Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Man cannot live by metal alone: A "mind-over-metal" stance is required for post-PCI successMay 21, 2010 22:01 EDT
I was paged to the ER for a STEMI, and lying on the gurney in the midst of a flurry of activity was a pale, sweaty 45-year-old-male with 40 minutes worth of chest pain. He wasn't a virgin in the coronary world, his first tryst with an MI occurring just two weeks earlier at an outlying hospital. Not having much time to be social, I noted the ST elevation on the ER monitor, explained the risks and benefits of the impending procedure, and whisked him off to the cath lab. While the ER doctor was filling me in that this gentleman with 60 pounds of excess abdominal girth, had quit his Plavix, and had continued to smoke, the patient quickly interrupted, adding that he hadn't bought his cigarettes but had rather "bummed" them from friends (thank goodness, what a relief).
By the time we reached the second floor, his ST elevation was probably 6 mm, his QT markedly prolonged, and his pain escalating. I stuck his right femoral artery through what was probably a fresh Angio-Seal plug and quickly engaged his right coronary artery (RCA). It was a monster of a vessel, abruptly occluded just prior to the posterior descending artery. He had a 4-beat run of a wide complex rhythm that wasn't exactly friendly-looking during the third injection. His BP was erratic, and he intermittently became bradycardic. It took me a few minutes to engage the left main because I had to change out to a 5.0-curve left Judkins. Two quick injections later, I declared the left main, left anterior descending, and circumflex arteries "normal." My interventionalist was already gloving when I pulled the catheter out. I ran to the waiting room to retrieve the two-week-old stent card that his relative was holding as we rolled out of the ER. A 3.8x18-mm Vision stent had been deployed two weeks earlier in that monster of an RCA, and even after the vessel was wired with TIMI 3 flow, the STs were just as impressive as ever. It was no wonder, because with that column of clot, I'm certain the microvasculature was logjammed, his heart muscle still aching in the throes of myocyte carnage.
The frustration of it all was raw for the techs, the patient, and myself. We do take it personally when patients try to kill themselves, whether it is by accident or on purpose. Furthermore, it was 9 pm. We were just starting a case, and we all had to work the next morning. We were dealing with a situation that was completely and totally predictable, preventable, and terribly costly for the patient, the hospital, and the community. To add insult to injury, after we were finished, I noted that he had no insurance and had just moved to our community and was unemployed. His plans to start a new job the next week were completely wrecked.
I called for Versed, morphine, and Zofran, hoping the sedation would dull his sense of our frustration. I commented in an ongoing dialogue that it was "a shame that he hadn't proceeded in a responsible and safe manner" after his initial PCI. The patient agreed, and the following morning, I took up where I left off in trying to understand exactly what goes on in the mind of a patient who nearly killed himself with neglect and noncompliance. He felt much better and seemed receptive to conversation. With his bottle of Integrilin still dripping, I pulled up a chair and asked a few questions.
"So, how come you stopped your Plavix?" I asked.
"Couldn't afford it" he replied. "I'm starting a new job next week and living with my cousin right now. I'm going through a breakup," he added.
"What level of education did you achieve?" I asked. "Dropped out my senior year," he replied.
"You need to get your GED so you can afford your medications," I suggested.
"I know," he agreed. "I've thought about it," he said, dropping his head.
"What exactly was explained to you about your medications, diet, risk factors, etc when you left the other hospital two weeks ago?"
"Nothing," he said. "The doctor walked in and asked, 'You ready to go home?' and I said great. The nurse handed me some prescriptions and I left."
I believe him. I believe him because I know it happens every single day in our country. We are hot to get the STs down, deploy the stent, and save the patient for the day. We pat ourselves on the back and high-five-it when they roll out the cath-lab door pain free. But sometimes, we are negligent when it comes to trying to save the patient for a lifetime. Now, this gentleman's ejection fraction has been whittled down to a mere 35%, and most of the work that was done two weeks ago is meaningless. His bill on hospital day two is already $ 24 575.50 at our facility alone, and I'll bet around the same amount at the other. So, he (and more accurately the state of Kentucky) is in debt $50 000 thus far on this marathon of an acute coronary syndrome.
With a few questions and some basic instruction, I started the job that should have been done two weeks ago. I explained the Mediterranean diet, the reason behind not smoking, the reason why it's lethal to NOT take the Plavix as prescribed, and the fact that he's most assuredly diabetic and doesn't know it. I glucose-challenged him and found a blood sugar of 250 postprandially . . . totally NOT a surprise. I consulted the nutritionist and educated him about exercise. We gave him a prescription for nitro. (He had been discharged home post MI with NO nitro two weeks earlier). We explained that he had moderate mitral and aortic valve leak, and though it had been noted on an echo at the other facility, it was news to him. He would need serial echocardiography. Later, the American public will get an opportunity to sponsor his defibrillator implant and his disability at a price tag of hundreds of thousands of dollars in cost over his lifetime . . . all because of the disastrous combination of personal neglect and incomplete discharge planning. Sadly, he will figuratively wear a sign that reads "Your Kentucky Tax Dollars at Work" for the rest of his life.
I am not missing the point that it's the patient's responsibility to quit smoking, avoid secondhand smoke, and comply with diet, exercise, and medications, but just as important, as cardiovascular healthcare providers we absolutely MUST convey the message that it's NOT all about the metal. "We," the collective healthcare system, had a part in this suboptimal outcome. How well the stent was deployed two weeks ago mattered very little. It's how well we as healthcare providers along with the patient can partner to maintain the work we do. One without the other will always fail.
"Mind over metal" should become the mantra of every heart patient, every cardiovascular healthcare provider, and every heart association in every corner of the world. We must take this very important message to all of our patients: man cannot live by metal alone, at least not for very long.