Coronary occlusion, denial and dissociation

A doctor puts emotions aside in an emergency, but dissociation does not help when the illness is in the family

The speedometer reads 160 km/h. I am driving. My husband Anthony is in the passenger seat. He groans and writhes clutching his chest in that classic closed-fist gesture. We are two rural general practitioners in personal crisis. It is only 45 minutes since he won a bike race in the mountains.

The paramedics know we are coming. We round a bend. There is the ambulance. Both vehicles stop. His blood pressure is 80/40. His pulse is 42. They do an electrocardiogram and hand it to me. “Oh, no ST elevation,” I say, relieved. One. They snatch it back. “There’s elevation everywhere.” I am dismissed.

The paramedic regional manager arrives. He says they’ll thrombolyse here. Anthony is saying, “I want a hot cath.” This is ridiculous; soon the charade will stop. He is not having a heart attack. Two.

Our adult children who followed in another car are here now and standing on the roadside like white posts. I return to the ambulance. The paramedics are injecting tenecteplase intravenously. They have given morphine. Anthony’s groaning continues. They give more morphine, antiemetic, morphine, close the doors and drive the 5 minutes to the hospital where the protocol is completed. His myocardium throws off some cardiac arrhythmias as it reperfuses.

The subsequent urgent coronary angiogram shows only minimal irregularity at the origin of the left anterior descending coronary artery. It seems that this small plaque ruptured and a clot formed during his extreme effort racing to the finish line. No clot can now be seen. Perhaps if he was less fit, if his heart was less used to contracting in a lactic acidotic environment, it might have stopped. He has had an acute myocardial infarction though; even I must admit that. I must.

So there we are, husband and wife, lovers, the parents of four children, co-workers and protagonists in many a clinical argument. He, wired and dripped with tenecteplase bruises spreading like black flowers on his limbs, is forcedly chipper. I sit holding his hand with a strained smile. I ask what I should do about the conference trip to South Korea in 3 days’ time. I am an invited keynote speaker. He says, “Oh of course you should go.” I say, “Yes, of course.” “Grace will be here with me,” he says. “I’ll be fine.” Grace is our 21-year-old daughter. “Oh yes,” I say. We agree that he’s through the worst. Three. I don’t want him to think I am worried about him. I think I mustn’t fuss. Four.

My time in Korea passes in a disconnected blur. Everything I care about is too far away. I can’t even pray. Then I am on the plane heading home. When I arrive we are formal with each other. He might break. I might break. The whole world might break.

One day I look at him and say, “You could have died.” “I knew that,” he replies. What confounds me was that I did not. What use was all my training if I could not see the ST elevation in my beloved husband’s electrocardiogram, if I did not have the wisdom to stay by his bed on day three? I made four critical errors in caring for him. Both of us exhibited impaired clinical reasoning.

On reflection, I think that the training to put our emotions aside and get on with the job in an emergency situation did not serve us well in this personal emergency. My job in this instance was to be there emotionally and practically, but I pushed the emotions away and my judgement was affected. I did not acknowledge how close death had been. A month passed before I cried.

In the weeks following his heart attack, whenever anyone asked, Anthony said he felt 97%. I believed him. Months later he admitted that he felt like crap. He tells me that he coped by rationalising, by talking with chosen experts about the pathology, the prognosis, the pharmaceuticals and their risks. For a while he claimed that he didn’t have an acute myocardial infarction; he had a “coronary occlusion”. As our children say, “Whatever…”. His task was to discover his path through life under this shadow, whatever it is called.

I misrepresented, denied and dissociated from the emotionally loaded information I was attempting to process. When that happens, personal decision making is impaired. Seriously.