Sink or swim

I have a pool in my backyard. Sometimes, people ask me for advice on whether or not they should get one. I tell them that no matter what they decide, get a rectangle or a square. No curves. If you have curves, you can’t have an automatic retractable pool cover. When my wife and I aren’t home, we can close the pool with a touch of a button and it becomes more impenetrable than a maximum-security prison. My boys were small when we put in the pool, so the cover was non-negotiable. They’re older now, 14 and 11, and great swimmers. If adults aren’t around, I’ll sometimes leave the pool open if my teenager is home alone (although I tell him it isn’t safe to swim alone). But any time the 11-year-old is home, I feel safest with the pool closed. I, of course, am immune to any misfortune in the pool. I’m an adult. I don’t go in the hot tub alone—it’s too hot and I’m often dehydrated from my ER shifts. Also, my blood pressure and heart rate tend to be on the low side. The last thing I need is to pass out in there. One of my colleagues told me that his buddy from med school passed out in a hot tub and died. Another friend’s parents both died in a sauna. But the pool is safe. When my boys are at school, there’s nothing better than a 5K run followed by a quick dip before work. A scorching afternoon It’s a scorching Friday afternoon and a middle-aged man named Nevin Green (not his real name) has landed on the acute side of our emergency room. I’ve been called to see him because his oxygen saturation is low. His presenting complaint is “near drowning.” I flip the chart to read his triage note: Had seizure while swimming, was dizzy beforehand, and was held up by a friend. His vital signs look OK, but the nurse tells me that he requires supplemental oxygen. On room air, his O2 saturation drops to the mid-80s. I introduce myself and ask what happened. “I had a seizure, I guess,” he says. The oxygen is turned up high, but he’s speaking so well that I listen to his lungs. After finding that they’re clear, I turn the oxygen off to see if he actually needs it. “Do you have seizures?” “No,” he says, “never had one before.” “So why do you think you had a seizure?” “Well, that’s what they tell me.” I ask him to start from the beginning. “I was working all morning,” he says. “Have you been outside today?” “I know,” I say. “It’s hot.” “I’m off this week, so I’m getting some work done around the house with a couple of friends. Around lunchtime, I thought I’d have a quick swim with my daughter to cool off.” He tells me that she’s 12 and had been swimming under his watchful eye most of the morning. “Were you feeling OK today?” “I felt great.” I notice that his oxygen saturation has dropped to the mid-80s. I turn his oxygen back up to four litres. “A few minutes after I got into the pool, I started to feel dizzy. I called out and asked my daughter to grab me. That’s the last thing I remember.” Nevin considers himself healthy. He used to smoke—heavily—but quit years ago. He has no medical problems and takes no medications. He appears fit, and his only surgery was a decade earlier— removal of a kidney for cancer. Distant metastasis? I immediately think of the woman with a remote history of breast cancer who woke up and couldn’t move her right arm. Even years after being cleared, distant metastases such as in the brain can appear—and cause a seizure. Over the last 20 years, I’m sure I’ve seen at least a dozen similar patients—people who had been cleared of their cancer for years and then showed up with a distant metastasis. Nevin’s neurological exam is normal, as are his cardiovascular and abdominal exam. He has no complaints now, other than some soreness in his neck, back and chest. “My daughter screamed for help and I think my buddies yanked me out of the water and dragged me onto the ground. They were doing mouthto-mouth and the paramedic said they might have been pounding on my chest.” A nurse brings me his ECG. It’s normal. I listen to his lungs again—they still sound clear, and 15 minutes later, I tell him that his chest X-ray is also normal. “So did I have a seizure?” he asks. “Let’s wait to see what the blood work and CT scan show.” Ninety minutes later, his results are back. I reassess him and he’s off oxygen and his saturation is back to normal. “The scan of your head is normal,” I say. “And your blood tests are perfect too. Your hemoglobin is normal, your electrolytes and liver function tests are normal, and your cardiac enzymes are undetectable— no reason to suddenly have a seizure and no sign that this was your heart.” “So what happened?” “I’m not sure yet, but I’m not ready to let you go home either. How do you feel?” “I feel great,” he says, “but my neck and jaw are really sore.” I ask for another electrocardiogram. It’s normal. “I’m going to repeat your cardiac enzymes,” I tell him. “If your neck and jaw are sore, that’s a little concerning.” A couple of hours later, I repeat the story to the admitting doctor. “His second troponin is a little over a hundred.” “No STEMI on ECG?” Normal ECG times two.” “I guess he had a heart attack in the pool,” he says “Most likely.” Admitted Nevin is admitted and treated with the usual cardiac cocktail of medications and cardiology is consulted. The next day, the cardiologist sees him. His cardiac enzymes, which never really spiked that high, are already dropping. This is unusual for a heart attack, and the cardiologist doubts that an acute coronary event was responsible for Nevin’s episode in the pool. He refers back to the initial triage note, noting that paramedics had brought him in for a “seizure while swimming.” He also notes that Nevin was “very agitated afterward,” alluding to a possible post-ictal state, reinforcing his opinion that a seizure had caused the near-drowning. He advises risk-reduction with aspirin and a statin, but cancels Nevin’s other anticoagulant, and suggests that he can follow up with him in the office after discharge—no urgent need for an echocardiogram or further cardiac testing. The following day, the neurologist sees him. He conducts a thorough history, physical exam and is able to complete an EEG, which is normal. The neurologist doubts that Nevin had a seizure and signs off on his chart. The following morning, the admitting doctor reviews everything— the presenting history, the blood tests, the CT scans and the EEG, the indeterminate cardiac enzymes that are still falling, and the notes by cardiology and neurology. Nevin is feeling well, and according to both sub-specialists, ready for discharge. The admitting doctor isn’t ready to let him go. He re-starts the second anticoagulant and orders the echocardiogram that the cardiologist didn’t. He hasn’t ruled out a seizure, but that can be investigated further as an outpatient. Nevin is middle-aged, a former heavy smoker and although he’s healthy, his blood pressure has been running high in the hospital. The following day, the echocardiogram is normal, but the doctor still isn’t convinced. He wants an angiogram before discharge. The following morning, the patient is taken to the catheter lab. The interventional cardiologist’s history is brief and supports the first cardiologist’s presumption: “The patient suffered a seizure while swimming, there was no preceding chest pain.” The procedure is complete in 30 minutes: 95% blockage in the left circumflex artery, angioplasty and stent insertion complete. Discharge diagnosis: an ischemic mediated arrhythmia to explain the episode in the pool. Never swim alone, no matter who you are or how old you are. I’ll add it to all the other house rules I’ve compiled in 20 years as an ER doctor. Even if you’re an adult, you never know what might happen. Dr. Raj Waghmare is an ER physician in Newmarket, Ont.

Sink or swim

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