Dropping the ball

We pull up alongside the doctors’ surgery, and my crewmate hits the “Arrive Scene” button as we’re blocking the entire street, bathing the narrow road in strobing blue light. I check the job description – a GP urgent for shortness of breath.

Walking into the main entrance of the still packed surgery, the receptionist informs us that the patient has been moved to “the treatment room”, and directs us round the corner. We’re greeted by the practice nurse, who introduces us to Jenny, the patient. An elderly lady is sat on a chair in the centre of the room. In addition to obvious difficulty in breathing (not the same thing as SOB), she’s clammy – visibly sweating – and anxious. On a quick examination, she informs us of a quite painful aching sensation across her shoulders that radiates up her neck and down her left arm, and that she’s feeling very nauseous.

I switch to “OPQRSTA” history taking mode. It started when she got off the bus (she was coming to visit the doctor on something unrelated), and got worse with exertion. It didn’t get better with rest or positioning. It rates somewhere between five and seven out of ten, and she’s had the same sensations before.

GTN spray

I asked Jenny to elaborate on this a bit more. Apparently she has difficulty breathing and shortness of breath semi-regularly, and has a GTN spray to control this. Sometimes the pain accompanies it, more often than not on exertion, but it usually goes away when she rests. But then there were two occasions when it didn’t go away, just got worse, and then she was told that she’s had heart attacks. I ask about the spray, but Jenny forgot it today. I ask the nurse if she has some (we don’t carry it as an SJA crew), which she thinks she does. But it turns it’s missing from her cupboard.

The nurse finds the patient’s notes on the computer, and passes me a print out. She has a long and complicated cardiac history, including current angina (hence the GTN) and as stated, two MIs, treated by thrombolysis and pPCI. I ask the patient about this, and she tells me that this feels just like the last time. She was told later that it was a heart attack – she never has chest pain, the traditional heart attack symptom, so it didn’t occur to her that her heart was dying.

“Have you done an ECG?” I ask the nurse. She replies not, because the GP told her not to. You what? I ask if she’ll do one, and she’s more than happy to, and goes off to find the surgery 12-lead. By this point the patient is already on high flow oxygen, and we’re digging out some aspirin for the them to chew. The nurse returns with the machine, but also an unwanted visitor – the doctor who originally called this patient in as a low priority emergency (we are expected to respond to GPUs within 4 hours unless otherwise specified).

“What’s going on?” he asks. I inform him that we’re querying ACS, to which he informs me that it’s impossible for Jenny to have a heart attack as she’s already been treated for two. Excuse me, what? He asks what we’ve done for her, and the nurse mentions that her GTN is missing, but he has an answer for this too – it’s in his car. I dispatch him to (reluctantly) fetch it.

In the mean time, the nurse has been trying to take the poor lady’s ECG. This hasn’t worked, for the simple reason that she’s sweating so much the dots keep slipping off. Doesn’t matter anyway, as I’m not allowed to make decisions based on interpreting it, and the doctor seemed to be as much use as chocolate teapot. I phone for an RV paramedic to back us up – as ETAs, there isn’t much more that we can do than we already have.

A "barn door" MI. Even I can tell it's not supposed to look like this.

As we wait for the paramedic to arrive, the lady tells us that the symptoms are lifting. The interventions we’ve made so far seem to be working – not only is she feeling better, she’s less clammy, and her blood pressure and heart rate are returning to more normal values. By the time he turns up, she’s breathing much easier, and claims the pain is lessening, retreating back up her arm and down her neck.

I hand over, and he connects her up to his Zoll monitor, which comes with much stickier pre-hospital ECG dots. He hits record, and examines the print out carefully. Very carefully. My neck cranes over his shoulder to take a look as he studies it intently.

Finally he announces, “there’s nothing wrong”.

What? Aside from some inverted T waves due to her past heart attacks, there’s nothing to suggest anything going wrong that would cause her symptoms. And that seems to worry all three of us more. We get her on the carry chair and quickly take her out to the ambulance. The paramedic grabs his big red bag of kit and jumps aboard. As her symptoms still haven’t completely disappeared (the pain remaining around three out of ten) he pops a cannula in as a precaution in case things go wrong in a hurry, and we set off to hospital.

