MI's and Nursemaid elbows ...

... "So, Mr. Johnson, how's the chest pain, now?"

"Better, buckshot, better".

He was still ashen. I glanced over at the blood pressure monitor and it read 90/54. That's not too good. It was 130/80 before we gave him the sublingual nitroglyerin.

I looked at his EKG tracing that the lab tech just handed me. Something wasn't right. I couldn't put my finger on it but he definitely was NOT having an acute inferior or lateral wall myocardial infarction. There were no "tombstones" in the limb leads and V2-V6 looked normal as well.

Mr Johnson looked up at me and forced a wan smile. "Better, bucksot".

I smiled back. I don't know why he had chosen 'buckshot' as my nickname but it was congenial and sincere and seemed to make him feel better.

I felt my phone vibrate in my front pants pocket. I removed it and saw that Laura was calling me from her mobile. While I'll let other family members and friends go to voicemail, I always answer when she calls.

"Hey," I said as I turned my back on Mr. Johnson and the ekg tech and the RN who was getting a repeat BP reading, "Can I call you back in, oh, 10 minutes?"

Instead of the usual "sure thing, babe", Laura replied "Actually, no - Peter hurt his wrist or elbow somehow."

I started to feel as ashen as Mr. Johnson.

"Whaddya mean? did he fall? Is he bleeding, is he all right?". I gave the RN and Mr. Johnson a 'just a minute' index finger wave and stepped outside the surgical room.

I felt sick. My stomach was hollow, like when you take the first drop on a roller coaster.

Laura was talking quickly. "I have an appointment at the Saint Paul clinic at 11," it was 9:15am, "we are at art class and I was sitting on the floor and he came up behind me to give me a hug and he started to fall and he grabbed on to me but he jerked a little. He screamed but instead of shrugging it off after a few minutes, he's still whining and holding his arm funny. You know that's not like him."

My mind raced. Differntial diagnoses cycled through my mind. Fracture, dislocation, muscle or tendon tear. Thoughts grew deeper - Pathological fracture due to a carcinoma?

The RN came out into the hallway.

"Um, Dr. C, his BP is dropping - it's 80/40. We need you."

Shit. I have to triage, fast.

To the nurse - "ok". To Laura - "Um ... I'd take him to the ER; if there is a fracture or something, then they can do more than they can do at the clinic."

"Really?" pause. "OK."

I was worried about Peter but I knew that Laura's maternal instincts were kicking into overdrive. Mamma bear was going to take care of baby bear, no matter what. I trusted her to do the right thing.

"Love you," we said simultaneously.

Click. I slipped my phone back into my pocket.

I went back to Mr. Johnson's room. Still ashen, still hypotensive.

I picked up the EKG tracing again. I couldn't give him any more nitroglycerin with his blood pressure that low. He was defintely having a heart attack by clincal presentation, but the EKG wasn't telling me where.

Wait. V1 looked funny. The 'R' and 'S' spikes were reversed. That's it, he was having a posterior wall infarction.

It's rare type of heart attack that usually is fairly harmless as far as heart damage goes ... unless your right coronary artery is dominant or is the main supplier of blood to the back wall of the heart. Then it could be fatal because doctors do what I just did - treating it like a "normal heart attack". Instead of pushing fluids, I gave him nitroglycerin, causing his blood pressure to bottom out because his left ventricle fails to fill in time with blood - this makes the posterior wall becomes floppy and ineffective. The blood pressure continues to drop and the ventricle fibrillates and stops.

He needs fluids. Now.

I grabbed a liter of saline from the medicine closet and handed to the RN. "We need to hang this. Open it wide".

She was wide-eyed. "But he'll go into heart failure. Shouldn't we start a pressor like dopamine?"

I had to put on my 'hard-ass doctor look' I save for just the occasion. "No," pause for emphasis, "that will kill him. Hang the fluid."

She did. Within 10 minutes, the nitro had worn off and over half a liter was infused into Mr. Johnson's circulatory sysytem. His blood pressure had climbed to 97/60. He went from ashen to pale and he had stopped clutching his chest.

"Let's call 911 and get him to the ER with a stat Cardiology consult." He was doing better but wasn't out of the woods.

"What going on, buckshot?" Mr. Johnson looked a little worried.

"You were having a heart attack but it's going to be ok. We figured it out and stopped it from getting worse ... for now. We have to get you to the hospital to get is all settled down."

"I had faith in you, buckshot. Thank you." He was holding my hand firmly but gently. "Let my wife know what's going on - she'll like you, you're a handsome devil, buckshot."

"You're welcome, Mr. Johnson." Sometimes, I like my job.

I had to go back to my regular schedule of various ailments and personalities. Mrs. Franklin was getting a chest xray to rule out a possible pneumonina and Ms. Rodriguez was waiting in my other exam room - she thinks she has bugs in her rectum - last week it was people breaking into her apartment to rearrange her furniture. All the appointments were full for the rest of the morning.

Finally, at lunch I had time to plop down into my office chair and catch my breath. The RN from earlier poked her head in. "Just thought you'd want to know. Mr. Johnson had a 95% occlused right coronary artery. They were able to angioplasty and stent him open. The wife just called from the hospital, he's doing fine."

Yep, sometimes, things work out okay.

Then I had the sudden realization - "Shit!" - as I remembered Peter and Laura.

Laura picked up her mobile on the 2nd ring. I could hear Peter playing in the background.

"So? How is he?"

"He's great. He had a ... nursemaid's elbow? I think that's what it's called. Anyway, the people at Children's ER were great. He was seen by a Nurse Practicioner and a resident; the NP just popped the elbow back into place and He's been fine since. He yelped a little, but I go him ice cream on the way home. He's playing on the cube since we got home and is no worse for wear."

I was relieved. It's a relatively common injury in toddlers and with Peter being as active as he is, I'm not surprised. He'll be fine.

I'll be fine. Laura hung up and I got back to my charts.

Barely a minute later another one of the RN's poked her head into my office.

"Dr. C - we have another walk-in chest pain. She doesn't look too good."

I grabbed my stethoscope, took a swig of diet coke and raced down the hall ...