Recently I had a case that stirred emotion: joy, frustration, concern, pride.
It’s not every day that my heart feels such a range of flutters while at work; generally, while I love what I do, I don’t always want to jump up and down on the couch screaming “Woohoo!”. With this case, I had a woohoo moment.
A reasonably healthy older patient presented to our emergency department after fainting. Actually, he didn’t just faint. Most people faint after feeling unwell, or having the classic sensation of light headedness, a black haze clouding their vision, ringing in the ears, maybe nausea…what we call a prodrome. Rarely, a person will lose consciousness suddenly, without warning, and go down hard. When a physician hears that kind of story, we call it syncope with no prodrome – and it always raises the red flag. With these cases, we must always consider a cardiac cause, i.e. an abnormal rhythm, that makes the individual pass out without warning, like a shark in the water pulling them down.
This patient had a syncope with no prodrome. When he was initially assessed by my resident, he felt reasonably well with no headache, neck pain, chest pain, palpitations or other symptoms. He did admit to feeling generally weak for the last few days or so. The exam was completely normal, and the first electrocardiogram (cardiac rhythm evaluation) was normal. Completely normal.
We sent the patient for imaging studies to make sure he had nothing serious as a sequelae of his fall. Trauma is a pretty straightforward field to an experienced emergency physician: it involves evaluation and stabilization of a patient’s airway, breathing and circulation, monitoring of vital signs, and head to toe evaluation for injuries. Diagnosis is clear as well: CT, xray and bedside ultrasound, along with routine labs. There are protocols and algorithms that guide us. For example, this patient needed a cervical collar because as an older person he fell outside the range of our evidence based decision rules (which allow us to say that a patient does not need xrays of their neck to rule out fracture). We asked for a CT scan of his head and neck. When I saw the images of a brain full of blood and a fractured skull, I knew this patient needed urgent transfer to a trauma center, and urgent platelet transfusions to combat the anti-platelet medication he was on.
I called the trauma team leader urgently and discussed the case, but stressed the point that aside from the traumatic injuries, this patient still needed a workup for the cause of syncope. I told the surgeon that I was concerned that the etiology was cardiac in nature, and that the patient would be at risk of further deterioration if it was not addressed. His answer? “I am more worried about the blood in his brain”. Needless to say, I documented that interaction very clearly.
Shortly thereafter, the ambulance crew arrived to take our patient to the trauma center. Suddenly, as I stood a few steps away from the room, and just prior to loading him on the ambulance stretcher, a code blue was called for our patient. My resident and I ran to the room, and found the patient not breathing and staring into space. He rapidly recovered but we rushed him to the resuscitation room with the immediate decision to intubate him for airway protection during transport. While in the resus room and preparing for the procedure, I glanced up at the rhythm on the monitor and my heart skipped beats just as the patient’s heart was skipping beats. Many beats. Dropped beats. Non conducted beats. Meaning, this was, finally, a cardiac syncope. The patient fainted not once, but twice – and the second time just happened to be here, in my ED, with his chest hooked up to a monitor that captured the rhythm as it happened. And there it was: the heart was beating in a totally dissociated rhythm, meaning that the 4 chambers of the heart were not coordinating, not sending appropriate signals to each other. A rhythm like this means that blood isn’t adequately pumped to vital organs, including the brain, so a person will faint.
Or the heart will stop.
His heart essentially did stop. For a few seconds. At least the major chambers of the heart stopped. The atria, the smaller chambers at the top of the heart, were sending signals that the ventricles lower down were not receiving. So the ventricles were not beating, for a good 15 to 30 seconds. Lucky for him and for us, he came back without intervention and we were able to get on top of it by applying pacer pads to his chest in case it happened again.
I called the surgeon back. Hello, his heart is the problem; the bleeding brain is the consequence. GET CARDIO INVOLVED ASAP. He agreed.
I shipped the patient off with a nurse, a respiratory therapist and my resident with a pocket full of lifesaving medication and a monitor that could start pacing the patient if needed – keep the patient’s heart beating in an organized fashion.
When my resident got back from the transfer, and I heard that he made it there without incident, only then could my own heart go back to beating smoothly. Not that my heart rate ever increased – it doesn’t, when I deal with stressful cases at work. But the feeling of my heart in my throat fluttering like a bird caught in a nest finally resolved. My heart was free, and rivers of pride and relief flooded me like a hurricane.
This case was so great not only because we saved a life – because we did – but also because it tied together everything I learned in medical school, residency and attending staff life. It reminded me, again, of the sheer scope of knowledge I have been blessed to possess after so many years of striving to learn it. I feel so in awe of the physicians who came before me, who learned all of this through trial and error and hard hard work. They created protocols, wrote textbooks, trained learners and now I hold all that history, and power, of medicine, in myself. And I am passing it on to residents, students, and the entire team I work with, every day. This is the joy of what we do – constant learning, constant growth, sometimes fulfillment.
And saving lives, even when the heart wants to stop.