04 December 2009


Crummy shift the other night: 23 patients in eight hours, and 21 of them were painful. For me, that is, not necessarily for the patients. Lots of worried well, influenza, some minor injuries and a few chronic pain players. Not a single sick one in the lot. One particularly irksome case was a chronic pain patient dumped on our ER from a neighboring ER, complete with discharge instructions reading "Go to (name of our hospital)." So by the end of my shift I was pretty well burnt out. But the last two patients put an interesting perspective on the night.

The first was a 99 year-old man. Yup, that's ninety-nine years old; born prior to World War One. He was having shortness of breath and it turned out he was in congestive heart failure from what turns out to have been his fourth myocardial infarction in as many months. For multiple reasons, common sense primarily among them, he was not a candidate for aggressive intervention like angioplasty. Fortunately he had a large and supportive family, who were quite reasonable in their expectations. After a difficult discussion, we admitted him on a morphine drip for comfort care, with a hospice consult.

The second was a 9-month old with a heart rate of nearly 300 beats per minute. It was pure chance that the family had noticed that his heart felt like it was racing. To tell the truth, I'm not sure I would have noticed that on my own kids. It was an irregular heart rhythm called SVT. In adults, SVT is typically a nuisance alone and rarely requires much treatment. In small children it is similarly benign with the exception that if it is prolonged (which is common, since a baby can't tell you his heart is racing) is can cause congestive heart failure. This child was lucky in that it was caught quickly and he suffered no ill effects. One quick dose of adenosine and he was all better.

So there you have it -- the bookends on my day. Two cardiac patients: one at the very end of life, one at the very beginning. I like a nice symmetry as much as the next guy, and this was a very satisfying "circle of life" conclusion to an otherwise unrewarding shift.

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