I Opened the Artery and Missed the Man

A good night

A man in his forties arrived with a large anterior infarct. The call was clean, the lab was ready, the lesion was where we expected. Door to balloon, fifty-one minutes. Good flow restored, no complications, ventricular function better at discharge than it had any right to be.

I have been doing this a long time and I am not embarrassed to say I was pleased. On the metrics that my unit is measured on — and on the metrics that actually keep people alive — that was as good a night as we have.

I saw him briefly on the ward the next morning. He thanked me. I told him, truthfully, that he had been lucky in his timing and that his heart had come through well. I said the thing I have said several thousand times: that he should take it easy for a few weeks, that he would be contacted about rehabilitation, and that we would see him in clinic.

Then I went home and slept, and I did not think about him again for six weeks.

Clinic

He came back looking well. Numbers good, echo reassuring, on all his medications, no chest pain. Six minutes into a ten-minute follow-up I had already finished the clinical business.

I asked how he was getting on. He said fine.

Something in the way he said it made me ask again, and this is the only part of this story where I did anything right. I asked what he was doing with his days.

He was not doing anything with his days. He had not gone back to work. He had not driven. He had stopped going upstairs in his own house more than once in the evening because the first time he did it after coming home, his heart rate went up, which is what heart rates do, and he had sat on the top step for forty minutes convinced he was dying and not wanting to frighten his wife by calling an ambulance.

He had been doing a version of that for six weeks. He had not mentioned it to anyone. He had not attended cardiac rehabilitation, because the letter had arrived while he was in the middle of all this and going to a gym seemed, in his words, insane.

I had restored flow down his left anterior descending artery in fifty-one minutes and left him frightened of his own staircase for six weeks.

What I had actually told him

When I went back over what I said to him on that ward round, I could not find anything untrue in it. That is what bothers me.

I told him to take it easy. I meant: do not do a heavy shift on a building site next Tuesday. He heard: this thing in your chest is fragile and exertion is dangerous. Nothing in my sentence distinguished those two readings, and I had never once, in twenty years, considered that it needed to.

I told him his heart had come through well. He heard reassurance about the past. What he needed was permission about the future — an explicit statement of what he was allowed to do, and what sensations were expected rather than ominous.

I never asked him what he was afraid of. I had assumed that a man who has been told his heart is working well has no remaining fear to address, which, written down, is obviously ridiculous.

What I do differently

Three changes, and I would defend all of them as clinical rather than pastoral.

• I am explicit and concrete about activity. Not "take it easy" but "you can climb stairs, you can walk up a hill, you should be a bit out of breath, that is your heart working correctly and not your heart in danger. Here is what would concern me."
• I name the fear before they have to. "Most people are frightened the first time their heart beats hard after this. That is normal and it is not a warning sign." Saying it first removes the need for them to admit to it, which many men of his generation will simply not do.
• I ask what they have stopped doing. Not "how are you" — that reliably returns "fine". "What have you stopped doing since you came home?" is a question that gets answered honestly, and I now consider it as much a part of the review as the echo.

The thing I keep coming back to

If he had reoccluded that stent, there would have been a review meeting. There would have been an audit. Someone would have gone through the films.

He lost six weeks of his life to a fear I could have dissolved in ninety seconds, and there is no mechanism anywhere in my hospital that would ever have detected it. I only found out because I asked a second question on a day when I happened to be running on time.

We measure door to balloon because we can. I have no idea what the equivalent number is for the thing I got wrong, and I have come to think that its absence is not a neutral fact.

Shared with the patient's written consent. Age, occupation, location, family details and timeline have been altered; the clinical sequence and the substance of the conversation are as they were.