Another case of chest pain. Almost anyone who comes to the ED with complaints of chest pain gets admitted. First task is to rule out ACS or Acute Coronary Syndrome. The differentials for chest pain are wide and varied, ranging from heartburn to musculoskeletal ache to something more serious such as a heart attack. A heart attack, or in medical jargon, a myocardial infarction (MI), is one of the conditions classified as ACS. ACS represents a spectrum of conditions that is characterized by a sudden reduced blood flow to the heart. The majority of patients who get admitted for workup of a chest pain end up having nothing serious. Once in a while, however, we get a “real” case.
This patient was young. An African-American woman in her forties, no past medical history, no risk factors. I found her on a stretcher waiting to get a chest CT. A CT scan, or computed tomography scan, is a medical imaging procedure that uses a computer to take multiple cross sectional x-ray images of a person’s body. I’m guessing that the Emergency Physician ordered a chest CT to rule out a pulmonary embolism or an aortic dissection, both of which are potentially lethal and can cause chest pain.
She was extremely uncomfortable. Chest pain, nausea, vomiting, dizziness, stomach ache, menstrual cramps. All these symptoms started when she woke up this morning, she said, and she fainted while she was combing her grandchild’s hair. She smoked cigarettes here and there, took medication for heartburn but denied using any other drugs. Overall she appeared to be a reasonably healthy single mom with three kids. The Internal Medicine attending physician on call that night came by while I was conducting my interview, and from a quick glance at the patient’s chart, cancelled her chest CT. It was not needed, he said. And because he was the attending, and because he was one of the most respected physicians at the hospital, we listened to him. This patient’s presentation, he said, does not match either pulmonary embolism or aortic dissection at all. Test her cardiac enzymes, and if they are negative (negative in medicine means normal), send her home.
I finished my interview with the patient, and examined her with my senior resident. Her first set of cardiac enzymes did not show evidence of heart damage, which meant that a heart attack was unlikely. Her EKG (electrocardiography, a device that measures the electrical activity of the heart), however, did reveal some unspecific changes. The protocol is to repeat the cardiac enzymes and EKG in 4 to 6 hours.
After some morphine, her pain subsided, but she was still very miserable, complaining of extreme nausea despite having received multiple doses of anti-nausea medications. Her cousin was in the ED with her, so I explained to both of them that right now we were not sure what was wrong, but we would conduct more tests.
“Am I going to die? I feel like I’m going to die.” She kept saying.
I felt like comforting her by saying no, but kept my mouth shut.
“We don’t know what is happening yet, we will let you know when we know more.” My senior resident replied. A much more cautious and correct reply to such queries.
We asked her for a urine sample but she was feeling too nauseous to go to the bathroom right then. No rush, we said, just give it to the nurse later.
“So what do you think she has?” My senior resident asked me on our way up to the floor.
“I don’t know, it could be a really bad GERD (gastro esophageal reflux disease which gives very bad heartburns). I know because I’ve had that experience myself. Or maybe she’s having a panic attack. She did tell me that she’s been under a lot of stress lately and she alluded to some sort of psychiatric history.” I replied.
Did I mention that I was really tired? After I finished documenting this patient’s story and findings, I snuck into the on-call room for a power nap. Of course, whenever you sneak a nap, you put both your cell phone and your beeper on the loudest setting and place them right by your ear. When something beeps, rings or buzzes, you jump up.
I slept quite peacefully without anyone bothering me for a while. Then my senior called my cell phone “ Melody, can you please come to the ED?”
Another admission, I thought. I took my time, printed some labels for my first patient’s lab tests that I was going to give to the nurse later before actually making my way down to the ED. On the way, I ran into another resident. “Melody, what’s going on downstairs, is the patient coding? Is it your patient?”
What? Who’s coding now? I sprinted.
(A medical code is an emergency. Depending on the code that is called, it could mean a cardiac arrest, among others.)
I found my senior resident and another intern coming out of the resuscitation room in the ED. “What happened?” I asked.
“Your patient died,” was my senior resident’s response.
For a second, I wasn’t sure if he was joking. Was this a bad prank?
“She collapsed and they ran the code for 30 minutes.” He added.
(They tried to revive her for 30 minutes. Chest compressions and all.)
“Are they running the code now?” I asked, still in shock.
“No, the code is over. She’s dead.”
So he wasn’t kidding. I opened the curtain to the resuscitation room, and there her body was, limp, exposed, lifeless.
It turned out that my senior resident had paged the wrong intern thinking that it was me, so I never knew that my patient was coding. I felt horrible. Guilty. Scared. Ashamed. I wasn’t even there for my patient’s code. Did I miss something? Was I not thorough enough in my history taking or my physical examination? Was I too fatigued to notice that something was wrong? Would we have caught something if that chest CT hadn’t been canceled?
I met with her family. About ten family members came, brothers and sisters, cousins, all standing two heads taller than me while I explained to them that we really didn’t know why she died. We suggested to the family to let the coroner perform an autopsy to find out what had happened.
Then came a lot of scurrying, phone calls, discussions, paperwork and signatures. I went to put my fingerprint on her death certificate. Meanwhile, my senior resident insisted that the nurse get a urine sample from the patient, even though she was already dead and had urinated all over the floor when she collapsed. Her bladder was empty, so it had to be flushed with saline in order to get a few drops of diluted urine to send to the lab.
What is the point of getting a urine sample when the patient is already expired?
Half an hour later, while I was still in the midst of phone calls and paperwork, my senior resident called me: “Melody, call the medical examiner. Patient’s urine came back positive for cocaine.”
Ah. Cocaine. The wrench in my heart loosened slightly. That could very much be our culprit. We see many cases of cocaine-intoxications at the hospital, I wonder if patients are aware of the very serious and nefarious effects this drug has on our body. One snort, one puff or one shoot can send your heart into irreversible arrhythmia or make it stop beating. Forever.
At least now we had a lead. And we didn’t mess up or miss anything… for now at least. We won’t know definitely until the official Medical Examiner report.