A few years ago, I was a registered nurse in the radiology department at a suburban Philadelphia hospital. I was working with a cardiologist who was focusing on CT angiography (CTA) scans, images of the blood vessels that we used to help assess cardiac conditions.
A floor nurse alerted me to my next patient; a woman in her late 20s who had recently experienced chest pain. Lab testing found some elevated blood levels that suggested she should be assessed further to find out exactly what was going on.
I was told that this patient was somewhat difficult; short-tempered with the medical staff and seemingly disinterested in her own health.
I explained the CTA procedure, and the fact that because it relies on contrast to provide readable results, she would need to take some medications.
She refused, saying, "I don't want to take any more meds." I explained why we couldn't do our work without the medication. But she refused again. So I told her I would have to call the physician who sent her to us to say we couldn't complete the CTA.
Her medical team was so concerned that, in short order, we convened a committee in our department: the ordering physician, the attending physician, a cardiac fellow, some residents, and a few interns.
Facing all of these medical experts, on her own, was a young woman who, as far as I could tell, knew only that she didn't want more medicine. I stuck around to see what would happen, and, I hoped, to be a second set of ears for her in case she had questions later.
And, as I imagined her team was also thinking, I wondered why she was so resistant to our help – and what was causing chest pain in such a young woman.
As our patient continued to maintain her refusal, the medical team kept saying she needed the test. But no one explained precisely why the test was necessary, that she had the right to refuse it, or how serious her elevated lab values were that were prompting us to want to do the CTA.
Eventually, they talked her into taking the medications and having the CTA. But after the team left and the two of us were alone, she seemed even more upset. I wasn't comfortable with proceeding until she consented without being under duress. I wanted to give her back her dignity.
I sat next to her, and said, "This is really your choice. I heard what was said about having to have the test done to rule things out, but there are other methods that can be explored."
She looked at me, defiance and defeat now replaced with confusion. She didn't know, she told me, that she had other options.
I asked her what happened on the day she went to the ER. She said that her chest pains began when she was arguing with her child's father. A few days before, she continued, she had been fired from her job. And her father, her main supporter, had recently died. She now had, she confided, no one to talk to.
I asked gently whether she would allow me to speak with her nurse about possibly getting her some emotional support. She agreed – and said she would do the CTA study.
A consultation with a psychiatrist, I told the nurse, might help her find resources to cope with the tremendous life changes she was experiencing. The nurse was surprised she opened up and was willing to seek help, and agreed to get the consultation.
When the test was done, the young woman no longer seemed defeated, or confused.
She was diagnosed with "broken-heart syndrome," technically known as takotsubo cardiomyopathy. This is a weakening of the left ventricle, the main pumping chamber of the heart. It can be prompted by severe stress – either emotional or physical – and mostly occurs in older women. Treatment usually includes medications such as beta blockers, ACE inhibitors, and diuretics. But it's essential to also address the stress that triggered the problem. The good news is that most patients do recover.
Meeting this young woman taught me something valuable. We as health-care professionals need to look at the whole patient – not only their medical diagnosis, but also any outside influences. I hope that I was able to help her. But I know that she helped me realize that my perspective needed to change, and just taking a moment to listen can change everything.