On Heart Attacks

I always thought heart attacks were fast and sudden. Either you survived one, usually due to paddles like on tv, or you didn't. Typically you fell forward with your hand on your breast and your pale face contorted in pain. Really, that's a stroke.

Heart attacks are much more slow-going, and last until the doctors fix them. The goal of therapy is to correct the coronary occlusion within 90 minutes of arrival to the ER. What that means is that a patient must be seen, diagnosed, prepped, and catheterized within 90 minutes. That's a lot of steps that have to happen in perfect sequence. And the amazing thing is that the patient is CONSCIOUS the entire time. How unbelievably scary, especially since your sympathetics have kicked in and your state of anxiety is naturally sky-high.

Sometimes heart attacks and associated disturbances (i.e. cardiogenic shock) are so severe that the patient experiences what's called flash pulmonary edema, or massive water on the lungs. In this case, the first step is to "defend oxygenation" and then to "tackle perfusion." What this means is that the patient is intubated and sedated and then loaded with all of the drugs in our arsenal so that we make their heart work for them. Sometimes we give too much and then have to "chase our tail" with antidotes.

Obviously, this sequence of events takes practicing to get right, and so we visit the human simulator a few times a semester. The simulator is essentially a robot that breathes and blinks and has pulses and a heart beat and responds to medications. On Thursday I practiced the above scenario and I was stunned by the need for morphine.

This whole post is a lead-in to this: in our discussion of the case after my small group successfully sustained the simulator until the catheter team arrived, our preceptor described a moment he has with a patient. An ER doc with a Monty Python haircut, he leaned on the side of the table like it was a gurney and said while looking in my eyes, "I know this is scary for you, but I will take care of you. I need to put you down now, and I will see you on the other side." I still have goosebumps two days later thinking of all of the patients who have heard those words and lived.