Posts Tagged ‘electrocardiogram’

Confronting a smoker with a heart attack

January 13, 2019


When it comes to attacks of the heart

Please listen, you docs who are smart

Whenever the bloke

Steps out for a smoke

Don’t yell, and keep your words smart.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Though the patient gave me permission to write about him, I won’t say when this incident happened.

He came in with chest pain. As per protocol, I did the electrocardiogram which strongly resembled previous tracings.  But I also asked for and obtained a blood test for troponin, which rises only when heart muscle has sustained damage.  It came back normal.

But we have learned that sometimes the damage doesn’t show up on the initial blood work, so I ordered the same tests 4 hours later.

I read the second ECG with alarm: a sag in the line connecting the wave representing the heart’s contraction, with the deflection of the heart’s electrical preparation for the next beat. I sat down with the patient and discussed the situation.  In the middle of a heart attack, I had to make arrangements for more specialized care.  He would require a cardiologist and a catheterization, perhaps stents or a cardiac bypass graft.

I started the complicated business of sending the patient to a higher level of care while the snow fell hard enough to make the task impossible. I repeated the same story on the phone, each time emphasizing that the patient remained pain-free and with normal blood pressure and pulse.

The snow eased my emotional frustration. No medevac helicopters fly in this health district.  I only ask for fixed-wing transfer when justified by the distance to the facility, and the weather throughout the province assured that the small planes involved in medical transfer could neither take off nor land.  Still, the decision-making came at day’s end.  Vancouver’s cardiologists had no beds, we would have to keep the patient.

As I finished the hospital admit process, the nurse said, “You know, don’t you, that he stepped outside for a smoke.”

No, I hadn’t known. I confess I lost my temper.  I slammed my pen on the desk and stormed out to the front entrance.

I confronted the patient.

Those who have known me the longest will confirm that when I get angry I get articulate, but I rarely raise my voice. I don’t have to.

What I said boiled down to, “You have a beautiful young wife and a son. There are a lot of people who love you, and we’re worried about you.”  But I said it, angrily, about 6 times.

I care about my patients, but I haven’t expressed that kind of fury for years. Maybe I’d worked too many hours with too much noise.  I finished more fatigued, and I felt worse for hours.

The next day the patient thanked me, as did his family. He felt better, the best he’d felt in a year.

Outside, the snow fell thick for the next five days, when, finally, we got word we could transfer.


Hardware, software, and chairware

June 24, 2018

A problem is found, tell me where?

Is a problem that’s not the software

I said to IT

Perhaps it is me.

Is the answer to be found in the chair?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

Eight years ago I took a course for doctors who want to be writers. Don’t use the word suddenly, they said, and never write, “All hell broke loose.”

I suppose all writing has rules, yet I haven’t figured out all the rules for effective blogging.

But I find myself enjoying this gig. A small hospital is an efficient hospital; one doesn’t waste a lot of steps.  Consider the context:  a functional Iowa town just big enough to have a hospital.  In two weeks I’ve dealt two marijuana users, and no drug seekers.  Every urine drug screen has come back clean.  Fewer than 10% of the patients smoke.

And I have time to spend with the patients. I listen attentively, I don’t interrupt.  I get to dictate my progress notes, and I can enter my hospital inpatient orders on paper.

I haven’t figured out how to use the Emergency Room EMR, not quite the same system as the inpatient program. I just couldn’t get it to turn on.

Today the Information Technology person asked me to show her the problem; I signed on and got a nice border on an otherwise blank screen.

“Is it the hardware?” I asked

She shook her head.

“The software?”


“The chairware?”

She looked at me, left eyebrow crowding the right.

“You know, the person in the chair?”

She burst out laughing, and told me she’d get back to me.

Despite cool, rainy weather, the clinic overheated. We got out the fans.  I sweated.  For the first time I realized that my large flat screen monitor produces a huge amount of heat.

The morning went at a reasonable pace. Online research, signing my dictations, reviewing labs.  Then at 11:00, suddenly, all hell broke loose.  The surgeon and the nephrologist each asked me for consultations.  The radiologist called from Orange City.  The neurologist called from Sioux City.  Two non-English speakers turned out to have a much more complicated clinical picture than we could have imagined.

I worked through lunch; the nurses and I did not get a chance to eat.

In the course of 4 hours I read 4 electrocardiograms, ordered 4 sets of labs and admitted 2 patients. I accommodated a walk-in.

I worked hard to replace my fluids lost to sweat.

And just as suddenly, things went quiet at 4:15PM. I finished with the two hospitalized patients at 5:00PM on the dot.  Food became my next priority.


