Two households, both alike in dignity,
       In fair Verona, where we lay our scene,
       From ancient grudge break to new mutiny,
       Where civil blood makes civil hands unclean.

In a Heart Unique
by Lisa Binkley

The patient, a 50-year-old white male, lay on the gurney, no longer struggling for each full breath. The attending physician, a doctor with many years of experience and additional training specializing in emergency medicine, listened to the summary that the paramedic provided. He didn't take notes - that being someone else's responsibility - but began his preliminary assessment as a nurse replaced the blood pressure cuff with an automatic one.

"Twelve lead?" she asked, preparing to page the technician. Another nurse switched the air supply from the portable oxygen to a port in the wall. The shriveled bag of saline solution was removed and another hung on the metal pole.

After complaining throughout the morning about indigestion and a sore left shoulder, the business executive had been found gasping from pain and clutching his chest in his office after lunch by his partner. He confessed feeling a huge pressure in his upper body. The secretary dialed 911 while the colleague hovered nearby in case CPR was needed.

"Coronary profile and a chest x-ray," the doctor ordered, and then moved on to the occupant of the next cubicle to await the test results. The battery would rule out anemia, liver damage, kidney insufficiencies, diabetes, and measure various heart-related enzymes, such as creatine kinase (CK), ultra-sensitive cardiac C-reactive protein, myoglobin, and troponin while the x-ray ruled out lung disease as the source of dyspnea (labored breathing).

Mr. Jones's secretary had supplied the name of his general practitioner, who was located in the suburb were the patient lived.

A phone call to that office generated a faxed copy of the most recent medical history including a previous EKG. The tracing showed changes signifying myocardial infarction. The strips of heat-sensitive paper were photocopied and the copy entered into Mr. Jones's growing chart.

Based on the patient's history, symptoms, and test results, he was admitted to the Coronary Care Unit (CCU) and placed under the care of a cardiologist. Reperfusion therapy (drugs that prevent muscle damage in the heart due to clots), which had been initiated earlier, was continued.

A cardiac catherization revealed occlusion (blocked arteries) so an angioplasty followed to reopen the vessels. A stent, a tiny mesh tube positioned at the site of the blockage, would insure greater success of the procedure. After surgery, Mr. Jones was counseled on weight management, maintaining lower cholesterol, stress-reduction techniques, and the benefits of regular exercise.

He took the advice to heart and enrolled in cardiac rehab, water aerobics, and enlisted the help of his worried family to stick to his new diet.

In advance of a regular follow-up visit a few years later, the cardiologist recommended an exercise stress test. While walking on the treadmill, Mr. Jones complained of difficulty breathing, which prematurely terminated the procedure. The special pictures detected another partial blockage. Another cath and angioplasty restored the blood flow.

Mr. Jones was tested for homocysteine deficiency and instructed to add folic acid and B12 vitamins as a precaution against further plaque build-up.

Between life-style changes, dietary improvement, exercise program, stress awareness, and specific medical attention to his ongoing cardiac status, Mr. Jones had an excellent chance at maintaining quality and expectancy of life.

The patient, a 50-year-old over-weight black female, lay on the gurney, struggling for each full breath. The attending physician, a resident exhausted from his too many hours of on-call, listened to the summary that the paramedic provided. He didn't take notes - assuming the ambulance report was complete - but began his assessment as an aide replaced the blood pressure cuff with an automatic one.

"Twelve-lead?" she asked. Only the week before an administrator had issued a memo about the volume of unnecessary procedures performed on noninsured patients and how these unpaid accounts influenced the hospital's already precarious financial status.

The resident nodded. As it turned out, the tracings were unremarkable and, without a previous sample to compare, not particularly helpful.

The aide switched the oxygen supply from the portable canister to a port in the wall. The bag of saline solution was removed and another hung on the metal pole.

The woman had fainted while working as a grocery cashier. Her customer had used a cell phone to call 911, while the manager tried to maintain calm among the employees and other patrons.

"Metabolic panel, CBCs and 'lytes" the doctor ordered, and then moved on to the occupant of the next cubicle to await the test results. The battery would rule out anemia, liver damage, kidney insufficiencies, and diabetes.

The supermarket had an emergency contact number, and Mrs. Smith's daughter supplied the name of the clinic where her mother sought medical care on the infrequent occasions when an aspirin didn't help. The clerk groaned, "Not the Clinic!" and started a series of phone calls for the chart that, eventually, revealed a sketchy history of possible diabetes and untreated hypertension.

Based on the patient's history, symptoms, and test results, she was admitted to a Med/Surg unit where, the next day, she was counseled on sugar management, dietary restrictions, and medication changes, before being discharged with instructions to follow-up with the clinic.

Mrs. Smith, a busy woman with children and grandchildren relying on her, lost a few pounds, took her blood pressure medicines when she remembered, and had her glucose checked once in a while.

Several months later, having felt tired and short of breath since her previous admission, Mrs. Smith passed out in her kitchen and appeared to stop breathing.

The paramedics found an irregular heart rhythm and, after numerous attempts with a portable defibrillator, were able to resuscitate her. They transported the victim to the closest ER, where cardiac enzymes were performed and discovered to be extremely elevated.

Mrs. Smith died prior to admission; the fresh infarction inflicting irreparable damage to her already scarred heart. An autopsy revealed blockages and evidence of earlier significant heart disease.

Mrs. Smith's resident, now in his cardiac rotation, reviewed the chart and wondered why he hadn't tested for cardiac involvement even though Mrs. Smith hadn't presented with classic symptoms or a positive EKG. With all her risk factors, he would have been justified to do additional tests, regardless of her uninsured status.

Between life-style changes, dietary improvement, exercise program, stress awareness, and specific attention to lowering her cardiac risk, Mrs. Smith could have had a better chance to survive.

Symptoms of Heart Attack

Lethargy and/or generalized weakness

Shortness of breath, cough, and/or difficulty breathing

Discomfort or pain in the neck, shoulder, jaw, or either arm

Nausea or indigestion with/without eating

Tightness, pressure, pain, or burning sensation in the chest

Sweating without exertion

The symptoms happen more often or more intensely during physical activity but can happen while resting.

Women often experience less severe chest pain, more nausea, and more weakness than men do.

If several of these indicators happen together or last for more than 10 minutes seek immediate medical attention.