ST

A 95 year old man is sent from clinic to the emergency department with a preliminary plan of "rule out TB." He has multiple medical problems including HTN, hyperlipidemia, COPD, chronic kidney disease, arthritis, GERD, and a positive PPD and presents with hemoptysis of one month. On further history, he has no chest pain or shortness of breath, but feels that a week or two ago, he suddenly became very weak. As is routine in the ED, they get an EKG simply because the patient is old.

I don't have his exact EKG but I found one that is similar and it is shown above. The ED sees this EKG and calls a STEMI code - they read this as an acute heart attack. His troponin is 0.3 (creatinine is 2). The interventional cardiology fellow comes and is about to whisk the patient away to the cath lab when the family says perhaps angiography and stent is not consistent with the patient's goals of care. They decide to medically manage this STEMI without aggressive intervention. We are called to admit this patient to the general cardiology floor.

The EKG above is not the patient's EKG, but when I looked at the patient's EKG, I also noted some ST elevation in the inferior leads and no reciprocal changes. As a result, I started worrying that this was not a STEMI as advertised but possibly percarditis. It is odd, however, that the patient had no chest pain whatsoever.

When the attending reviewed the EKG and the story the next day, however, he became suspicious that this was neither a STEMI nor pericarditis. Although those are the two most common causes for ST elevation on an EKG, a much rarer diagnosis can do it as well. It turns out that this patient had an LV aneurysm; he likely had an old MI a week or two ago with persistent troponins due to his chronic kidney disease. During the interim, he developed a large LV aneurysm which lead to the false STEMI activation.

This case was a fascinating lesson in EKG interpretation; context is so, so important to diagnosis.

EKG is from wikidoc.org, shown under Fair Use.

Chest Pain

Chest pain is one of the most common chief complaints in the emergency department and can be one of the more expensive ones to work up. In an older patient, a complaint of chest pain almost always buys an EKG and labs; often, it gets a hospital stay as a heart attack is "ruled out." Being an intern on cardiology means I get all the chest pain admissions. Often, it is trying to find a needle in a haystack; so many things can cause chest pain and only a minority are cardiac. But what I've learned from this rotation is that the history and physical are key. They teach us this in medical school, and it is true; a thorough history can get you much farther on a diagnosis than any set of laboratory tests. The other common cardiac admission is congestive heart failure. This rotation was really good in helping me review the standards of care and goals in heart failure management. Bread and butter cardiology can get a little boring but is so common and important to review

Cold

Although those on the East Coast would pish-posh, it has gotten quite chilly for us Californians. Unfortunately, I often walk to and from work at the witching hour and so I bundle up quite a bit. It's been pretty rainy too, which I don't mind when indoors, but it makes the walk slightly more harrowing. Weather seems to be a pretty poor topic for a blog, but I'll have something much more cardiac tomorrow.

Image is from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Poem: Masquerade

I wrote this poem at the last creative writing workshop. It was inspired by Mary Karr's "Viper Rum." The prompt was: masks are a prominent party of Halloween. Write a poem about a mask or masks.

-
Masquerade

For nineteen years I danced.
I danced to forget, unknowing, ill-caring.
There were no faces, eyes sanded away
leaving only the frame of things, the rock and sway
of blues, the kiss and linger of waltz.
Masks of glitter, masks of gold,
masks of clay and wood.
The sprung floor ached rhythms
and we wrung tears from the paneling.
A face painted black and white lead me blindly.
Eyes were painted over eyelids,
they fixed me upon my axis,
I could only spot on white pupils with each turn.
A woman with feathers leapt with pas de basque,
skirmishing the others until hearts subsided.
I found a mask on the ground, trampled, formless,
and yet we need not heed the warning.
We danced month after month, year after year
until drumming and fire flickered in ritual,
our madness conjuring motion from dust.

He came for us in the end, how could he not,
and he sent us awry, ascatter.
His mask was white, bloodless, rent and bloodrung.
I knew then he came for me.
The stamping became more furious,
the drums would not hush. I fled.
The mask I wear is the one I destroyed nineteen years ago,
the one my wife, my daughter, my family knew.
The cult-summons gleaned confession from me,
sweat escaped the sides of my face's tomb.
I tore it off, stripped a layer of skin,
recoiled in apprehension. The webs and spiders of the room
flooded me, harnessing, and when in years past,
I would let the rebound catch, this time, I pushed through.
The room was humming in ghosts and macabre.
Out in the river, I emptied my pockets,
the rope, the gun, the razors.
The water caught my glance, then hurled it back.
I touched my face; unconcealed, wet,
the first time I had touched it
since I had last seen myself.

