Entry 5

Entry 5

Entry 5
A weeklong electronic journal.
Feb. 13 2004 4:32 PM

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Alexi (left) and Ingrid: traveling the road together
Alexi (left) and Ingrid: traveling the road together

The EKG arrived by fax, followed by a frantic phone call from a physician: "This case just doesn't hang together," he said. "We need your help." Forty minutes later, at 2 a.m., the patient arrived by chopper. We had only a few details to go on: He was a 62-year-old tax attorney with high blood pressure who came into the emergency room at an outside hospital complaining of chest pain. We knew from his lab tests and EKG that he was not having a heart attack, but his EKG showed he'd had one he hadn't felt in the past. As soon as we set eyes on him, we felt better: He was sitting in the stretcher, joking with the flight crew that brought him in. He told us his story on the way down to the unit: "Two weeks ago I had a horrible cold with big swollen glands," he said, gesturing around his neck. "I still have the sore throat. … Then yesterday my chest started hurting and I fell down in the kitchen."

We pressed him for details, asking him to describe the pain, what made it better or worse, how long it lasted, and whether anyone had seen him fall. Intriguingly, his pain seemed to vary with position, increasing whenever he coughed, leaned forward, or laid down flat in bed. His story sounded like a classic case of pericarditis, a disease caused by swelling around the heart; it often develops mysteriously a few weeks after a cold, particularly a viral illness, and the swelling causes irritation and chest pain accentuated by movement. But one fact argued against this diagnosis: Very few people with pericarditis faint.

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We examined him immediately. I strapped a blood pressure cuff on his right arm, and inflated the bulb. He was 75/64—low for a man with hypertension. I looked at his neck veins, one of the ways we measure how much fluid is in the heart, and they looked a little higher in his neck than normal. I listened to his chest—it was difficult to hear his heart beating. We began to worry that the swelling from his pericarditis might be compromising his heart's ability to function, causing a backup of blood that would explain both the low blood pressure and his swollen neck veins. We woke the cardiologist on call and asked her to come into the hospital. While we were waiting, we got a chest X-ray: His heart was large, the top bigger than normal.

Thirty minutes later, the patient lay flat on his back beneath an ultrasound probe. The cardiologist squinted at the screen, moving the probe back and forth across his chest, trying to get a good look at his heart. There was a large amount of fluid, but there was something more worrisome: The aorta, the largest artery in the body, appeared swollen like a balloon. It was hard to see behind the heart, but it looked as though there might be a large clot in the wall of the artery. The only thing that could cause that was an aortic dissection—this is when the inner layer of the artery splits open spilling large amounts of blood into its wall. It is one of the most terrifying and life-threatening diseases known; untreated, 90 percent of people with aortic dissections will die.

From that point on, every minute counted. With each passing hour, the chance that this man might die increased. (Terrifyingly, each hour meant a 1 percent increased risk in mortality.) Our attending physician rushed him to the CT scanner to get a better look at his aorta, calling the surgeons on the way. Thirty minutes later, we were staring at the films from the scan. Sure enough, there was a large tear in the aorta, and a clot of old blood extending from the beginning of the tear down into the heart. The blood had traveled down the vessel wall into the pericardium, a closed sac that surrounds the heart like a Ziploc bag, explaining the fluid that we saw there. We called the surgeons and rushed the patient directly to the operating room.

In medicine, dramatic saves like this are rare, but when they happen they're exhilarating. There's nothing like the feeling that comes from saving someone's life. Often, knowing what to look for is half the battle. We have an amazing array of technology around us, but trusting one's intuition is often more effective than ordering studies. There are the facts—symptoms, labs, and imaging—and then there is what you might call "the gestalt," the feeling you get when you know something is not quite right.

Internship is all about learning how to develop a sixth sense that helps us to determine what's wrong with a patient. That is why we "pre-round," laying eyes on all of our patients, deciding alone in the darkness whether we feel they need help. In the end, medicine is more of an art than a science, and it's developing this heightened sense of awareness that ultimately helps us fight injury and disease.

Ingrid and I have been fortunate enough to travel this road together, working at the same hospital, taking call on the same nights, and occasionally sharing the same team. Our journey as new physicians is by turns engaging, exhausting, thrilling, and most of all, awe-inspiring. Each day our patients remind us why we chose this field. They are the reason we rise in the early hours and stay late into the night. Each has their own unique story, and many of the patients we've met this year will continue to haunt and inspire us for the rest of our lives. Medicine is as much a calling as it is a career—and internship is the ultimate immersion.

Ingrid Katz and Alexi Wright are physicians completing internships at a major teaching hospital in Boston. They are currently rotating through the cardiac intensive care unit and are the authors of Interns' Diary, an online journal.