Takotsubo

A heart is a terrible thing to waste.  Songs are written about this very fact on a daily basis, and I’ve been known to listen to a T. Swizzle heartbreak song before.  In the hospital setting, we go to great lengths to either confirm or “rule out” a primary cardiac issue when someone presents with anything related to the chest: pain, shortness of air, cough, and even nausea.  We get stat EKGs, troponins, chest x rays, and an ICU admission with telemetry all because someone comes in and says, “Ya know, my chest kinda hurts.”  Because we’ll be damned if we’re the one doc who misses a heart attack.  And even with all that…we… miss… heart attacks #Whoops

I’d like to think that when I’m finally put into the position where I’m the one making the calls that I’ll use a little more clinical judgment than I’ve seen a few of my practicing professionals exhibit.  But, when that time comes am I going to allow myself to “miss the heart attack” or will I order those two extra tests and sweet talk whoever the hospitalist is into watching them for 24 hours?  Even if it’s 99.9% likely a pec strain they suffered while trying to do P90x for their first exercise in six years. 

I say all this because day one on the job in Haiti we had two patients come into our clinic with chest pain.  I’m not sure if they were well known or not, but Dr. Leo seemed to know who they were and what they’re history was.  First thing was first, we had a brand new EKG machine from the states… Better use it (Allows us to upcode their visit!!).  So I figure out how to affix leads and get the first patient set up.  Ten minutes of button mashing later we have a printout of the limb leads.  Perfect.  Couple more button mashes and the precordial leads print too.  Now what…  Myself and two of the other docs look at it kinda perplexed.  I called it sinus tach with probable partial bundle branch block.  However, the Haitian resident was calling it atrial flutter with a 2:1 conduction.  It’s nice in American life to turn to your super friendly cardiologist and say, “What the hell is going on here?”  It’s also nice to have the machine auto calculate all the intervals, the rate, and even offer a preliminary diagnosis.  Not so much here.  So I do the next best thing.  She had a medical record chart.  In the chart was an EKG performed about a year ago by a doc in Port-au-Prince on a machine that offered a preliminary report.  By in large the tracings looked similar enough to where I would call it unchanged.  #ProblemSolved #InternMedicine

The story behind her heart problem is a little more curious.  She’s 43 and 4 months post-partum.  Her chest pain and dyspnea started 2 months ago.  I’m no ECHO expert, but even I saw a giant heart when I placed the sono to her chest.  Peripartum cardiomyopathy is rather rare, but sure seemed like we had a rip-roaring case of it here.  And with her massive ascites, it almost looked as if she were still pregnant.  I placed a paracentesis catheter, blind mind you with a regular IV kit #Improvisation, and we drained 3 L out of her abdomen and started her on heart failure medication. 

The second patient was 13 years old and had florid heart failure.  Her heart murmur indicated this was also a structural problem with one of, if not more than one, the valves.  Again, I’m not an ECHO-ologist so I couldn’t point to the aortic valve and say that is massive regurgitation, but clinically the management is likely going to be the same.  Refer to Port-au-Prince should she or her family ever gather enough money to: 1. Send her there.  And 2. Pay out of pocket for any test or treatment they offer.  Not likely going to happen.  So we’re stuck managing what is likely a surgical problem with medication.  Fortunately, @TheDrSinclair had just given a baller lecture on the medical management of heart failure.  And thank goodness that we actually had all the meds.  I didn’t realize how insecure basic medications were to the Gran Bois clinic until this trip.  After a quick check in with my OB consult on call to ensure that nothing too different was required in the post-partum period we were squared away with both patients.

As the patients recovered in our inpatient unit I started thinking about how I saw them walk up to our clinic.  Yes, they were both using a moderate amount of assistance, but still.  They both had nasty heart failure and had hiked from their homes to our clinic.  I can’t say it’s a La Fit kind of hike, but I know for damned sure that it’s more than the flat two miles my lazy ass would have to walk to get to work every day.  And we’re in the mountains.  I’ve been dyspneic ever since I climbed out of the truck.  I don’t know how these people do it.  Basically the patients pass a stress test on their way to the clinic #CardiacRiskStratification  

As an aside, we started blood pressure medicines on an 82 yo m today in clinic today who’s pressures were 180s/110s.  This was the first time he had ever come to the Haitian clinic.  His chief complaint: a rash on his back.  He left his appointment with an ACE, a diuretic, and some hydrocortisone cream.  I’m just thinking to myself, “He could run circles around 90% of America…I’m not sure he needs a daily pill.”  You can follow him on Twitter at @Im82AndIHikeMountainsOnTheReg.  But this just goes to show, whether in Haiti or the U.S. we physicians are sometimes guilty of not seeing the forest through the trees.