On seasonality of medical care

September 6, 2015

Here’s a thing I have come to know

It’s September, before the first snow

There must be a reason

For the pace of the season

For the flow of the woe to be slow.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

In the days when I owned part of a clinic, we noted a definitely seasonality.  Cold and strep season started up as the weather chilled, six weeks after school started.  That business increased at Thanksgiving, with a big jump after Christmas.  Influenza generally provided a lot of work till spring, when the athletic injuries started up and would last most of the summer.  School physical season would start about July and ran through August..

But things slowed down in September.  Warm weather, open houses, outdoor activities, and sunshine discourage the spread of respiratory infections.

For years I worked long hours in the summer while my partners vacationed, but I went on hunting trips during the slow business month.

People don’t come in at nearly as brisk a pace now, as summer slows into September.  The school sports physical season has almost finished.  We see a good number of those with sore throats, but the people with “summer colds” (really allergies) have diminished in number.  Folks suffering from poison ivy, half my business in June and July, now show up about once a day, and not nearly as severe as before.

I didn’t have a chance to care for a patient till after 9:30 this morning.  We got in a good number of people needing drug screens for their employment.

The memorable patients today (more than one) had heart problems, thankfully, not requiring ambulance transport.  I explained several times that the way a person’s hand describes the pain provides a valuable diagnostic clue.  The open hand next to the breast bone more often describes heartburn or anxiety, but the closed fist or clawed fingers usually describes blocked arteries.

But two-thirds of the electrocardiograms told alarming stories of drama and irony in squiggling lines.  For all three patients I made calls to facilities with expertise and options outside our Urgent Care scope of practice.

In the middle of the day, with plenty of time permitting, I took a chair out the back door and ate lunch al fresco.

Through the day I kept wondering when I’d see something I’d never seen before.  Because it happens every time I see patients.  Seven patients checked in after 7:35PM.  Closing time came and went.  Staff, understandably, wanted to go home.The PA and I slogged our way through.

Then, the very last patient had a physiologically inexplicable finding.  The PA had never seen anything like it, either.

Taking the pulse to get through the denial

November 19, 2012

How do we know what we know,

In a patient denying it’s so?

A two-week-old start

For a pain from the heart

Was part of a tale of woe.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A doctor has to listen as carefully to what the patient says as to what the patient doesn’t say.  I don’t think any of the standardized tests given to doctors measure the ability of a physician to detect deception and denial in the history given, nor how to sneak through the web of drama and irony to get through to the truth.

I nodded while I listened to a patient talking about symptoms identical to the last three visits.  Taking full responsibility for the ruination of a perfectly good set of lungs, the patient seemed to me a little too cheerful.  In the middle of a digression I reached out my hand to the patient’s, and feeling the pulse, waited till the smile faded a little and I could speak without interrupting. 

“I think you had crushing chest pain for hours, going up into both sides of your jaw, with sweating and nausea and shortness of breath even worse than usual, about two weeks ago, and it went away and ever since then you’ve felt just terrible.”

The gaze dropped and the sigh came through over the gentle hiss of the oxygen as the smile faded. “That’s about the size of it.”  I kept my index and middle fingers on the pulse and I waited.  “You don’t think it was a heart attack, do you?”

“I do,” I said. 

“Well, I guess I thought so to, or else I wouldn’t have made the appointment.  I just didn’t want my daughter to know, she’d have made me go to the hospital.”  We looked at each other and burst into laughter.  “That sounded pretty stupid,” the patient said.

“There’s a difference between fear of hospitals and stupidity,” I said.  “We need an electrocardiogram and a chest x-ray.”

After the lab studies confirmed what I already knew, I started into the part of the interview known as the Review of Systems.  “Any depression?” I asked.

A shake of the head, followed by, “No, no, not at all.  Not anything worse than usual.”  I reached my hand out again and the patient’s forced smile fled.  “Yeah, I guess I’ve been pretty depressed ever since.”  I nodded and we laughed again and then we laughed because we were laughing about depression.

The patient gave me permission to write a good deal more information than I have, about a visit stretching over an hour and a half, and touching on issues of intergenerational conflict, ripples of familial dysfunction getting worse and getting better in children and grandchildren and great-grandchildren, nosology, intellectual honesty, freedom of choice, and game theory. 

I ended up giving bad news and reassuring at the same time.  I arranged for proper follow-up and explained new medications. 

Of course when that patient left I went on to the next one and apologized for running late.


After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

December 30, 2010

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.