Heart to Heart, Mom to Mom

It was a cold Easter evening, and I was reaching the end of what felt like a much longer 10-hour shift as an attending physician in the emergency department (ED). At the time I had a 5-month-old daughter at home and, as a nursing/pumping mom, was eager to get home to her. Little did I know that the last patient of my shift would forever change my life, and I hers.

The patient was a young woman in her 30s, and like me she had just given birth to her second child, a daughter, 1 week prior. She was tired and overwhelmed; I could see the stress that being in the loud, overcrowded ED waiting room was causing. Eventually, she was one of the “lucky ones” who got placed in an actual room that night, as opposed to a cart in the hallway. The resident physician assigned to me that evening presented her case to me. The patient had a constellation of symptoms that started with a headache earlier in the week. It was not the worst headache of her life — she attributed it to a lack of sleep, visiting in-laws, and the general stress of having a newborn. It wasn’t until she felt some chest pain that made her decide to come to the ED. That decision would ultimately save her life.

Signs Both Serendipitous and Cautionary

Sometimes I truly believe God places people in the right place and surrounds them with the right people. I evaluated the patient, talking to her about her chest symptoms, headache, and very mildly elevated blood pressure taken in triage, which had normalized once she reached the quiet treatment room. Although I had only been out of training for about 3 years, I already knew to fear the postpartum state. In emergency medicine we are trained to think the worst and need to think of the quickly fatal diagnoses first. For the headache differential, I considered things like preeclampsia, intracranial hemorrhage, migraine, and cerebral venous sinus thrombosis. The chest pain, despite being mostly resolved, prompted evaluation for pulmonary embolism, postpartum cardiomyopathy, and myocardial infarct. I ordered a slew of tests — computed tomography (CT) and magnetic resonance imaging scans of her head, preeclamptic labs and urine, cardiac biomarker measurements, and a D-dimer test.

I didn’t initially consider her eventual diagnosis, an ascending aortic dissection that would have likely killed her within the next 24 hours had it gone undiagnosed. I remember giving the young woman a cocktail of migraine medications and reevaluating her multiple times. Her headache improved, and I could tell she wanted to go home. I empathized with her maternal instinct to get back to her newborn and the new reality of caring for two young children. I could see her pain and frustration when I told her that some of her results had come back abnormal and that she would need to stay for further testing. The single D-dimer would eventually lead to the potentially lethal diagnosis.

The patient went for a CT scan of her chest to rule out pulmonary embolism. Shortly thereafter I received a call from the radiologist, who believed that she might have an ascending aortic dissection. He had seen a flap in the aorta, however, because the intravenous contrast had been timed to evaluate for pulmonary embolism, he was not 100% convinced that what he saw wasn’t just a scanning artifact. I immediately called a cardiothoracic surgeon, who reviewed the images and also could not discount artifact. The definitive test that needed to be done was a transesophageal echocardiogram (TEE), which would require a cardiologist to drive in from home, at this point around midnight, to perform the test at the bedside. The “typical” aortic dissection is seen in an elderly comorbid patient and involves uncontrolled blood pressure and ripping chest pain radiating to the back, certainly a far cry from the previously healthy 30-year-old young woman sitting in front of me. Still, I couldn’t shake it off. Long after my shift was over, I sent my resident home and decided I was in it for the long haul. Taking intermittent breaks to pump milk for my own baby, I braced myself for some challenging conversations.

The cardiologist agreed to drive to the hospital to perform the TEE. It revealed that the patient’s symptoms were indeed caused by a life-threatening ascending aortic dissection. She was taken immediately to the operating room. During pregnancy and the postpartum state, hormonal changes weaken the walls of vessels, including the aorta. When combined with increased physiological changes during pregnancy, such as an increase in blood volume, heart rate, and cardiac output, this pathologic state puts pregnant and postpartum women at risk of aortic dissection.¹ Nonetheless, aortic dissection during pregnancy or postpartum is exceedingly rare, with only a limited number of cases reported.² I was shocked, in disbelief, and mentally and physically exhausted.

A Deeper Connection

Since that memorable Easter encounter, the young woman is one of two patients who have emotionally impacted me in a way that I am unable to fully explain. I think being a mom of a young baby myself made me capable of putting myself in her shoes, understanding her emotions, her pain and fear. I truly believe that she was placed in my hands that night. To this day, she is also the only patient I have ever gone to check on the following day while she was in the hospital. Fortunately, the operation had been successful and her prognosis was favorable.

Fast forward 6 years. I show up to work one evening and come across a handwritten card in my locker. I open it and start reading the words written to me by that erstwhile patient. The woman had recently returned to the ED and was telling her story to one of my colleagues. She said she had always wanted to find the emergency room physician who she felt saved her life, and my colleague passed along my name.

In the card, the woman thanked me with all of her heart. She acknowledged how difficult it was to make the diagnosis, how I was persistent and pushed for more testing, and how easily the diagnosis could have been missed. She thanked me for giving her daughter the opportunity of a life with her mother. This was the best gift I most likely will ever receive in my career. I sat in that room with tears welling up in my eyes knowing that both of us were forever changed for having crossed paths for those few hours.

Embracing Emotion Leads to New Outlook

Emergency medicine is rough. We see patients in their worst moments. We are viewed as the middlemen at times, quickly diagnosing the problem and shuffling the patient off to the subspecialist who actually intervenes to save the patient — the cardiologist who opens a blocked vessel, the surgeon who removes an appendix, the neurosurgeon who stops a brain bleed. The job is grinding and emotionally exhausting. It is thankless most of the time. It is rare for a patient to have such insight and to know that their life was changed as a result of what we do. Moving forward, that letter will stay framed hanging on my wall to remind me that what I do matters, even when my patients don’t recognize it. I will think back, especially around the Easter season, and remember the ones who did.

This particular experience has helped me reframe my approach to patient care. In the past, I had avoided becoming overly emotionally invested in my patients. The ED is full of pain, suffering, and death. I had thought that by disconnecting I was somehow protecting myself from carrying that weight. I learned from this patient that emotionally connecting, understanding, and empathizing with patients helps health care providers find a renewed sense of purpose. This purpose and fulfillment motivate me to provide the highest-level care to my patients and, moreover, to find joy in the human aspect of each clinical encounter.