A Job Well Done

Once more, I’m covering the medical side of the hospital for a week of nights. Last night, I got paged by the nurses on the Coronary Care Unit (CCU) and they told me they’d just received a call from the paramedic ambulance crew and they were bringing in a patient with an ST Elevation Myocardial Infarction – a heart attack.

I walk round to CCU toget there before the patient and start thinking about what is about to happen.

A heart attack is caused by one or more of the arteries that supply blood and oxygen to the heart becoming blocked by a blood clot. The part of the heart beyond the clot gets starved of oxygen and energy and, if nothing is done, that part of the heart will stop working. If enough of the heart muscle stops working, then the whole heart can’t beat properly and the person dies. This is how heart attacks kill people.

In hospital, our aim is to try and open up the blockage caused by the blood clot and this can be done in one of two ways.

The first is called primary angioplasty. This is the best treatment and it involves the doctor passing a wire from your groin to your heart where the blockage can be cleared manually. The second is called thrombolysis, this is more old-fashioned and it involves the medical staff giving you a “clot-busting” drug into your veins to try and dissolve the clot. It works most of the time but there is a 1 in 200 risk of severe side-effects like bleeding into your brain and dying.

We cannot do primary angioplasty at our hospital, we don’t have the right equipment or doctors or nurses trained to do it, so patients with heart attacks coming to Town Hospital get given thrombolysis. It truly is a post-code lottery in the NHS.

The patient comes in. He’s 48 years old with no previous heart problems. He had woken up a couple of hours earlier with central chest pain. It didn’t go away so his wife called NHS Direct who called and ambulance for him. The paramedics handed me the ECG that they’d done while the CCU nurses are connecting him to the cardiac monitor.

An ECG is basically a series of wiggly lines that show us how electricity is moving round the heart muscle and this allows us to deduce if any parts of the heart aren’t working. There are very strict ECG criteria that the patient has to meet before we can give thrombolysis.

Like I said, an ECG is a bunch of wiggly lines and his ECG was on the borderline. You could argue it either way – that it fits the criteria or that it doesn’t fit the criteria.

Now, none of the medical jobs I’ve had have been cardiology jobs and I’ve never personally given anybody thrombolysis before. Because of the very real risk of the treatment (thrombolysis) paradoxically killing the patient, as the doctor you have to be ABSOLUTELY sure that the patient meets the criteria before deciding to give it.

I wasn’t sure.

Thrombolysis is meant to happen within 20 minutes of the patient arriving into hospital. This man probably had heart-related chest pain but his ECG was borderline. The paramedics said that they weren’t sure about it so they’d brought bypassed A&E and brought him straight to CCU to be on the safe side. The CCU nurses (who between them, have seen hundreds of patients having thrombolysis) were not sure about it either.

Then came the moment I’d been dreading. The patient is looking at me, his wife is looking at me, the two paramedics are looking at me, the two nurses are looking at me, and one of them asks:

“What are you going to do doctor?”

The honest answer would have been “I don’t know.” I’m staring at the ECG tracing as if some sort of divine inspiration is going to leap off the page at me and help me make the decision. A decision that has the potential to save this man’s life and also has the potential to kill him.

It is then that I remember what is probably the most important rule of being a good junior doctor.

IF YOU DO NOT KNOW - GET HELP

So I say:

“I’m not absolutely sure about this one, I’m going to get the registrar. He’s pain-free right now so let’s give him some oxygen via a face mask. You guys (the paramedics) have already given him some aspirin so lets give him 300mg of clopidogrel (a tablet) and I’ll be right back”

As I’m walking out of the room, one of the paramedics smiles at me and says, “I’m glad I’m not the only one who wasn’t sure.”

The medical registrar, Ben, is on MAU just round the corner so I get him and he comes round to see the patient. Ben furrows his brow when he sees the ECG and then goes out and comes back with a portable ECHO machine. He does an echocardiogram – an ultrasound scan of the heart - and this shows that part of the bottom of the heart was not working as well as it should. We then repeat the ECG and on the new tracing, the wiggly lines are much more obviously meeting the criteria. Inspiration at last!

Ben looks at me, I nod, he nods and then I tell the nurses “let’s do it.” I’d already explained the risks and potential benefits to the patient who agreed to the treatment and so we give him the clot-busting drugs.

By now, my heart is racing, I’m sweating and a thousand scenarios are going through my head. What if he has an allergic reaction? What if he starts vomiting blood? What if he starts bleeding from his nose and his eyes? What if he has a stroke? What if he dies? He might have been OK if I’d done nothing at all – what if he dies? What if I’ve killed him?

So I stay and I watch him and I wait. I wait for all those bad things to happen.

Nothing happens. His heart tracing slowly improves and he remains comfortable and pain-free with no bleeding. It worked!

His heart is still beating and he feels fine, if a little tired (after all it’s 5am).

This is the first time I’ve “thrombolysed” anyone and it was successful. Between us, me, Ben, the CCU nurses, the paramedics, the NHS Direct phone staff and the patient’s wife may well have saved this man’s life.

I’ve got that warm, satisfied feeling as I’m sitting here typing this before I go to bed.

A job well done.

n.b. my indecision and Ben’s decision to do an ECHO before thrombolysis meant that he received his clot-busting drug 28 minutes after arriving, which is longer that the 20 minute government guidelines – but right now, I really don’t care about that.