.

One of my best encounters was with the facility’s hospitalist, Robert Lee, MD, a bright, young physician who noted I was bradycardic and worked to get me “upstairs” ASAP. I found him to be brilliant, personable, caring and one of the brightest parts of my stay in the crowded in the ED.

The Long Wait

I didn’t get sent to a room until midnight, nine hours after I arrived. Is it any wonder why EDs are crowded when hospital staff leave the patient on a valuable ED bed that long?

When I finally got to my room in the telemetry unit, my whole experience changed. When you spend a couple of days flat on your back in a hospital bed, anchored to ECG and IV infusion devices, you begin to appreciate care and compassion more than you did in the past.

The staff in the telemetry unit quickly won my heart. They made sure I had everything I needed, made me comfortable in my “confinement” and, by continually communicating with me, they reduced much of my discomfort and fear. That’s an important message for EMS providers: Communicating and keeping patients informed can impact their care, comfort and opinion of your service. Not knowing whether you’re going to live or die is pretty intense.

Enter the interventional cardiologist. He involved me in his care plan and kept me informed and relaxed about what was going on and why.

Even though he thought the cause might be epigastric in origin, he said his job was to address life threats and, based on my age and symptoms, recommended I undergo cardiac catheterization instead of a stress test because he already knew that my heart was stressed and I had pain. In addition, he’d be able to immediately insert stents if he found a blockage while inside my arteries.

My night shift caretakers took extra time to make sure all my questions were answered and my concerns addressed. They even showed me a video clip of a cardiac catheterization procedure to make me feel comfortable with everything that was going to occur.

After three days of anticipation, it was time. Like most patients, I was both scared and curious. I had to lay completely flat for 4–6 hours after the procedure so that the femoral artery they entered wouldn’t hemorrhage.

The procedure took less than 45 minutes, and they found all my arteries were open and my problem was gastric esophageal reflux disease, better known as GERD. The most painful period occurred when the physician pressed firmly on the insertion area for 10 minutes to ensure it clotted and closed properly. A half-day later I was released, made my curtain call and left my confined space.

Leaving the Curtain Open

Being trapped in a hospital bed for 3.5 long days gives you a lot of time to observe and think. I was particularly reminded about how important it is for EMTs and paramedics to communicate with every patient, and be understanding and sensitive to patient needs and comfort.

My father taught me that in EMS, we’re not just a 20-minute encounter with a patient—we’re an encounter they’ll remember forever. We should always leave them with a positive impression. At a time when medicine and government are so sensitive about patient comfort and care, it was a good reminder to me, and should be to you.

References

1. Cleveland Clinic. (2016.) Munchausen syndrome by proxy. Retrieved Dec. 23, 2016, from http://my.clevelandclinic.org/health/diseases_conditions/hic_An_Overview_of_Factitious_Disorders/hic_Munchausen_Syndrome/hic_Munchausen_Syndrome_by_Proxy.

2. Gex G, Gerstel E, Righini M, et al. Is atrial fibrillation associated with pulmonary embolism? J Thromb Haemost. 2012;10(3):347–351.