Ischemic and Uninformed

The man smiles at me with that kind of nervous smile: half appreciative, half terrified. He was cordial and perfectly polite, laughing at his jokes and ours, but the sound was unnatural. Forced.

The doctor takes me aside.

"This guy has had chest pain for a week. Can you believe that? A whole week!"

The doc explains to me that the man felt a sudden onset of crushing chest pain along with shortness of breath as he attempted his normal exercise routine last Friday. Since then, he has had transient periods of dyspnea and chest "pressures," especially when he exerts himself. The doctor shows me the EKG with flipped T waves in the lateral leads. On the next page of the report are the lab results, and the Troponin levels are clearly elevated. The doc casually rattles off the rest of the man's risk factors. Smoker. Positive family history. Obese. History of hypertension. History of high cholesterol.

"We're sending him to Hospital Z," the doc says. "I think he's gonna need a stent."

We walk back to the patient's room, where my partner is getting the patient ready for the transport. The doctor chastises the man for waiting so long.

"Next time you come to the hospital right away, okay? This kind of thing can kill you. Seriously, kill you. Its not to be taken lightly. Understand?"

The man stammers, letting out a shuddering "okkkkay" as the doctor leaves the room.

I smile at the man, hoping to ease the tension. "Let's get ya all unhooked here so we can get you on our equipment." I make jokes about the wires. There are too many, too long. They're just for show, to be honest. The man cracks another nervous laugh but it is plain that he is preoccupied and afraid. I cant blame him. Textbook presentation for cardiac disease, EKG changes, and elevated enzymes? Its a scary picture.

We hook up our gear and roll the man into the back of the ambulance. I burn off a quick 12 lead for our records.


The man watches me as I read over the EKG. He clears his throat and asks me how it looks. I explain that it seems pretty much the same as the EKG they did in the emergency room.

"You've still got a little bit of an issue on the left side of your heart here, but it doesn't look too bad just yet."

The man seems to be clinging to my every word as he looks at me with wide eyes, and I pause for a moment.

"Have they explained any of this to you?"

The man put his head down.

"Not really. They're so busy in there I didn't want to trouble the doctor with too many questions. Everything was moving so quickly. They said that they're going to try and open up an artery or something?"

I am amazed. How is it that a man could come in to an emergency department, be found to have a serious cardiac issue, and wait till he was on his way to surgery before he begins to understand what is happening? The man sat patiently in that department for at least an hour, sitting quietly through the tests and exams, as EKG wires were plugged together and discussions between doctors occurred just out of earshot. All the while, in the dark.

He picked up on the tone, though, and it wasn't good. He tells me that more than once he was spoken to about "coming to the emergency room earlier," and that he shouldn't have waited a week. He knew that there was something wrong with his heart, but not exactly what, where, what it means, or what exactly could be done about it.

I lean forward from the bench and show him the pink printout. I point to the lines on the paper, explaining that some are going down when they should be going up. I pull out his old EKGs from the file so he can compare, explaining the difference between ischemia and infarct in layman's terms. "Its almost as if your heart is short of breath, and is getting bruised up because of it," I explain. "...But the danger is that it can get worse, to the point where it cant be helped." We talk about vessels closing and opening, about supply and demand.

He asks me questions. Lots of them.

"If a part of my heart dies, will it grow back?"

"Does this mean that I wont be able to get up and do things anymore?"

"What are they going to do to me at the Hospital? Will I be awake the whole time?"

"Is any of my heart already dead?"

I answer each question in turn, using basic language that I hope the man fully understands. He clarifies what he doesn't, and listens intently to my replies. We spend the entire trip to the hospital talking about cardiac physiology, treatment modalities, and prognosis. I exhaust my knowledge upon him, and when I get to the end, I remind him to ask his doctor when we get to the hospital.

I tell the man: this is your heart, and these are your decisions. You have a right to know about what is going on, and nobody can do anything without your permission. Do not be afraid to ask questions. Insist that you are informed, and advocate for yourself as much as you are able to. It may not seem like it, but you are in charge.

I left the man on his new ED bed with a firm handshake, and he thanked me with an emphasis that echoed through me for the rest of the week. I truly made a difference in this man's day, helping him through a difficult time with academic knowledge, patience, and a caring tone.

It was easily the most satisfying thing that I've done as a paramedic so far.