Clot busting – the opposite of homopathy

22Feb10

Jo came in with some chest pain today. Sudden, central, radiating to her arm and jaw. Classical MI. A and E did an ECG and it showed some changes that showed they heart was under strain, and that she was having a heart attack.  It took a few attempts to get a good trace because she was in so much pain she kept moving around. The A and E reg wasn’t too sure whether or not these changes were definite evidence of an MI or not. The changes needed to be at least 1mm in 2 different places, and they were only just 1 mm. They could have been due to some other things. They could have been present on every ECG that Jo would ever have. They wanted a second opinion – should they thrombolyse?

I looked at Jo  – she certainly looked like she was having a heart attack, cold clammy with central crushing chest pain. I looked at the ECG, if you looked carefully two leads showed just 1mm of changes, and some changes in other leads as well that support it.

‘Lets do it’

‘I’m afraid you’re having a heart attack, we can give you this treatment to break down the clot in the artery but it can cause bleeding and it can cause strokes’.

No one is in a good state to give informed consent when they feel that they have an elephant sat on their chest. You can’t go and research your options on the internet. All you can do is leave it to the doctor standing in front of you to hope that they are right. She trusted me. I was the nice doctor who had just given her the nice morphine that relieved her pain.

We didn’t have any old ECGs, so we had to assume that Jo’s old ECGs were normal, and the changes we were seeing were new. We would only know for certain in 12 hours time when we did a blood test, a troponin to see if there was any damage to the heart. Thrombolysis is an incredibly effective treatment, it will reopen the artery and increase her life expectancy. But it could kill her, it could cause a stroke or fatal bleeding. High stakes but effective. Compare that with  homeopathy where you don’t do much harm, but are unlikely to do much good either. We could cause her to have a stroke for no potential benefit to her heart. If we don’t give it when we should we would deny her a chance of living without heart failure. The ECG will stay in the notes so that people can look at it forever more and tell me if  I did the right thing. I imagine myself standing in the coroners court explaining why I gave a treatment that killed her.

Actually giving it is a bit of an anticlimax. Just a little injection into the cannula.

But the ECG remains in her notes for ever more, so people can pick it up and suck air in through their teeth and decide if I did the right thing.

Advertisement

Filed under: Acute Medicine   |  Leave a Comment
Tags: cardiology