JimFormation

Last we spoke I’d just gotten into the emergency room …

The most remarkable thing about being a 45-year-old heart patient in an emergency room is the amount of whizzing about that goes on around you. Within moments, someone had taken my blood. Another person a chest x-ray. Yet another an EKG. A nurse started an IV — well, she didn’t start an IV; she accessed a vein and put a heparin lock in just in case they needed to start an IV or push some medications into my veins.

I told a half-dozen people that I really wasn’t in any pain — maybe a little discomfort behind my shoulder blade. Maybe a little along my jawline. Maybe.

I’d given a history to that half-dozen people too.

They hooked me up to a telemetry machine (cardiac monitor), a continuous pulse oximeter (to record the levels of oxygen in my blood), and a blood pressure cuff that took my blood pressure every 15 minutes.

Most of my emergency room entertainment came from guessing what my blood pressure would be once the machine kicked into action. And watching as emergency room workers avoided eye contact with me.

My oxygen saturation was 99%, meaning the oxygen pumping through my arteries was completely oxygenated. Still, they put oxygen on me.

“What’s this for?” I asked.

“It’s oxygen. To perfuse your cardiac muscle.”

I looked back at the oxygen saturation reading. “How much better than perfect do you want me to get?”

The nurse looked at me. I put the oxygen cannula in my nose. When she walked away, I took it out.

This started a series of discussions with my wife that really rankled her — my wife worked for years in critical care nursing, including cardiac care. “Doesn’t anyone assess the patient anymore? Don’t they make decisions on those assessments anymore?”

Every time I got a shot of lovenox to thin my blood or nitro paste to help more blood get to my heart muscle, she wondered if I really needed it or if it was just part of the cardiac clinical pathway. Again, you have to understand, I felt fine — I was having no pain, no shortness of breath, no nausea, nothin’.

Clinical (or critical) pathways are predefined interventions for patients with targeted diagnosis and a predictable clinical course. Think of them as a pilots pre-flight or emergency checklist.

I was on the Acute Coronary Syndrome Pathway or, perhaps, the Myocardial Infarction Pathway. Either way, there is a set routine that must be adhered to regardless of how the patient presents him or herself. This includes everything from blood pressure every 15 minutes to continuous oxygen administration to the use of nitropaste and lovenox, and the like.

They say they made clinical pathways so that nothing is missed in patient care. I think the lawyers gave us clinical pathways.

As a patient, you get sucked into the clinical pathway and the vortex is so strong the only way out is refusal of care.

I continued up on the floor — I was put in the Surgical Intensive Care Unit (SICU) as the Coronary Care Unit had no available beds. The SICU has some of the sickest people in the hospital. Everyone of my fellow patients on that floor was on a ventilator. The staff laughed when I was brought up and jumped off the gurney and into my bed. “Patients here just don’t do that,” I was told.

And there I languished for two-and-a-half, almost three, days (Friday evening through Monday morning). My cardiologist was off that weekend and the covering doctor just, well, covered. He wasn’t really willing to discuss my prognosis or my future. Well, he did say that I had a “tiny” heart attack. I like hearing “tiny” and held onto that word whenever I explained my situation to people.

He also said that, even though it took me a week to get into the hospital and get care, “taking that aspirin when you initially had chest pain may have saved you.” See! I did something right!

My cardiologist showed up on Monday morning. “Jim, you had a heart attack. We’re going to give you a cardiac catheterization this morning and see what we should do from there.” I was a little taken aback because he spoke to me as if he’d never seen me before — I’d been going to him once or twice a year for five years. I mean, he has a lot of patients, but c’mon!

“Listen, Doc. If I have to have a cardiac cath, I’d like to go to Deborah,” I told him.

“Why? We can do it right here.”

I happen to know that they just started doing cardiac caths at that hospital and aren’t yet allowed to do any interventions like angioplasty or stent placements. I didn’t want to be the 100th person the hospital cardiac cath’d; I want to go to Deborah and be the millionth! Also, I didn’t want to be cath’d twice — the first time for diagnostic purposes and the second time at some other hospital for an angioplasty or to get a stent. Once is good enough, thank you.

“Oh. We can do interventions here. We are allowed to do emergency interventions and we’re involved in a study where on a limited basis we can do routine interventions too.” He explained to me that the study included doing a cardiac cath on a patient, determining if s/he needed intervention and, if s/he did, calling some number while a random algorithm decides if you can be fixed there or somewhere else.

“A lottery! Thank you, no. I’d rather just go to Deborah.”

My doc got pissed. I’m the perfect candidate for their study. If I needed an intervention, I’m probably going to live. Not only that, I’ll probably make it the year or two or five that they’re looking for to get the thumbs up to do interventions via cardiac catheterization into the future. Not only that, in the short run he personally can’t bill for the procedure nor the extra day or two that I’m going to be in the hospital.

He tried to talk me into it one more time. When I declined. He abruptly cut the conversation short and I didn’t see him again. Not a handshake. Not a “good luck.” Nothin’.

Fuck ‘em. I’m going to Deborah.