T

he thing people hate most about being in the ER is not the pain or the fear. It’s the waiting. You come rushing in in a panic, only to skid to a stop on the tiled floor and cool your heels for three hours waiting for a knight in shining scrubs to come to your rescue. Nobody likes waiting around in the ER.

That waiting around was definitely what was bothering Doris. But first I needed to figure out what was bothering her husband, George, who had arrived in the ER via ambulance and was complaining of chest pain.

“Male, 76 years old,” reported the paramedic. “Reports pain and heaviness in the chest, pain radiating down to left arm.” He rattled off his vitals. “We gave him aspirin and nitro, we sent the ECG to you, it’s sinus rhythm.”

I stepped into the room. George lay back on the bed, Doris fluttered nearby. “How are you feeling?”

George tried to smile. “Not that bad,” he said. “Just a little pain.” He put his hand, palm open, onto his chest and tried to breathe deeply.

George’s symptoms could mean several things — a blood clot in the lungs, dissection of the aorta, pneumonia, even something boring like reflux. But one of the first things we look for, because it’s a time-sensitive, fairly straightforward process, is myocardial infarction, MI for short. Otherwise known as a heart attack.

“We’re going to do an EKG,” I explained. “That will give us some information on what’s going on with your heart today.”

We moved quickly. Time is of the essence in heart attack treatment, especially in an ST-elevation myocardial infarction, or STEMI. During a STEMI, one of the arteries that supplies the heart with blood suddenly becomes blocked. If it remains blocked, the heart can’t pump properly. After a short time, the heart muscle begins to die.

“I’m sorry,” George apologized to me and his wife.

“It’s never a problem,” I assured him. “These are not the kind of symptoms you should ever ignore.”

If detected early, we can operate to clear the blockage and prop the artery open with a stent. STEMI patients that are treated quickly have fantastic recovery rates, and we keep a STEMI team ready and waiting during the day. We also maintain a system where we can call the STEMI team into the hospital in the middle of the night when necessary, similar to the way Hatzolah operates.

“He’s not having a heart attack,” Doris said loudly. “Look at him, he’s okay, he’s talking. Does he look like a man with a heart attack?”

“It’s okay, Doris,” George said. He lay back and allowed the nurse to attach the leads.

Actually, his EKG looked pretty good. Certainly he didn’t meet the criteria for a STEMI. We gave him aspirin and nitroglycerin to open the blood vessels, took some blood and sent it off for analysis, and began to consider other diagnoses. But nothing seemed to fit.

“I told you it was nothing,” Doris told George loudly. She turned toward me. “Can we go home then?”

“Let’s keep an eye on him for a bit,” I said. “Let’s wait and see what the bloodwork shows.”

I looked in on George 15 minutes later. Tiny beads of perspiration dotted his upper lip. As I watched, he lifted an arm to wipe his forehead.

Uh oh. Rule of emergency medicine: If the patient is sweating, the doctor should be sweating.

“Let’s do another EKG,” I said.

“We did an EKG already,” Doris reminded me impatiently.

An EKG is like a snapshot — it shows you what’s going on at one single moment in time. Maybe something had changed in the quarter of an hour that had elapsed.

“It’s okay, Doris,” George said again.

We hooked George up to the heart monitor and turned toward the screen.

“Look at them,” Doris stage-whispered to George. She rolled her eyes. “Watching those lines go up and down, up and down, like they’re watching a movie. Do they think we have all day?”

The nurse glanced at me. I looked over at Doris. Her lips were pursed. How many years had she and George been together? Of course she was scared.

“It’s okay,” George whispered back, “they’re just doing their jobs. It’s gonna be okay.”

The EKG had changed a bit, but still didn’t meet the criteria for a heart attack. I turned from the screen to the patient. “How are you feeling?”

“Same,” George said, clearly uncomfortable about making a “big deal.”

“How’s your pain?”

“Same,” he repeated.

“Did the nitro help?”

George shrugged. “A little.”

“We’re going to wait for the bloodwork and keep an eye on you a bit longer,” I told George. Doris sighed loudly.

“Hey, Logan.” I snagged one of the nurses as I stepped out. “We need to keep a close eye on this room, okay?”

Thirty minutes later I returned. “How you feeling?”

“Same,” George said again.

“It’s nothing,” Doris sniffed. “Maybe just anxiety. Or angina. Or acid reflux.”

“Anything else that starts with an A?” George joked feebly, through labored breathing.

Angioplasty, I thought. I didn’t say it though.

“Let’s do another EKG,” I said instead.

“Another one!” Doris exploded. “We’ve been waiting here for hours!”

The leads were attached, we turned to the screen. I raised my eyebrows. “Do you see what I see?” I muttered to the nurse.

“I see it,” she said. “It’s a tombsto—”

Tombstone pattern, right. I cut her off; the last thing you want is the patient to hear the word “tombstone.” But this third EKG was clear and unambiguous: The ST segments of the EKG were elevated in classic tombstone pattern. George was having a heart attack.

Instantly, we activated the STEMI team. George was rushed to the cath lab where they performed an angioplasty to open the blocked artery.

I met Doris in the family waiting room. Her daughter, Beth, had joined her. “That’s the doctor,” Doris told her loudly.

“Your dad is doing great,” I told Beth.

“My mother says they waited around doing nothing for three hours before he was brought into surgery,” Beth said accusingly. “What took so long?”

“Beth,” I said, “we could not have brought your father into the lab any earlier, because he wasn’t having a heart attack yet. Not all chest pain is a heart attack. We didn’t want to anchor on a diagnosis and miss something else. We had to wait until his condition declared itself before we could accurately diagnose and fix the problem.”

Life is not static. Nothing stays the same. We need to watch the patient — who might not be in heart failure now — to make sure he’s not going into heart failure soon.

So why does everything take so long in the ER? Why is there so much waiting around?

Because that’s how the world works. There’s a lot going on that we can’t see. Things are always changing. The trick is to be standing, ready and waiting, to meet those changes head on, whatever they may be. —

All names and identifying details have been changed. Patient profiles may be based on composite cases.

 (Originally featured in Mishpacha, Issue 761)