Thread by @gradydoctor

1/
The night before this day—20 years ago—I was a senior #MedPeds resident finishing up the last days of my rotation in the cardiac ICU. I was on pre-millennium eve overnight call that night.

Yup.

I remember because that was the same night that my dad had an ST elevation MI.

2/
A page came through. A call from the operator. It was my dad. He chatted first—not unlike my dad. But then he went straight to a complaint. That isn't like my dad.

Him: “My shoulder hurts.”
Me: “Which one?”
Him: “The left. But I played 36 holes today.”
Me: “Okay.”

Um. Okay.

3/
Him: “It’s probably that.”
Me: “Maybe.”
Him: “I took some ibuprofen but that didn’t help.”
Me: “No?”
Him: “No. But it’s not really that kind of pain, so. . . .”

Um. Okay.

4/
Me: “So. . .what kind of pain is it, Dad?”
Him: “I don’t know. Like. . . a pain that stays but that doesn’t seem like it’s in my joint? Does that make sense?”
Me: “Kind of?”

*silence*

Him: “It’s probably the golf.”
Me: “Yeah. Probably.”

He changed the subject.

5/
He shared a quip about 1 of his 11 siblings. Then an update on 1 of my 35 first cousins. Or someone from the old neighborhood who got married or ran for city council or something.

Him: “Do you remember him? He played little league with you.”
Me: “Maybe if I saw him, Dad."

6/
I was leaning my chin in my hand and doodling on a piece of paper at the nurses’ station. I love that they always let me sit there during down time.

Anyway.

Me: “Hey Dad? Can you try to describe the pain in your shoulder?”
Dad: "Like an ache? I don't know."

Um. Okay.

7/
Him: “It’s funny. You know how I’d describe it?”
Me: “How?” *still doodling*
Him: “Like. . .like when you accidentally bite some ice and it gets in your tooth nerve.”

Like. . . what?

8/
I yanked my foot from under me, stuffed my foot back into my clog, and sat bolt upright.

Me: “Wait. Say that again, Dad?”
Him: “It’s probably the golf.”
Me: “Like. . . .ice in a tooth?”
Him: *chuckling* “I told my doctor that when I called. I know it sounds crazy.”

9/
*thinking*

Me: “Do you still feel it, Dad? The ache?”
Him: “Yeah.”
Me: “Dad?”
Him: “Yes?”

*thinking*

Me: “I think you should go to the hospital.”
Him: “What?”
Me: “I mean. It’s probably the golf. But go, okay?”

10/
I’d be lying if I said the heavens opened up and out flew a diagnostic cherub strumming a harp and singing:

“This is an acute coronary syndrooooome.”

Nah. But I'd been taking cardiac histories all month. And knew that atypical stuff was way more typical than I’d realized.

11/
This was also the same year that Schulman et. al. had published that paper describing how bias can affect what happens when patients present with cardiac complaints. We’d discussed it in Journal Club at some point.

But now, the application of this study felt urgent, man.

12/
It was probably the golf. I mean, 36 holes IS a lot for anyone. Especially a 55 year-old dude.

Isn’t it?

But that story was not right. Especially in someone living with hypertension, increased lipids, a family history, and an upbringing on Alabama soul food.

Nope.

13/
Me: “Dad? Tell them you have chest pressure and that you’ve been sweating.”
Him: “But I don’t have chest pain.”

I felt like crying.

Me: “I want them to believe you.”
Him: “Believe me about what?” *nervously laughing*

I did not laugh. This was not funny.

14/
Dad went to emergency. And, at first, they had him waiting. Until he went back and told them about the chest pressure and diaphoresis.

Wrong, I know. But still.

Things moved faster after that. His first EKG? Unmistakable ST elevations across the anterior leads.

Damn.

15/
He called me from the CICU. Still in high spirits.

Him: “I wish they’d give me more than this glass bottle medicine. But they said it’s at the max.”
Me: *gulp* “Did they say what your cath showed?”
Him: “What is that?”
Me: “The big-needle-in-the-groin test.”
Him: “Huh?”

16/
Dad hadn’t yet had a cath. It was now the next morning. I was post call.

Weird. It didn’t even occur to me to ask to leave. But that's another story for another time.

No cath. Troponin of 22. Then 26. I still remember the values.

Did bias delay things? I’ll never know.

17/
The cath about 10 hours later showed a near complete proximal LAD. He’d need surgery. When we spoke again, he still had that pain.

Still.

I got this in aliquot pages while rounding. The cardiologist patronized me when I called. By the end of the morning, I was a wreck.

18/
My attending, a cardiologist, asked what was wrong. I told him. Now, I was hysterical.

I will never forget how amazing he was. How he listened and gave me marching instructions. And how he helped me advocate for my dad.

Dr. Biblo: “Your dad needs revascularization. Now.”

19/
My attending helped book my flight from Cleveland to LA himself. While I personally called the on-call CT surgeon. I still can’t believe that surgeon spoke to me. He wasn’t even yet aware of my dad.

Nope.

Dad went to the OR ~30 minutes after I hung up the phone. Crazy.

20/
Things I'll always remember:

1. Everyone is someone’s n of 1.
2. Listen to your instincts.
3. Bias kills.
3. You can color outside the lines as an advocate.
4. I'm not alone.
5. Asking for help early is brave.
6. Talk to your family often.

Oh, and go to journal club.

21/
I’m proud to say that 20 years later, my dad walks 5 miles daily, has a normal EF, and is thriving independently. He’s also under the care of a great cardiologist and PCP.

Neither of whom mind talking to his pesky academic internist daughter in Atlanta.

Ever.

22/
So nope. I didn’t get to party like it was 1999. But, 20 years later, I do still get to hear about my 35 first cousins and the neighborhood kids at least 4x per week.

Ha.

Happy 2020, y’all. And may you continue to fight for every patient like they are your own N of 1. 👊🏾

P.S.

Thank you Dr. Lee Biblo for asking what was wrong, for listening to me, and for helping me to prioritize what mattered.

And to Dr. Z, that kind community hospital CT surgeon, who afforded a worried junior colleague 1 minute of your precious time.

That is all.❤️👊🏾