I was on duty and nothing too exciting was happening.  I was relaxing in my office watching the Olympics when one of the ER medics came to me to tell me I had a phone call.  It was the Brigade Surgeon from the Stryker Brigade, calling to tell me he was sending me a patient who was having a heart attack.  He said the patient was a Turkish contractor who had suddenly developed severe chest pain and came to the Aid Station at his FOB (Forward Operating Base).  His EKG showed evidence of an acute myocardial infarction (aka AMI - doctor's terms for heart attack).  "Oh man,"  I thought. "This is not a good thing."

The patient arrived about 15 minutes later.  He was a 43 year old Turkish guy with no significant past medical problems except for occasional GERD (gastroesophageal reflux disease or "heartburn").  He developed this sudden onset of burning chest pain in the middle of the chest that woke him up from his sleep (bad sign) approximately two hours before he arrived at the CSH.  He also became diaphoretic (sweaty) and nauseated (more bad signs).  He was still having severe pains by the time he arrived to us.  He had already received an aspirin, Lopressor (a blood pressure medicine that is helpful in AMI's), morphine, and lasix.  Our initial evaluation revealed one of the most awful EKG's I had ever seen; he had 5 mm ST elevations in leads II, III, aVf, V5, and V6.  He also had what I initially thought were reciprocal changes in leads V1, V2, and V3, however the more I looked at the EKG I remembered something Dr. Dove taught me and I turned the EKG upside down and realized it was actually ST elevations posteriorly.  He was having an acute posterior, inferior-lateral MI.  In other words he was having a heart attack that involved probably over 2/3's of his heart.  "This is bad."

"This guy needs t-PA."  (t-PA is a super-dooper clot buster medicine given to people who are having heart attacks or strokes to break up the clots in their arteries).  "Oh shit, I have never given t-PA before..."  I thought (hopefully not out loud...).  While our pharmacy tech was preparing the t-PA, we started giving other medications.  More Lopressor, a nitroglycerin drip, more morphine.  Nothing seemed to be helping.  So we pushed the t-PA (I guess I am no longer a t-PA virgin).  You start by giving a bolus (an initial dose given up-front), then you run in half over 30 minutes, then the rest over the next hour.  Well, the bolus went in and nothing happened.  The rest of the medicine was running and nothing was improving.  The patient was not getting better and he was losing heart muscle by the minute.  If we were in a full service hospital with interventional cardiologists this guy would go to the cath lab for a cardiac catheterization.  Guessing by the extent of this heart attack he probably has several blocked coronary arteries and probably needs coronary artery bypass surgery.  It will probably surprise you to know that we do not have a cath lab and do not do coronary artery bypass surgery here at our combat hospital in Mosul Iraq (sarcasm).  However, we had been told that they do cardiac catheterization and bypass surgery in one of the local hospitals in downtown Mosul.  We decided to transfer him downtown to an Iraqi facility.  The patient was not happy about this, nor were his employers (who had since arrived); Turkish is not a commonly spoken language in this area, and a large percentage of the Mosul population are not friendly towards the Turkish.  Sorry amigo, if you stay here at this rate you will surely die.

While we waited for the Iraqi ambulance to arrive, we decided to put in a central line (a large IV that goes in the neck in order to manage a lot of different IV medications).  Just as we were finishing placing the central line, we noticed a change in the readout from the heart monitor - could the t-PA be working?  It was right about at the 90 minute mark and the t-PA infusion was just about complete and wouldn't you know it he was starting to improve.  His ST elevations and depressions had essentially resolved and he was now completely pain free.  Of course at about the same time the Iraqi ambulance arrived at the gate and our ambulance crew was ready to transfer the patient to the gate.  Now what do we do?  The patient was strongly requesting to stay.  Our anesthesiologist (who was assisting me with this management)  and I did not know what to do.  Send him to a place where he may not be safe, or keep him here and risk further infarction?  We decided to keep the patient with us.  Like on cue, the patient suddenly developed ventricular tachycardia (v-tach which is a very fast heart rate that typically is a really bad thing when it happens after an acute MI).  Oh shit, this is bad.  The anesthesiologist and I looked at each other with the kind of "what could possibly happen next" look.  He said to me, "he needs amiodarone."  (a drug used to treat this type of abnormal heart rhythm).  Oh shit, I have never given amiodarone before...

OK, so we start giving amiodarone (it is given similar t-PA, a bunch up front, then a bunch over 6 hours, then decrease the rate and give the rest over the next 18 hours).  At this point we have changed our position yet again and were recommending the patient go downtown.  Well, now the guy did not have any chest pain and he was feeling significantly better.  Good enough to put up a bit of a fight and refuse to go downtown.  We discussed our limitations here and that if he started infarcting again or if we could not control his abnormal heart rhythm that he could die.  However he refused transfer and wanted to stay with us.  Against Medical Advice (AMA) is a term used in the medical field when patients refuse to follow the recommendations of a physician.  This is most commonly used when a physician want to admit a patient to the hospital and the patient refuses admission and wants to leave.  They sign a form saying that they are "Leaving Against Medical Advice" and that the physicians and hospital are not responsible if something bad happens.  Well, I never heard of this before, but this guy was "Staying Against Medical Advice."

Back to the amiodarone.  He received his bolus and shortly after his abnormal heart rhythm began to improve.  We admitted him to our ICU.  We kept him on a constant drip of amiodarone (in addition to his nitroglycerin drip, Lopressor, aspirin, and Lovenox).  And other than an occasional brief episode of v-tach, he did well overnight.  In the morning his cardiac enzymes (a blood test to check for evidence of a heart attack) were positive (no surprise there).  Additionally, his CK (the only enzyme we can quantitatively measure) was over 5,000 (the upper limit that our lab is capable of measuring).  This is really high; for example, normal is under 200.  He was 131 when he first arrived.  Your average heart attack raises it a few hundred.  Over 5,000 is a HUGE heart attack, HUGE.  Well, later in the day a Turkish ambulance came down and picked up the patient for transfer back to Turkey where he safely can have his catheterization and most likely bypass surgery.

Although I think there was a good deal of luck involved, the anesthesiologist and I were a bit pleased - that was a big save.  What makes things like that so fulfilling is that we were able to accomplish it in the environment that we did.  In hind sight this was a really cool case, but I have to admit, while it was going on I was probably having as much chest pain as the patient was.  Man, I hope this kind of stuff doesn't happen too often.