Sat in “the airway seat” as he talks to the patient from the side, I spot something going on with the ECG behind him. She appears to have a ventricular ectopic creeping in every three beats – that is, a beat of the heart that is triggered by a pacemaker within the ventricles and flows up the heart, as opposed to a normal beat triggered by the sinoatrial node (SAN) in the right atrium that flows downwards. Now, lots of people have these and normally they don’t cause any problems. But they are a problem in people with a cardiac history, as they can lead to a horrible heart rhythm known as ventricular fibrillation if they overlap with the normal heart beat, stopping the heart from depolarizing properly and leading to the ventricles essentially just wobbling about. This is a bad thing, as the heart cannot shift blood when doing this, and so violates one of the essential tenets of being alive (those being “air goes in and out, blood goes round and round”) and very rapidly leads to not being alive. Incidentally, this is where the term de-fibrillation comes from – stopping the wobbling heart with an electric shock in the hope that the SAN will take over and the heart will start beating normally again.

Normal beat, normal beat, CRAZY beat, normal beat....

Now, ECG changes are generally considered to be a bad thing. Especially when accompanied by heart attack-esque symptoms. I chat with the paramedic about where and why these beats are arising, and why they’re so regular as we trundle on a little further, stuck in road works enhanced rush hour traffic.

Then another change. The ectopics are arising every two beats, and the interval from the end of the regular beat to the beginning of the ectopic is shortening. On go the lights and sirens, and within minutes we’re in hospital with a cardiac team surrounding her. The ectopics are composing every other beat, the pain is worsening, and her blood pressure is shooting back up.

*****

At this point, the story ends as we had to give the paramedic a ride back to his car before our shift ended. I haven’t seen or heard about the patient yet, I keep meaning to follow it up but getting sidetracked. Entertaining yarn perhaps? But the point that I want to rise is: This GP almost let his patient die.

Something was going wrong with her heart. Ok, so things had been going wrong with her heart for a long time, but this was something new, something acute. And things going acutely wrong with hearts generally don’t go wrong for long, as you normally end up dead quite soon.

This woman was also ticking just about all the boxes for someone suffering with something wrong with her heart, namely acute coronary syndrome or ACS (or in simple terms, either a heart attack or angina that isn’t going away). We could tell just from seeing her. The nurse sure as hell knew. The patient even knew. But for some reason, the doctor brushed it all aside. The patient came to see him for help, and all he did was call her an ambulance to arrive some time in the next four hours and sit her in the waiting room without even the drugs he prescribed her to deal with such attacks.

The nurse recognised there was something going on, and moved her into the treatment room. The doctor told her not to worry, and not to do an ECG. We recognised there was something going on, and got told patronisingly, “well, it’s a good job you ambulance boys turned up so quickly then,” without being offered any help from his supposedly superior medical knowledge and skills.

Surely, surely they teach the symptoms of a heart attack at medical school? Try this:

That patient should not have been left on her own in the waiting room. What would have happened had the nurse not been so on the ball? What would have happened if we had not just come clear up the road? Why didn’t he provide Jenny with the care she needed?

We come across a lot of bad GPs in this job. Those who call ambulances for no reason (the painful eyes that didn’t hurt, the fractured ankle that the GP diagnosed in two minutes over the phones). Those who miss the obvious (meningitis, strokes, intracranial bleeds). But this takes the biscuit. A patient who presents to the doctor themselves (they don’t even have to go anywhere!) with symptoms equivalent to wearing a t-shirt with MY HEART HURTS! in huge letters written on it, and he does almost nothing. He can’t even be bothered to leave us a note with what he’s done and why he thinks she needs to go to hospital.

No matter how many GPs I meet who are good at their job, this one guy tars the entire profession with the same brush. And I don’t know what to do about it, because I fear for the patients. This GP dropped the ball in a big way, behaving completely unprofessionally and against his duty of care, and I seriously worry that this isn’t just a one off and that someone will die because of this behaviour.