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In the real world of medicine, "great saves" are rare. Most patients that you expect to die will die, and those who experience a cardiac arrest or code rarely survive. Mr. GR is the closest I've seen to an exception to both of these rules, and his story illustrates the best but also the worst of what our health care system achieves.
I first met Mr. GR in the emergency room (E.R.). As the cardiac ICU resident on call, I was urgently paged down to the E.R. for a "cath lab activation." The "cath lab" (cardiac catherization laboratory) is where cardiologists balloon and stent open arteries using flexible instruments called catheters. A "cath lab activation" is an emergency call placed when a patient is suspected of having an acute heart attack. From the moment I saw him I knew Mr. GR's chances of recovery were slim. He was "found down" by emergency medical services (EMS) without a pulse, shocked back to life, and then intubated on arrival to the E.R. Once stabilized a stat EKG was obtained. The diagnosis instantly became clear. From across the room "tombstones" could be seen marching across his EKG - concave-down electrical waves that are telltale signs of a major heart attack.
My team was called down, and he was taken emergently to the cath lab. (Picture a gurney whizzing down crowded corridors, me getting slammed against the wall at every sharp corner.) After wiring a series of catheters through his groin, cardiologists found a "tight" blockage of his LAD artery, which feeds most of the blood supply to the heart, and popped it open with a metallic stent. Still on the ventilator, he was then transferred to the cardiac ICU, where we infused ice cold water down his nose into his stomach to cool his core body temperature down to 32 degrees C (89.6 degrees F). His heart and his lungs had been stabilized, but after nearly 10 minutes without adequate blood flow to the brain, there was no telling if he would make any meaningful recovery.
Twenty-four hours later he was gradually rewarmed. The following day we weaned the heavy sedatives that allowed us to cool him, and held our breaths. Gradually, hour by hour, he showed signs of life. He began to take breaths on his own and make purposeful movements. The next day he followed simple commands, wiggling his toes and squeezing our hands, and was taken off the ventilator. He began talk, giving simple "yes" and "no" answers. By the time my rotation in the cardiac ICU was over, we were beginning to talk about transferring him to a rehabilitation facility. The extent of his neurologic recovery remained to be seen - while he was talking, he seemed to have limited short-term memory (every day we had to reorient him to place and time) and his mother lamented he didn't seem to recognize her. But he was very much alive and getting better day by day.
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It's hard to convey how remarkable his story is. Even though I'm in medicine, I can't help but marvel not only in our technical capacity to literally bring this man back from death but also in our successful and timely execution of an incredibly complicated set of tasks. Here is a brief reconstruction of the early hours of the case:
10.06 AM: Patient found down by strangers. 9-1-1 called for concern of "seizure."
10:11 AM: EMS at the scene. Heart monitor placed, ventricular fibrillation detected. Patient shocked. Normal rhythm restored.
10:18 AM: Ambulance arrives in the E.R. Patient intubated, central line placed. EKG obtained. Cath lab activated.
10:41 AM: Patient in the cath lab. Coronary artery blockage identified and ballooned open.
11:15 AM: Patient in the cardiac ICU. Cooling initiated.
Stringing together this series of events required multiple systems of care. Onlookers who witnessed the patient collapse had to recognize his critical illness and know to call 9-1-1. EMS had to be immediately available and the phone call appropriately triaged as a medical emergency. The ambulance team had to have the right equipment and right training to immediately place a defibrillator, recognize a life-threatening heart rhythm, and deliver an electrical shock. The E.R. had to quickly stabilize the patient and amidst a chaotic situation recognize an acute heart attack. The cath lab had to have the equipment and staff on hand to immediately receive the patient and proceed to angiography. The hospital had to have a cooling protocol and the right equipment and staff to initiate it (at our hospital by paging "C-O-O-L").
A breakdown in any of the steps above would have dramatically changed this patient's course. The data is clear: every minute the patient is down without adequate oxygen delivery increases the risk of permanent brain damage and death. "Time is brain." But for every success story like Mr. GR's there are many more not don't end well. As someone who practices medicine, these breakdowns are not hard to imagine. Onlookers think patient has only "passed out" and delay calling 9-1-1. There's heavy traffic on the way to the hospital. The ER is busy with a trauma patient and an EKG is not ordered in time. It's the middle of the night and the cath lab team takes over an hour to assemble. Cooling is not initiated because the right equipment is not available. That all these moving and imperfect parts came together to help Mr. GR is almost miraculous.
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Through the week I spent taking care of Mr. GR, I had the opportunity to learn more about him from his family. Though he had a job and health insurance, Mr. GR did not have a regular doctor. He was a lifelong smoker and drank 5-6 beers on the weekends. He had high blood pressure but was never started on medications for it. Moreover, for the past 4 months, he had been complaining of episodes of abdominal pain that were brought on by exertion. He had sought care at a local hospital E.R. on more than one occasion but was told he had heartburn and prescribed an antacid. In hindsight, this abdominal pain was likely the earliest salvo of the heart attack that almost claimed his life.
I don't blame the outside hospital E.R. for misdiagnosing his abdominal pain. Abdominal pain is common and it is difficult to know how Mr. GR presented at that time. Each time he went to the local E.R. he likely saw a different doctor. E.R.s are best designed to handle emergencies; chronic and refractory medical problems often slip through the cracks. In a primary care office, he may have initially been diagnosed with heartburn as well. But if his symptoms worsened despite appropriate medications, the primary care doctor would have been more likely to re-visit the initial diagnosis. He or she would have also addressed his controllable risk factors for coronary heart disease, including tobacco use and hypertension.
Mr. GR in many ways typifies the larger problems with our health care system. Our health care system is designed and is really best at acute care. This underlies our ability to coordinate and execute the incredibly complex series of steps needed to resuscitate Mr. GR. However, for all of our specialized and acute care, we have yet to figure out how to deliver primary and preventive health. We can shock, intubate and cath people who present with a cardiac arrest in under 90 minutes, but can't get patients to see a regular doctor, to take their medications, to follow up when they aren't doing well.
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I don't want to dismiss what we did for Mr. GR this past week. Rather, our success in his case emboldens me to believe that with the right science and the right resources we can improve the delivery of primary and preventive health. It dares me to dream not just of a health care system that handles medical emergencies perfectly each and every time but of one that doesn't have to. After all, the greatest save is not having to make a save at all.
- Shantanu Nundy, M.D.
Copyright Shantanu Nundy, M.D.
If you enjoyed this post, please visit Dr. Nundy's web site BeyondApplesor read his book, Stay Healthy At Every Age.
