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Friday, December 13, 2013

Awakening from cardiac arrest: a shocking experience from a doctor's-eye view

Yes, you read that right. I nearly died a month ago on a treadmill halfway through a stress test.

The short story is this: I had just gone to bed and was about to go to sleep when I started to have some chest pain that I told myself was just my usual heartburn, only worse. As a gastroenterologist, I knew better. It was bad enough that I couldn’t go to sleep. After two sleepless hours of denial and mounting pain, I conceded that it was time to get help. I woke my wife and called 911 for ambulance to the ER.

I chose to go to my own community hospital even though I could have gone to an Ivy League “world-class” hospital that is equidistant; the staff at my own ER know me and they are family. One of my most trusted ER doctors saw me. But strangely, by the time I arrived, the pain was nearly gone. I proceeded to have a normal EKG. The cardiac enzyme levels in the blood returned negative. So, probably no heart attack. But was it angina? My cardiologist recommended a stress test immediately, since my wife and I had long-anticipated plans to get on a plane that afternoon and fly across the country to visit my kids.

Well, I failed my stress test. Big-time. Halfway through, just after I finished relating a humorous scene from a movie where a character drops dead, my heart stopped. They laid me on a stretcher, pounded my chest and performed CPR. I was brought back from ventricular fibrillation with a defibrillator and a single shock of 200 Joules (=Watts of electricity). I was rushed to a tertiary care center where I underwent emergency angiography showing a high-grade narrowing at the origin of my largest artery. (Narrowing to that degree in that location is sometimes called a widow-maker.)

I was placed on IV anti-platelet agents and other blood thinners while my doctors waited for me to decide between a bypass and having stents inserted. They recommended bypass surgery over stenting and I chose surgery. My operation was performed through an incision between two ribs, with my heart beating, by a surgeon using what is known as a robot. My cardiologist friend up the street tells me they aren’t even doing heart surgery that way yet in the Ivy League hospital in New Haven. Thanks to my surgeon’s talent and the efforts of everyone along my journey, I am alive to write this entry, and I expect to write more on this topic. I walked out of the hospital 3 days after my surgery. I am indeed a very, very lucky man.

But one of the reasons I am telling this tale is to share what it was like from my viewpoint to experience waking up from cardiac arrest. Now I have participated in a few “codes,” as cardiopulmonary resuscitations are called in hospitals, as a witness, particularly when I was in training, and I have watched a few people wake up promptly. It is unforgettable experience. One that stands out in my mind took place when I was an intern in the emergency room at Lenox Hill Hospital in New York City. A man had arrived in chest pain and we were doing the usual EKG and blood testing when he suddenly lost consciousness. The cardiac monitor above his head revealed why. His heart was in ventricular fibrillation, the abnormal heart rhythm that can result from a heart attack among other things, and end in death if not corrected.

I was told to start pumping on the chest as I had done so many other patients before, futilely, as the usual crowd of nurses and supervisors and anesthesiologist arrived. But this time the outcome was an exception. My resident charged the paddles, yelled, “Clear!” just the way you see do on TV, and administered the jolt. The man’s torso practically jumped 6 inches off the stretcher and he almost immediately sat up and asked, “What’s going on? What are all these people doing here? What happened?” My resident and mentor, before even turning to the patient with an explanation, announced to the assembled team, “See? Electricity is GOOD for you!” as if he did this stuff for fun. We, the house staff, celebrated the occasion in the retelling.

In my own case, in the role of patient, the experience was quite different altogether. I didn’t get to witness the event. One minute I was walking and asking the cardiologist what level of exercise I had achieved thus far. I was anxious to finish the test so my wife and I could make it to the airport in time. My main thoughts were on our trip to San Francisco for a wedding celebration with friends and a visit with our children.

With my usual off-beat sense of humor I was asking him “How many mets, Mario?” This puzzled him because his name is Bob. I explained, as the treadmill was gathering speed and I was already breathing hard, that there is an old movie called “Putney Swope” that features an opening scene of a corporate board meeting in which the chairman berates the members, gesticulates wildly, and abruptly clutches his chest, and the board members don’t get it that he is having a heart attack. One of them, clearly a bit senile, thinks he is playing Charades. He asks him repeatedly, “How many syllables, Mario?” until the man finally keels over dead. I had no idea how ironic I was being. The last thing I remember was the nurse saying, “Are you getting tired?” or something like that.

An unknown number of minutes later, I was awakened from a sound sleep by a hand slapping my cheek and the cardiologist’s voice saying “WAKE UP, DAVE”. My annoyance vanished in a millisecond when I opened my eye to see a roomful of people in great activity, a red cart to the right of the bed and a large hard square object between my legs that was clearly a defibrillator. When you’re a doctor and you awake to this scenery, you figure out pretty quickly what has happened to you. As if I needed to told, my friend and colleague told me from his supervisory perch at the foot of the stretcher, “Dave, you are NOT going to San Francisco today.”

Now let me say what else didn’t happen. Perhaps I was not in arrest for long enough, but I did not see any white light or view myself as if from above. They tell me they caught me promptly and lifted me down off the treadmill. I am told I had my chest thumped and then compressed until the defibrillator could be charged and I came right back after the first shock. They tell me I seized during the arrest. I later had proof of that when I realized that my tongue was severely lacerated by my teeth and my jeans were wet.

But what did I experience immediately was an overwhelming sense of gratitude. Gratitude that I was still alive. Gratitude to all the people in the room. And along with it, an immense feeling of being completely cared for in a way I don’t remember since childhood. All my life I have been caring for others in one way or another, even when I was a child. For the first time in as long as I can remember, I completely relinquished the imperative to make decisions. I placed myself completely in the hands of my colleagues and co-workers. And they came through for me in a big way.

My cardiologist probably had a far more traumatic day then I. I have been told that the incidence of sudden death during a stress test is 1 in 10,000. To have that happen to a colleague, referring doctor and a friend, on your watch, even if though it is an inherent risk that could happen to anyone, must have been very difficult emotionally. He was trying to keep his cool when he called my wife, who was across the street picking up some necessities for our flight. But she says his attempts at reassuring words were belied by his white complexion and shaking hands. In fact, I think I had an easier time of it than he did.

The strangest thoughts go through your mind sometimes. In all the commotion, I noticed that a nursing supervisor I have known for 25 years had highlighted her hair. And as they were wheeling me out of the room, I called out to her, “Nancy, I really like what you’ve done with your hair!” My journey from there to the Hartford Hospital cardiac cath lab to surgery was a whirlwind and a blur. And the road to recovery has been slower, but still seems to have proceeded at amazing speed. But more on these topics another time.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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