May 8, 2019 // Perspective

Sometimes you have to throw a ‘Hail Mary’

Dr. David Kaminskas

The Catholic Doctor Is In

Let me share the story of a special lady I had the honor of taking care of. Quite a few years ago, I met this woman when she was in her late 60s. She presented with unstable chest pain. She first began to have symptoms of chest pressure and tightness with activity. She also had difficulty carrying the groceries into her home and noticed chest pressure when climbing a flight of stairs.

By the time she saw me, she was having episodes of chest discomfort without even exerting. Her history alone told me she had a critical coronary lesion and we moved quickly to catheterization, which documented multiple severe blockages. The best treatment for this finding, at that time, was bypass surgery. She underwent a quadruple bypass.

She recovered very well, and I began to see her in the office once or twice per year in follow-up. She was always accompanied by one of her multiple daughters. She had lost her husband several years before her bypass surgery. She was a very happy lady, loved life, and I think it would be fair to describe her as gregarious. I would always leave the exam room with a smile on my face. She was a great pleasure to see, and her daughters were very much like her — always kidding around with lots of laughter.

About a dozen years after her bypass surgery, she presented to the hospital once again with similar symptoms of angina. Coronary arteriography showed us that two out of her four bypasses had closed and that she now had diffuse disease in her coronary arteries. This means there are multiple blockages throughout the heart arteries from beginning to end, with no good options for intervention such as stenting or repeat bypass surgery. She also had deterioration of her heart function, or what is termed an ischemic cardiomyopathy (reduced left ventricular function).

We were able to stabilize her by adding multiple antianginal medicines, and she was able to return home and enjoy life once again with some restrictions. I continued to enjoy our interactions in the office and always looked forward to seeing her again.

One morning while making hospital rounds, I was notified of her admission the previous night for a prolonged episode of angina. The very next night I was the cardiologist on call, and I was called “stat” to see her. She was having severe chest pain. She was pale, sweating profusely and looked awful. Her blood pressure was critically low. An EKG showed a heart attack. She was in cardiogenic shock, and it looked to me like she would likely not survive the night.

I was surprised that despite her low blood pressure she continued to be coherent and able to talk with me and participate in the decision process. I knew that taking her to the catheterization lab would be of marginal benefit, since she had the diffuse blockages that I probably could not fix.

I remember kneeling at her bedside to be eye to eye with her. I told her we were in big trouble and admitted I didn’t have good options. I asked her if she was ready to meet the Lord, and in typical fashion for this lady she gave me a quick definitive answer: “No.”

I did have one long shot, a “Hail Mary” idea. The very last thing that happens when people have an acute myocardial infarction is that a clot forms at the sight of a severe cholesterol blockage. If I gave her a strong clot buster and opened the artery up, we might be able to restore blood flow and save enough heart muscle that she might survive.

I explained the risks and benefits of giving tissue plasminogen activator to her. The most feared complication is that a small percentage of people receiving this have a fatal brain hemorrhage. In her case, her cardiac mortality was so high it made every sense to give it a try despite this risk. She quickly gave me permission to give the intravenous tPA. It was about 4:30 a.m., and I was exhausted from being up all night, so I went to lay down in one of the call rooms as the medicine was being dripped into her IV. I woke up startled at 6:30 a.m. with the phone ringing just inches from my head. The nurse who had cared for her the rest of the night wanted to know if she could have breakfast.

I thought that was somewhat of an odd question for a lady who was near death when I left her bedside just a few hours ago. I immediately asked about her vital signs and clinical status. The nurse told me that after about 90 minutes of the tPA infusion, her chest pain went away and her blood pressure began to rise. It had now normalized. She was actually hungry. Praise the Lord! It was not her time.

This lady went on to live another year, giving her family more precious memories: But it was during her very last hospitalization that something happened I can never forget.

She was admitted with severe congestive heart failure and hypotension (low blood pressure). I put her on a continuous drip of IV medicine to help her heart and support her blood pressure. Over the next two weeks we tried on multiple occasions to wean the drip off only to see her blood pressure fall again to levels that could not sustain life. She was dependent on this medicine that only came in IV form to keep her alive. Finally, I asked all her family members to meet me in the early morning hours on my rounds to discuss the situation.

I told this wonderful lady and her family we were out of options, and that my recommendation was to wean the drip off and accept the consequences — which meant almost-certain death. The patient knew her time had come, and the family was very accepting as well. We turned the drip off and her blood pressure began to fall. Her daughters asked me how long she might last.

I always try not to give a specific answer, since even with years of experience, physicians can only offer an educated guess. The daughters continued to press me for a more specific answer, and I reluctantly succumbed and told them that most people would likely only last a few hours with blood pressure this low.

I had to drive to an out-of-town clinic that day. As I saw patients, I kept wondering why I had not received a call from the nursing staff reporting her death. I drove home well into the evening, and that night I called the unit to check on her. I believed she had likely died, and the nurse had forgotten to call or maybe informed one of my partners who was on call. I soon found out that she was still alive. I decided I could not go home without visiting her and her family one more time.

I found her hospital room full of family and close friends. She had not moved or said anything to her loved ones for the last hour. Her oldest daughter then told me that they had prayed all day that God would take her. They believed her mom would just not let go and give up her spirit. I went over to her bedside and while holding her hand whispered in her ear that all her family was right there with her and that God was ready for her. I hugged her daughters and walked to the nursing station to write a short progress note. In less than a minute, her nurse came running down the hall to tell me that her heart stopped and that she had passed.

I found myself thinking about what had just transpired for many weeks to come. I could only go to Scripture to make any sense of it: Mark 13:38. “As to the exact day or hour, no one knows it, neither the angels in heaven nor even the Son, but only the Father.”