I recently, at the age of 49, survived an out of hospital cardiac arrest. It helped that I am a GP and was on a ward round in a local care home. The nurse sitting next to me started CPR immediately and I was defibrillated within a few minutes by a team of paramedics. Usually only 5% survive such an event. Often survivors suffer cognitive deficit, which hopefully for me is minimal.
I did not really have any major risk factors except a strong family history: four generations of heart disease presenting at a young age. My mother and uncle are still alive after their heart attacks at ages 46 and 36 respectively. The emergency angiography showed my coronaries were 100%, 95% and 90% blocked. I now have three stents, hopefully doing a grand job.
Because of my family history and some atypical sensations at age 48, I thought it would be a good idea to get screened for heart disease. So within the year before my event I had an exercise tolerance test. This was equivocal to the cardiologist, so he recommended I have a thallium scan. This showed no evidence of significant risk for ischaemic heart disease. I was seen in an outpatient clinic four months later by the registrar, who counselled me on lifestyle modification and then she discharged me from the clinic.It was an odd consultation. I did not think she knew I was a doctor. I left the room feeling unhappy with how our encounter went but I know this can happen.
I was unaware that the sensitivity of thallium scanning locally is 93%, a false negative rate of 7%. I wonder if this had been discussed with me whether I would have requested further tests. It has left me thinking about patients I knew with negative investigations and subsequent drastic events – often advanced cancer. I have had difficult consultations when they have asked why nothing was found before.
From the cardiologist’s point of view it has really made me see how difficult their jobs are, especially when NICE guidelines are based on risk scores. For lower risk cases minimally invasive tests are recommended. Because an angiogram comes with a risk of complications, they are only performed for higher risk cases. The atypical pain meant I had a thallium scan. If it was family history only I would have had a CT angiogram.
This leaves me wondering about the use of our sixth senses and the importance of medical acumen. This has to be balanced against the risk of over investigating a population and the harm that can cause. I usually avoid going to see a doctor but in this case it was my strong family history that made me seek help. If I were offered further invasive tests and I knew the risks involved would I have declined it? I found that even as a doctor, I reverted to the patient role and relied on specialist advice.
Three months post event I went to see my first consultant to try and understand what had happened. Being human, I was stern and sort of angry. It must have been hard for him to sit and listen to me. Although nothing could be changed, I hope he realised that I thought communication could be changed for future throughout the process and that it might protect him more.
The lessons I have drawn from this are: the use of a good consultation, that screening tests have pitfalls and patients may need to be more aware. In the future for my patients’ sake I will endeavour to be better informed on the sensitivity or specificity of each test. Finally, I have learned when to use your acumen and sixth sense.