There is one patient I will never forget from my month on the cardiology consult service. Most of the patients I saw had CHF (congestive heart failure) or new arrhythmia. I was called to see Mr. Grady for another typical cause- to manage his high blood pressures. Mr. Grady* was in his fifties, a man who seemed too young to have suffered from multiple transient ischemic attacks. He had been admitted to the hospital because of a stroke.
Transient ischemic attacks and strokes are related. High blood pressure damages arteries at a microscopic level. This silent destruction puts a patient at risk for plaque formation which can rupture causing clots that prevent blood flow. Transient ischemic attacks affect smaller vessels and the body is able to clear them within 24 hours. An ischemic stroke, however, affects the blood supply to a larger area and will not improve within 24 hours. At first, these two events may be indistinguishable.
Mr. Grady had avoided treatment for a few extra days because of prior transient ischemic attacks- he was sure his symptoms would improve on their own. However, they continued to get worse. His right facial and arm weakness became so severe, that he was unable to speak clearly or use his right hand.
When he came into the hospital, it was too late to give TPA (tissue plasminogen activator), a substance that can be injected along a small catheter into the blocked vessel. His brain tissue in the affected areas had been deprived of oxygen more than 48 hours, and at that point his recovery would mainly be determined by physical therapy.
While he was in the hospital, he was found to have extremely high blood pressure. He was a morbidly obese man, who was already experiencing mild symptoms of congestive heart failure at his young age. He was taking appropriate medications including aspirin, a beta blocker and a cholesterol lowering drug. Yet his blood pressure was found to be high.
I performed a complete history and physical exam. He was cooperative and oddly cheerful considering the recent bad news that his symptoms of weakness might be permanent. As I completed my review of symptoms (ROS includes a long list of questions to assure no symptom is missed), I asked about any hearing loss.
“Huh?” he said, jokingly. Then he let out a rumbling laugh, which made me smile. He didn’t have any complaints.
He was morbidly obese and sweaty, but he seemed comfortable. Heartbeat was distant, but regular. No shortness of breath. Lungs clear. Abdomen soft. No swelling in his hands or feet. His neurological exam supported the obvious findings from his stroke.
Asymptomatic hypertension. The fellow examined him and confirmed my diagnosis and plan. We would increase his beta blocker, add a second drug, and get more tests to rule out other causes.
That afternoon I was checking test results, and his ABG (arterial blood gas) showed high carbon dioxide and low oxygen levels. ”Oh no!” I thought. I called the fellow immediately and told him I was worried about a PE (pulmonary embolism, or blood clot in his lungs). The fellow responded quickly when he saw the results, paging his team to begin high doses of heparin for anti-coagulation. He was sent for the confirmatory imaging study, a CTA (computed tomography angiogram).
I couldn’t erase the image of him from my mind. He didn’t exhibit the traditional signs of a pulmonary embolism. His heart rate was normal, his breathing had been fine and his legs weren’t swollen to indicate venous clotting. He was laughing, for goodness sakes! But why hadn’t I thought of checking more aggressively for a PE?! He was sweaty and obese, he had clots in his brain and he had been immobile for a few days.
We went to reassess the patient with our attending. Just a few hours had passed, but Mr. Grady looked awful. He was breathing on an oxygen face-mask, and he could barely say two words between breaths. His eyes seemed bigger, and he was not smiling or laughing anymore.
The attending immediately mumbled under her breath that we had to transfer him to the ICU. Then, I’ll never forget her reassuring remarks, “Don’t worry Mr. Grady. I know it’s scary to go to the ICU, but everything will be alright. We just need to monitor your breathing better.”
Those remarks lingered hauntingly in my mind the next day. Everything wasn’t alright. Mr. Grady quickly got worse and died early the next morning. His scans showed huge clots in both lungs.
The worst part was that when I looked back at his EKG, there were signs of right heart strain, which the fellow and I had contributed to his heart disease. I felt partially responsible for this man’s death. Why didn’t I advocate for ruling out a PE immediately? Even as the medical student, I might have made a life or death difference.
A fellow and several other doctors had seen this patient too. What if one person had chosen to order the confirmatory test right away? Then we would have started heparin sooner, and maybe we would have saved Mr. Grady’s life. The lectures and exams in medical school never prepared me to face challenging situations like this one.
Dear Mr. Grady, I’m sorry I missed your pulmonary embolism. I’m sorry we told you everything would be alright. I’m sorry I never got a chance to tell you, “I’m sorry.” You’ve changed the way I’ll think about pulmonary embolisms forever.
*Please note all patient identifying information has been intentionally changed or omitted. While the details are modified, my overall experience remains true.
Posted by Liz 
