The ER Diaries
Dr. Zachary Levine gives us the 911
Dr. Zachary Levine
THE CASE
A 70-year-old man visiting from Italy came to the ER because he had been feeling nauseated for three days. He was on medication for high blood pressure and smoked occasionally. What was striking was his pale-greenish colour. He was also sweaty and appeared weak.
THE SYMPTOMS
His nausea was constant, but he hadn’t noted any worsening on exertion. He thought it was gastroenteritis or food poisoning, so he took Gravol and waited. But there were only two episodes of vomiting and no diarrhea. He felt weaker and short of breath as time passed. He felt some chest discomfort but no pain.
THE TESTS
First, a physical. The exam was unremarkable aside from lowish blood pressure, though he was known for high blood pressure. His heart sounded normal, and his lungs were mostly clear. A bedside ultrasound of the heart showed no significant amount of fluid around it (which is normal), but the heart did not seem to be contracting with the normal amount of force. Lab tests checked blood cell counts, liver and kidney function, electrolytes and cardiac enzymes that, when high, indicate heart muscle damage – which showed to be the case. A chest X-ray also showed that the aorta – the big blood vessel that delivers blood from the heart to the rest of the body – was intact, and an electrocardiogram (heart tracing, or EKG) was requested.
THE DIAGNOSIS
It was the EKG that changed everything. It showed an acute ST-elevation myocardial infarction – a heart attack, when one of the coronary arteries, which supply blood and nutrients to the heart, is blocked and the part of the heart supplied by that artery begins to die. The longer it’s blocked, the more of the heart muscle dies. With this patient, the heart attack didn’t present with the classic symptom of chest pain. But the shortness of breath, light-headedness, nausea and sweating he was experiencing are also symptoms of heart attack.
THE TREATMENT
The patient was treated with blood thinners, and a coronary angiography was performed, wherein the cardiologist can see the blood flow within the coronary vessels in real time, followed by an angioplasty to open up blocked ones with a balloon, leaving a stent in the artery to keep it open. They found complete blockage of his major (left anterior descending) coronary artery and 80-per cent blockage of another (the circumflex artery). They were both successfully opened. Unfortunately, there was damage done to the heart muscle over the three days he was untreated.
THE OUTCOME
The patient left the hospital three days later feeling and looking much better. In addition to his blood pressure medication, he now takes two blood thinners and a medication to control his cholesterol. He returned to Italy two weeks later and is undergoing cardiac rehabilitation to improve his overall heart fitness.