Horseshoes and Hand Grenades

Reason for visit: cough – follow up from urgent care

6 weeks from the end of my intern year, I met B first time.  I walked into the room and saw a healthy appearing 33 year old, dressed in the uniform of kitchen staff from my training hospital .

B had visited a local urgent care twice in the last month for a cough and shortness of breath.  He received azithromycin and a cough suppressant both times.  The second time, the urgent care doctor referred him to the residency clinic so that he could have a more thorough evaluation if it hadn’t resolved.  The cough and shortness of breath had not improved.

I proceeded to do my normal initial patient visit history and physical.  B had a couple of interesting past medical history items.  He was being treated for glaucoma and had had his spleen removed as a child for Idiopathic Thrombocytopenic Purpura.  Interesting, but nothing directly related to his chief complaint.  He denied any history of asthma or other chronic lung problems.

History of present illness

Me:  What has been going with your cough and breathing?

B:  For the past few weeks, I have had an annoying cough and feel increasingly winded doing simple activity.

Me:  Can you describe how winded you feel?

B: well, like on my way over here, I had to stop and rest coming up the stairs in this building.

Now, my clinic rooms were only on the second floor.  I checked his vital signs again: heart rate, respiratory rate, and oxygen were normal.  His lungs were clear, his heart sounds were normal.

An otherwise healthy 33 year old should be able to walk up a flight of stairs, even with bronchitis.  Maybe not with a significant pneumonia, but his vitals didn’t suggest that.

a closer look

I turned and just looked at B.  Up and down, looking for some other clue in his visage that might point me in a direction.  He had short cropped sandy-blond hair, wearing wire-rimmed glasses.  He looked comfortable.  His skin was a bit pale, not hemorrhaging GI bleed anemic pale, but enough to favor a portrait of a Victorian-era consumptive.

I didn’t know much as an intern, but I had learned people who get rare diseases tend get other rare diseases.  I was nonplussed.  Other than the fact that his story just made me worry, I didn’t have a direct line of inquiry.  Just to give myself some time to think, I had my nurse take him up the stairs with a pulse ox, see if that pointed anywhere.

He started up the stairs, oxygen stayed steady, but within a few steps, his pulse shot up to 120.  Something isn’t right here.  I talked to my faculty (still an intern – have to precept every case).  My thought process had frozen, I knew something wasn’t right, but what other tools do I have in clinic?  She helped me out, “how about a chest x-ray and an EKG?”

ORDERs: CXR and EKG

His chest x-ray wasn’t very impressive. I thought maybe his heart seemed a little big for a 33 year old, but the radiologist wasn’t impressed.  His EKG was a different story.

EKG didn’t show any ischemic changes, he had sinus rhythm and no conduction problems.  Those were pretty much the only normal parts.

Axis was confusing, but seemed rightward, P waves were huge, T waves were either inverted or gigantic. He didn’t have obvious hypertrophy, but voltage on his precordial leads seemed moderately elevated. To this day, it was the most bizarre EKG I have seen.  I wish I had a copy.

admit to hospital

I went into the exam room.

“B,” I said, “There is something not right with your EKG.  I am not sure what it means.  It doesn’t look like a heart attack or anything like that, but I think we need to get you to the hospital to figure out is going on.”

B seemed neither relieved nor worried, “Okay.”

I called my fellow on-call intern and the chief resident.  Presented the case and arranged for B to admitted to the hospital.  The work up began in earnest.  Most favored a pulmonary embolus as the cause of B’s symptoms.  The team ordered the requisite CT Angiogram of the chest.  The read came back.

NO pulmonary emboli identified.  pulmonary arterial trunk measures 4.5 cm, highly concerning for severe pulmonary hypertension.

The echocardiogram the next day confirmed that B did indeed have severe, end-stage pulmonary hypertension (PH).  Right ventricular hypertrophy. The cardiologist and pulmonologist were called in.  The work up provided no treatable cause of B’s PH.  The label became “Idiopathic,” which is doctorspeak for “we don’t know.

Henry Vandyke Carter [Public domain], via Wikimedia Commons
When the cause of a problem is unknown, treating it very effectively becomes rather difficult.  The cardiologist scheduled a heart catheterization for an arterial dilation test.  This was to determine which therapy might be appropriate.

