My personal answer to Michael Tilson Thomas is revealed through the story of a patient. This particular patient was 69 years old, and in December of 2008 she woke with an irregular heart beat and mild shortness of breath. Her heart accelerated to 130 beats/minute on a home blood pressure cuff, but her blood pressure was stable later that day when she was seen in the Emergency Department (ED). She was diagnosed with rapid atrial fibrillation and admitted around 8 pm on a Thursday evening for anticoagulation therapy with heparin, and a plan for electrical cardioversion the next day after a transesophageal echocardiogram.
Because an inpatient bed was unavailable, she spent the entire night in the ED. She was not admitted to a hospital bed until late Friday morning, after other patients had been discharged. She had slept poorly in the ED hallways, and was hungry after having fasted for the procedures that day. The cardiologist spoke with the patient and her family in the afternoon on Friday, and explained that because of the delays in her admission, the planned procedures had been cancelled, and she would remain on blood thinners over the weekend until the transesophageal echocardiogram and cardioversion could be performed on Monday.
Unexpectedly, on Saturday afternoon, the patient suffered a sudden and massive stroke with complete occlusion of the carotid artery from the arch of the aorta to the intracranial branches of the middle cerebral artery. She was rushed to the operating room where a neurosurgeon attempted to remove the blood clot, but the carotid artery tore, leading to massive intracranial bleeding and brain death. She was kept alive in the Intensive Care Unit until preparations for her funeral could be completed. She died at noon on the following Tuesday, 112 hours after she first stepped into the hospital. The patient was my mother.
Some of you may recognize this story from an article in the New England Journal of Medicine
that was published on the 2½-year anniversary of my mother's passing “The Waits that Matter.”1
I was amazed by the response from around the nation, and even the world, to the coverage the story received in The New York Times2
and The Wall Street Journal
Four months after the article was published, I received a surprise in the mail, a $300 check—the honoraria granted to Perspectives authors by the Massachusetts Medical Society. I decided to use the money to pay for a copy of my mother's medical record. It was difficult to relive the final hours before my mother's devastating stroke, to hear her final words as recorded in the nurse's notes. After reviewing the 811 pages, it became clear that there was more to the story of my mother's death. The admission notes documented that she should have been started on heparin shortly after being admitted with a heart rate as fast as 160. However, the heparin was not started until 11 am the next day, almost 15 hours later. It is unclear whether the medication was unavailable from the pharmacy, an order was missed, or there was difficulty prescribing the anticoagulation. A transthoracic echocardiogram had been normal the evening of admission, and I believe the lethal thrombus propagated during a prolonged period without anticoagulation.