September 12, 2017 // Columns

Sometimes you have to bend the rules

Dr. David Kaminskas

The Catholic Doctor Is In

Recently a gentleman presented to one of my cardiology colleagues in the office for evaluation of symptoms that can best be described as vague and nonspecific. He happened to be Catholic, and he attends a parish in our diocese. He gave me permission to share his story.

One of the symptoms he reported was what doctors call a Globus sensation. This is a feeling of something caught in your throat. The most common cause of this symptom is actually anxiety or nervousness. When doctors hear this described, they don’t normally think it’s the heart. He also described some intermittent discomfort in his upper back. His electrocardiogram was distinctly abnormal and strongly suggested cardiac ischemia (reduced blood flow to the heart muscle). My astute partner diagnosed him with unstable angina, despite his unimpressive symptoms, and recommended immediate hospitalization for testing. He believed there was a high likelihood of a significant coronary artery blockage.

I was one of the cardiologists working in the hospital that week, so I assumed his care. It wasn’t too long after I met him, and outlined our plan for a coronary angiogram, that he told me there was a complicating family issue. His only daughter was getting married on Saturday, less than 48 hours later. I told him that I was hopeful that we would find a coronary blockage that could be fixed with a stent on Friday. Hopefully, we could then discharge him Saturday in time for his daughter’s wedding. But the heart catheterization was performed and, unfortunately, that was not the case this time.

There are times when the blockages we find are very strategically located and not optimal for stenting. The best and safest option in these circumstances is referral to our surgical team for bypass surgery. One of his blockages was a very critical 99 percent LAD stenosis. You know, the one they call the “Widow Maker.”

Even though I had just met this man, all the other physicians on the team were more than happy to leave the decision as to the timing of his bypass surgery to me. (Thanks, guys!) I reviewed his angiograms and believed that he needed prompt bypass surgery. The coronary blockages were ugly, as we sometimes say in the business, and I had to recommend he stay at rest in the hospital through the weekend on intravenous blood thinners to prevent one of the critical blockages from occluding before we could get him to the operating room.

The partner of mine who had initially seen this man in the office also reviewed the angiogram. I distinctly remember what he said to me after reviewing the pictures: “If one red blood cell goes through that blockage sideways, it could be all over.” It was time to have a serious heart-to-heart discussion with my patient.

We sat down in his hospital room and had a talk. He asked me if there were any other options for him to walk his daughter down the aisle. I first told him he would have to accept a risk that I estimated to be about a 5 percent chance of a disastrous outcome if he left the hospital. But I told him I would work with him and not mandate the plan. He decided to go to his daughter’s wedding and accept the risk.

We then devised the plan. At 10 a.m. on Saturday we would stop his heparin. At 11 a.m., as the heparin began to wear off, I would give him a shot of subcutaneous Lovenox (a blood thinner that would slowly be absorbed through the subcutaneous tissue, keeping his blood thin for 12 hours) to hopefully keep him from clotting off his 99 percent lesion. He would then mysteriously disappear from the hospital. I told him if he was not back by 10 p.m. to be started back on his heparin drip he would turn into a pumpkin.

You may be wondering why he had to mysteriously disappear. This is the other interesting piece of the story. In the old days, I could let patients go on a leave of absence from the hospital, but not now. Insurance companies now say that if you leave the hospital even for a short time, that indicates you really didn’t have to be in the hospital. Therefore, they might use this as an excuse to not pay for the hospitalization. They are always looking for ways to cut costs or not pay. The team of nurses covering this unit were very cooperative in our clandestine plan, but worried they might be found out and get into trouble. I calmed their nerves by telling them I would not throw them under the bus, and I promised to take full responsibility If our plot collapsed on us.

Just one hour after he left the hospital our plan nearly blew up, when one of the cardiovascular surgeons came by to talk to the patient and found the bed empty. A quick-thinking nurse said to the surgeon she just wasn’t quite sure where he was right then. They heard the surgeon mumbling something under his breath as he left the unit. In the late afternoon, I was going to see another patient and walked by his room to find his door open, but curtains drawn so you could not see his empty bed. There were several nurses sitting at the station right across from the room. They observed me going into the room, and standing inside the closed curtain so I could not be seen but heard, I asked in a loud voice, “How are you doing this afternoon sir?”

As I walked out of the room, I smiled and told the nurses that they could now chart “Dr. Kaminskas came by to check on the patient.”  Well, it’s all true, isn’t it?

Our escapee — I mean, patient — came back to the hospital at 10 p.m. with little time to spare. He told me he walked his daughter down the aisle just as he had always dreamed he would. He also was able to enjoy one slow dance with his daughter and one with his wife during the evening’s festivities. He went on to have successful coronary bypass surgery on Monday morning. Praise the Lord.

I spent the next several days wondering what I would have done in the same situation. Would I have stayed in the hospital on IV blood thinners or walked my daughter down the aisle? I decided I would have said a Hail Mary … and gone to the wedding.