His pressures were too high to complete the test safely.  The cardiologist aborted the procedure.  He arranged transport to the nearest university medical center.  B needed to be on a transplant list.  33 years old.

good catch, man!

My classmates congratulated me on my “good catch.”  A well appearing man walked into my clinic with a rather benign complaint and I started a work up that caught a zebra.  We rapidly identified a diagnosis, involved the correct specialists and provided, I do believe, excellent care.

I went to see B in the hospital the day before his transfer out of the city I trained in.  He was cautiously optimistic and glad to have an answer and to be getting to where he needed to be.   He thanked me.

I asked him if he had family coming.  He said his parents would meet him at the university hospital and his sister was flying in from out of state.

“That’s good,” I reflected, “Family is important when you are going through something like this.” We shook hands and said goodbye.

Nothing puts swagger in an intern’s step like catching a zebra where one least expects it.  I felt pretty damn good.

when your best isn’t good enough

One of my favorite things about traveling around rural parts of the country is picking up rural aphorisms.  One that I grew up on in my household was, “Close only counts in horseshoes and hand grenades.”

Two weeks after B left our care and hospital, I went into his chart to show a colleague his EKG.  The computer attacked my vision with the notice:

YOU ARE ENTERING A DECEASED PATIENTS CHART. 

I sat back stunned.  We came close, but medicine isn’t horseshoes or hand grenades.

Later that day, I talked with my fellow intern who cared for B in the hospital.  I let him know the news, he had a similar reaction.  We had felt so good about the care we had provided to B.  We were at the top of our intern game and yet, he died.

humility is a punch to the gut

Did we do anything wrong?  I certainly don’t think so.  Diagnosis, treatment, transport to appropriate care in a timely manner.  All done better than average, I would argue.  We were proud, especially for a team of family medicine residents and interns.

By Rama – Own work, CC BY-SA 2.0 fr, https://commons.wikimedia.org/w/index.php?curid=3632261

By the stars aligning, my fellow intern’s significant other was an ICU nurse who moonlit in the university ICU.  On her next shift, she asked around.  It turns out B was admitted there, kept in the ICU for monitoring.  One night, shortly after his arrival, he went into ventricular tachycardia, an unstable cardiac rhythm.

The ICU team attempted to revive him for 2 hours through the use of every life saving medication and procedure they had.  Codes are normally called after 30-45 minutes.  He was 33 years old.

reconciling polar opposites

Sitting in my bed one night, staring at the ceiling, I talked about B’s death with my wife.  I don’t talk about patients with my wife often.  So, when I do, she knows the patient affected me deeply.

Usually, when someone dies or there is a bad outcome, I am able to derive a lesson for honing my art.  Next time, I will do XYZ, and it’ll go better.  I make sense of the loss through striving for improvement.  It helps add meaning.

What happens when you did better than would be expected and it still goes south?  “Nothing we could have done better, that is just life in medicine” seemed like a poor salve for my wounds.

Overtime, I thought back to the last conversation I had with B.  His family was coming to see him, they new the diagnosis by the time he died.  The grief doesn’t disappear because of knowledge, but every removed uncertainty helps, I think.

Most importantly, I believe they had a chance to see their son and brother before he might have suddenly died of a cardiac arrest.  That was a gift I gave him and his family: some answers, and some time.  We can’t always save, but we can always heal.

the dead are never gone

Having now gone through my own loss, my perspective on B’s story has evolved.  Families carry the care and comfort we give to patients who die, just as they carry the memories and lessons of their loved one.   This can be a blessing, and it can be a burden.

If we can give patient’s families memories that their loved one’s time under our care was full of support, strength, and understanding – it can be a great gift.   It is invaluable in their grief and healing.

Anger is an all too easy trap for grief.  It is a natural and normal part of the process, but it can be seductive.  Anger is often easier to feel than the unending sadness or permanent loss. Anything we do as healers that makes the transition from anger to the other parts of grief easier, is of immeasurable value to patients and their families.

I now know this all too personally.  Death is not an option, only a matter of time.  Yet, we as human beings, and especially as physicians, have the power to meet it in different ways.  We can meet death with love and the support of family and community, it can strengthen the bonds between those who are left behind.

As physicians, we have the power to facilitate that journey.  It is a terrifying journey, people need guides.  We have that power, if we choose to use it.

If we choose to help people meet death on their own terms, we choose to help them know life in the richest way possible.

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