A Risk

The biggest risk I ever took was in the context of my job.

I was in the initial year of working at my first real doctor job after residency, in Michigan’s Upper Peninsula. I saw patients in the clinic four and a half days a week and I also took care of my patients that needed admission to the hospital. Naturally, as someone fresh out of residency, I was somewhat unsure of myself.

One day I was in the ICU taking care of Robert. He was 68 years old and got admitted from the ER the day before. He had a little chest pain and was put in the hospital so we could rule out a heart attack. At the time, this involved getting a series of blood tests every 6 hours to look for elevations of certain enzymes found in heart tissue. So far Robert was ruling out just fine.

While I was there talking with him, he got out of bed for something, I don’t recall what now. Suddenly he collapsed completely without warning! He didn’t give any sign of being in any distress at all. He had a monitor on his finger showing what the concentration of his blood oxygen was. Normal is 95-100%; his oxygen was suddenly in the low sixties. He was grey, gasping for air and looked as terrified as I felt.

My mind was racing, trying to figure out what had happened. A stat EKG showed no evidence of a heart attack. Then I remembered that Robert came to the ER straight from a 14 hour bus ride. Also, he was a pretty big guy and these factors made me suspect that he was suffering from a pulmonary embolism (PE). A PE is a blood clot that forms in one of the body’s deep veins, usually in a lower leg, that breaks off and travels to the lungs. A PE of sufficient size can completely keep blood from entering the lungs for oxygenation, and is fatal. Robert’s size and recent prolonged bus ride were two big risk factors for a PE.

But at that time, treatment options for a PE were pretty limited. The treatment for a large PE, such as I suspected Robert had, was immediate cardiothoracic surgery to physically remove the clot. In a patient who wasn’t crashing, the treatment was immediate administration of blood thinners. In any case, the usual course of events involves nailing down the diagnosis with a CT scan.

However, in our little rural hospital we had no cardiothoracic surgeon, the nearest was two hours away. And that day there was no radiologist available to perform and read a CT scan. And Robert was looking worse by the second.

It crossed my mind that I did have clot-busting drugs available. They were relatively new at the time, and there were very strict guidelines for when they could be used. They were only approved to break up clots in coronary arteries as well, they weren’t approved for pulmonary embolisms. Also, I recalled the time in ER during my residency when a 75 year old man was having a heart attack in front of our eyes. The attending doc explained to the family that while this patient was too old to qualify for the clot-busters, they were the only possible option for this patient. The family chose to give the medication, and the patient ultimately suffered a fatal brain bleed.

But again in this case clot-busters were the only possible option immediately available to me, short of  initiating an ambulance transport to the big hospital two hours away and letting Robert die on the trip. But he was going to die either way. I hurriedly explained the situation to his wife and got her consent to push clot-busters. I gave the nurse the order to administer the clot-buster, then prayed.

During the absolute longest two to three minutes of my life, I watched Robert slowly pink up and saw his oxygen climb steadily to the mid-nineties. By this time he had been sedated and intubated so I couldn’t tell what his mental status was. I was a little worried that his oxygen had been low enough long enough to harm his brain. At any rate, I called the ambulance and we transported Robert off the the tertiary care hospital.

Robert did just fine from that point on, however. He came home a couple of days after his admission to Marquette. A heart catheterization in Marquette demonstrated completely clean coronary arteries with no evidence of any disease so it appeared my diagnosis had been correct. 

I stayed in Michigan for several more years before switching to Urgent Care medicine, long enough to be able to watch Robert enjoy his grandchildren growing up. I always wondered if he was the reason I got in to medical school. His outcome was certainly worth all the hard work and heartache and debt. But I took a big risk that could easily have turned out differently.