Wednesday, August 05, 2009

Broken heart

NewFNP was awaiting the EKG results for her 20-year old methamphetamine treatment seeking patient when her awesome lab supervisor came out and handed her this:

NewFNP was a little stunned.  Q-wave in III.  rR' in V1-V3.  A 20-year old guy.  "What the fuck," newFNP thought to herself.  Her lab supervisor helpfully offered that the young man had a large vertical scar to his chest.

Ah, cardiac surgery.  If newFNP were a cardiologist, she might have been able to identify the EKG changes immediately.  Alas, she is not so she was left to question the young man as to his cardiac history.

She asked him to tell her about his heart surgery.  He replied that he had never had heart surgery.  Hmmm.  NewFNP then inquired as to the etiology of the large suprasternal scar.  

"Oh yeah," he replied.  "I had a heart transplant."

"A heart transplant??!" newFNP responded and then inquired if he was taking any medications.  He replied that he was not, leading newFNP to deduce that he was likely mistaken as to the nature of his surgical procedure.  

She asked him why he may have had heart surgery as a child.  He was unable to tell newFNP.  

NewFNP conducted his cardiac exam which was -- not surprisingly -- abnormal.  His pansystolic murmur over the aortic region obliterated S2.  His murmur over the pulmonic region was palpable.  The other murmurs were less extraordinary.

At this point, newFNP was stumped.  In retrospect, she should have put it together.  Pulmonic stenosis.  Childhood cardiac surgery.  But newFNP has never seen anything like this and she just couldn't put the pieces together.  

Thankfully, the young man's dad showed up to the clinic and explained that the patient had Tetralogy of Fallot repaired when he was 18-months old.  Prior to the repair, he had multiple Tet episodes leading to numerous hospitalizations.  The surgical repair was delayed due to a lack of health insurance.  As a result, he spent his first 18 months lacking oxygen.

It is fair to say that this young man is not bright.  In her interactions with him, newFNP often sensed that his IQ was quite low.  Now she had a reasonable explanation as to why.  The bummer is that because his IQ is so low, he cannot appreciate the consequences of his actions like others might.  

For instance, methamphetamine is cardiotoxic.  His heart is repaired, but not normal.  This combination might give someone else pause.  It was clear that this young man did not understand the potential impact.  His parents understand though.  It was difficult to see the sadness and desperation in their faces as their son averted his eyes and spaced out during the visit.

He is set up with a cardiology referral, an addiction treatment referral and a list of clinics where he can have neurocognitive testing completed and get referred to vocational education.  He still doesn't understand why these appointments are important.  He has other things to worry about.  His girlfriend wants to have a baby.  His friends want to go out and party.  He has no concept of consequences.



Whitny said...

Oh my gosh, I just found your blog. So happy I did. Wonderful wonderful. I'll be visiting you often.

Anonymous said...

Wow. What a story... Good for you for trying to help him despite all of the obstacles!

What I wouldn't give to get a listen to those heart sounds. I'm a cardiac nerd. :)

Steve said...

Glad the recovery referral was made. That would be the first order of business. Without that piece, the cardiac interventions will be ineffective.

I'm not sure a high IQ or lack of childhood trauma is preventive with respect to addictive behavior. The high functioning ability to reason from cause to effect may not have as much sway as your implied premise suggests when it comes to just saying no. There are plenty of PhD and MD (and RN, for that matter) addicts and alcoholics that are refractory to recovery.

Anonymous said...

Ahhh, they always emphasis the importance of good history taking... but before you can do that you need a patient that is a good historian... (or at least their dad!)

Nice to fall across your blog.