4/21/15

This story is not my own, but I find it so evocative that it feels like mine.  It was told to me and a few other students by Dr. Richardson, a cardiology attending who was filling in for our regular one.  These approximate his words.

When I was a cardiology fellow working the night shift in the ER, we were always excited when we got a referral from Martha’s Vineyard.  There was a really sharp GP (general practitioner) there named Loxie and when he missed something it was because it was a real tough nut to crack.

Anyway, one night around ten I got a call from Loxie telling me that he was sending me a patient with acute episodes of shortness of breath.  He could not hear any heart sounds, and interestingly the man did not have an increased jugular venous pressure (a particular interest of Richardson–he always pronounced the initial “u” with a long sound like  “you” or “jujubee”.  Everyone else always said “jug” like “little brown jug”.  Anyway, the word means yoke.)  He had an enlarged heart.

The patient, Mr. Smith, was flown in to Boston by helicopter and arrived before midnight.  Immediately a team of cardiologists, fellows, and residents pounced on him and began to gather data.   He was a muscular, well-developed man in his seventies, with a big mane of hair and a winning personality.  He indeed had no audible heart sounds of any kind, and his neck veins were sure enough flat, unusual for someone going in and out of congestive heart failure.  His EKG showed an enlarged heart, as did an M-mode echocardiogram.

While they were working on Mr. Smith, he died.  He began to breathe rapidly with great difficulty, then he keeled over.  His monitor showed VTach (ventricular tachycardia), but shocking him did not help.  His heart just kept going back into it.  After over an hour of resuscitation, Richardson “called it”.  With a feeling of failure, he called Loxie back. (For some reason I’m flipping from first to third person.  I’m going to stick with it.)

“We lost your guy.”

“I’m sorry, I’m sure you did your best.”

“I have a favor to ask you.  Can you get permission for a post? (autopsy)  I really want to know what happened to this guy.”

“I can sure try.  I have to drive out to the other end of the island so it will take a little while, but I’ll get it for you.”

Richardson was overcome by a wave of tiredness mixed with depression, and went to the call room to try and catch some sleep.  It was two o’clock.

About an hour and a half later his phone rang.  It was Loxie.  “You have your post,” he said.

At four in the morning the pathologists had the answer: critical aortic stenosis with a pinhole valve opening.  The hole was closing off so much that not even the characteristic murmur of aortic stenosis could be heard, much less the slapping together of valve leaflets.  The neck veins were flat because the issue was not high blood volume but low blood flow.  The heart was enlarged from years of straining against the tiny opening.

At four thirty I called Loxie back.  “It was critical aortic stenosis.”

He could almost see Loxie shaking his head over the phone. “Missed it, and it was right there.”  Long pause.  “Well thanks for your help, doc.  Hey, ya wanna hear something great?”

“Yeah!”

“While I was on the other side of the island I delivered a baby girl!  Eight pounds, four ounces!”

“That IS great,” I said.

As I hung up the phone I realized, Loxie really had something there, working on an island taking care of friends in a close-knit neighborhood.  And me being a cardiology fellow at a prestigious Boston hospital, but now I’m depressed and he just delivered a baby.  Go figure.

This story has stayed with me over decades, and changed my way of thinking about what I do.

Thanks for reading.