Saturday, April 23, 2011


She wasn't on the unit when I arrived at work in the morning because she had already been sent to Nuclear Medicine to finish up her stress test. The "stress" portion was done the day before and that was clear.

Though young and athletic (she was in fact a school gymnastics instructor,) she had come to the hospital for chest pains and was found to have an arrhythmia; rapid atrial fibrillation. She felt palpitations at home, took two aspirin because she had heard that was good for the heart, and a family member brought her to our doorstep.

She converted to normal sinus rhythm after being on a Cardizem drip for a bit; that was stopped and now she was to take this medicine orally. The cardiology physician's assistant had seen her and their service signed off. The internal medicine doctor wrote orders for her to go home. I provided educational materials on aspirin and cardizem. We had our most excellent dietitian chat with her about a proper cardiac diet. Unlike many people I serve, she was motivated, intelligent, and likely to comply. Everything looked good.

We weren't even going to wait for the nuke med results. The doctor said he'd call her later at home to talk about that with her. She was eager to leave the hospital because her son was playing a game that night and she wanted to be there.

I had removed her telemetry monitor and we were finalizing her discharge instructions; in fact, she was just about to sign a copy for our chart on her when my phone interrupted me.

I hate that.

It was the radiologist. The nuclear portion of the stress test showed a small reversible ischemia in the inferolateral area of her heart, at about four-o'clock to six-o'clock. Ruh-roh, Reorge. We had to stop.

If she infarcted it could look like this:

Big black holes aren't allowed. I don't care what Stephen Hawkings says. By the way, doesn't he look just fabulous in this early photo?

He's incredible. I love that guy.

When I called the cardiologist we received orders to hold up the discharge and consent her for a cardiac catheterization that afternoon. When I told the patient, she cried. I explained everything in plain but explicit and sympathetic terms. I spoke to my boss about her and they also saw the patient to console her and help her understand what needed to be done. The patient decided that she'd rather not bother and asked to leave and have the cath done in a few days on Monday.

She allowed me to run that by the cardiology team, but when I again called them they reluctantly insisted that the testing be completed before leaving. Aside from the legal considerations that's just proper medical practice. We are accountable to complete investigations of issues such as young healthy athletic people who suddenly and unexplicably develop cardiac arrhythmias.

"She knows this!" my boss said while talking with us at the nurses' station, adding "She's a bloody gymnastics teacher, for fuck's sake!"

Ah... that's my boss. Ever the subtle one. They're the best.

After phoning relatives (some of which talked to me on the phone so I could explain the situation,) she decided to stay.

She went to the cath lab at three p.m. and was done in an hour. In report the cath lab nurse said everything was clear and I heard the cardiologist in the background say that the patient could go home later. She had to maintain bedrest for a bit afterwards when she returned to her room on our unit. Generally she was gracious; very much so, and glad it was over and all she would have to do is take some aspirin and cardizem and see the cardiologist once in a while.

I had her out by six-o'clock. Just in time for her to get her son to his game.

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