Code Blue II

The patient described in the last blog had initially come in with cardiogenic shock of unclear etiology. His troponins were modest, but he had a severely depressed ejection fraction in a normal sized heart. His hemodynamics were so bad that he went into multi organ failure with shock liver, acute renal failure, and respiratory failure requiring intubation. His clinical course was complicated by heparin-induced thrombocytopenia and bilateral deep vein thromboses. He was put on argatroban for clot prevention. He slowly made a recovery; we were able to extubate him, we weaned down sedation, his laboratory abnormalities were normalizing. But then the next day he coded and died. As we got serial ABGs, we realized the patient had a large A-a gradient suggestive of a massive pulmonary embolus. We pushed t-PA but there was really nothing more we could do.

We got an autopsy on this patient. I blogged a long time ago on autopsies; the last I attended was two years ago. I think they are an invaluable resource. We didn't know the diagnosis; we didn't know why his heart went bad at the start and our theory of pulmonary embolus was hypothetical. But going down to examine the organs was incredibly enlightening. We were able to see the wedge infarcts and visualize the clot burden. We were able to hold the heart in our hands and feel it. We were able to confirm our diagnosis of why the patient coded, and as soon as the pathologists complete their microscopic analysis, we'll have a better sense of why he had cardiogenic shock in the first place.

Code Blue I

The truth is, most "codes" called in a hospital turn out to be false alarms. All medical staff are instructed to call a code if we even think about it; it's the quickest way to get help in the hospital. No one can be reprimanded for calling one; even if it turns out to be benign, better safe than sorry. When a code is called, a ton of staff come out of the woodwork. Not only do you get an ICU fellow, a code team, a host of nearby doctors, nurses, pharmacists, and respiratory therapists, but depending on the hospital, you also get security, a chaplain, and a runner (someone to go find supplies you need). Sometimes it is better to call a code even if you have multiple doctors in the room simply because we'll need someone to get a bipap machine or mix up a drip or place another IV.

The truth is, I have only been at a handful of codes and none that have been incredibly acute. Recently though, in the CCU, one of our patients coded and we were there from the very start. In fact, it happened on rounds; the resident was first called away, then he pulled the fellow in, and then a minute later they poked their heads out and asked for more help. The attending strode in and started directing the code. Although running a code tends to be the job of a senior resident or fellow, it was entirely appropriate in this case and I immediately saw why. The patient had an uncertain diagnosis and the attending's mind worked so quickly. He not only went through ACLS by rote - another round of epinephrine, continue chest compressions, charge to 100 Joules - but talked aloud, allowing us some insight into his rapid and complex thought process. He immediately laid out the differential diagnosis, described the rhythm he saw on telemetry, and proceeded to complex therapies way beyond ACLS (we even tried inhaled nitrous oxide). He remained coolheaded throughout, asking for ideas, maintaining absolute control of this situation. A CCU patient crashing is terrifying because these patients have no reserve; there's no higher level of care; there's no room before they die. But at least in the CCU, the staff is trained for this level of complexity, the patient had abundant access, and he was already on drips we could titrate. He didn't make it, but that's something for the next post.

Students

Another role we take on as interns is that of mother duck. Particularly on ward months, we get assigned third year medical students who follow us around like ducklings. We co-follow patients with them, teach them, review their notes, encourage them to come up with an assessment and plan. I have grown to love this role. It is really fun to realize that I have knowledge to pass on. But more than that, it is so satisfying to see students come up with answers themselves. I remind myself to avoid simply telling students answers to questions that they could potentially figure out themselves. While I am loathe to assign "homework," I do like to prod and push the third years to read independently and think critically about their cases. Their questions challenge me, force me to see different perspectives, renew my enjoyment for learning. I also think students contribute to the care of the patients they follow. Student notes are the most thorough; if I wonder who a patient lives with or whether they have pets or about their family history - things I am notoriously poor at recording - I have no doubt that the MS3 knows. Students also prompt us to broaden our differential diagnoses, look into the most recent treatments for diseases, and address even the small issues. Teaching itself is also such an incredibly important skill to practice and develop. It is one of the best parts of intern year.