We have just finished seeing our morning patients, when the ER pages my team to see a patient in distress. He is a 73-year-old man with a white beard and a potbelly, clutching his chest. I know his condition is serious. He is speaking in short sentences, gasping for air between thoughts. I also note the telltale cold sweat breaking out on his pale face.
After graduating from medical school in San Francisco earlier this year, I am now part of a cardiology team at a big city hospital in New York, trying to diagnose this man and save his life.
Immediately, I read the electrocardiogram, which tracks his heartbeats. This is the real thing, I think. Classic signs of a heart attack. The elevated waves on the EKG look like tombstones. For further confirmation, we do a blood test and find that his damaged heart is leaking proteins into his bloodstream.
For me, this is an exciting moment — to catch a heart attack before it kills. I knew what to look for and found it. Every new doctor has to memorize textbook symptoms for a heart attack. So far, this man has been a perfect case study.
We mobilize. Up to the cath lab. In a flash, a half dozen people swarm into the room prepping the patient. We hook him up to thousands of dollars of equipment. Time is tissue, they say. The longer it takes to fix his heart, the more muscle will die.
A specialist threads a catheter through his groin, then squirts fluorescing dye into the blood vessels of his heart. Eureka. I see it immediately: A near complete blockage of an artery feeding the bottom of his heart. Into the artery goes a stent that opens it right up, like a freeway opening up after a car accident. In a second, the blockage is gone. I watched his poor heart asphyxiating one moment. The next, it is pumping away beautifully.
The day was so satisfying. This is real medicine. Understanding physiology. Correlating it with the patient’s story and lab tests. And saving a life.
But my elation is cut short. The next morning I find out that in the middle of the night, the patient abruptly went downhill. His potassium rose dangerously high. His heart jumped into an irregular rhythm. By 2 a.m., he had died.
In medical school, we are taught to use the principles of Occam's razor when making a diagnosis. The 14th-century English logician, William of Occam, believed that the simplest explanation is the most likely explanation. Gather up all the data and pare it down to just one diagnosis. But in practice, medicine is not so straightforward. It is complex and humbling. A few diseases may occur at one time. And even if you nail the right diagnosis, it can evolve and then elude you.
After four years of medical school, I know my education has just begun. To be a great doctor is to put yourself in the mindset of a great chess player. Study the patient and anticipate the many moves ahead.
Rachel Sobel is a medical intern working at a New York City hospital.