For one Yale Medicine patient, a chance encounter with an emergency department doctor led to speedy diagnosis and treatment.
Two days after her shoulder surgery in March 2015, Kathy Hofmann was due back at the orthopaedist so the doctor could examine her repaired bicep and rotator cuff. She was not feeling well that morning, so she postponed the appointment until that afternoon.
Hofmann was feeling better as her sister drove her to Yale Medicine’s Guilford office, but she felt ill as soon as she got out of the car.
“As I was climbing the steps to the office, I said to my sister: ‘I don’t think I’m going to make it. I think I’m going to pass out,’” said Hofmann, who was 61 at the time.
The automatic doors opened, and Hofmann collapsed on a bench in the vestibule.
A call for help
When Hofmann's sister screamed for help, Charles Wira, MD, an assistant professor of emergency medicine at Yale School of Medicine and liaison with the Yale New Haven Stroke Program, happened to be on the second floor of the office. He was waiting with his wife, Christina, for an appointment with the same orthopaedist, after his own shoulder surgery. The couple heard the noise and jumped up to help.
“My wife ran down first,” Dr. Wira says. “I was a little slower because I was still in a shoulder sling. And when we were all there, I saw Hofmann lying on a bench and going in and out of consciousness.”
His wife called 911 as Dr. Wira checked Hofmann’s pulse, which was faint but rapid. “It was an extremely terrifying situation,” Dr. Wira says. "While we see this on a routine basis in the ER, we didn’t have the proper equipment here, not even a stethoscope. All we could do was take her history, check her pulse and call for help.”
Guilford EMS arrived within 90 seconds—“a phenomenal response time,” Dr. Wira says.
The paramedics discovered that Hofmann’s blood pressure was 50 and her oxygen saturation was 55 percent. Those were dangerously low levels, and they indicated that her lungs’ ability to take in oxygen was so compromised as to threaten death. To Dr. Wira, those readings indicated a pulmonary embolism (PE), which is a blockage (or clot) in the pulmonary artery of the lung.
According to Dr. Wira, blood clotting can be a complication of any surgical procedure for two reasons. “The patient typically doesn't ambulate as much, and also because I.V.s into blood vessels can stimulate the clotting cascade,” he says. Thrombolysis, the breakdown of clots using drugs, is the therapy used to dissolve those dangerous clots.
In a matter of minutes, Hofmann was placed in an ambulance, given intravenous fluids and oxygen and rushed to Yale New Haven Hospital.
Alerting the hospital
Meanwhile, Wira called a colleague at the hospital, Basmah Safdar, MD, to alert her that Hofmann was on the way. Thanks to that call, the Yale Medicine staff was on high alert that a critically ill patient was being rushed to them.
‘We’re ready for you’
Safdar, an associate professor of emergency medicine at Yale School of Medicine and the co-director of the Chest Pain Center at Yale New Haven Hospital, recalls how dire the situation was. “When she came in, she was about to code—to go into cardiac arrest,” Dr. Safdar says.
The hospital staff immediately performed resuscitative measures: providing oxygen to Hofmann, giving her fluids to bring up her blood pressure. They monitored her vitals on an electrocardiogram (EKG) to determine whether she was having a heart attack and prepared to put a tube down her throat in case she stopped breathing.
“Our biggest concern was whether she had a massive blood clot,” Dr. Safdar says. “Our typical way to look first for that is CT (computerized tomography) scan of the lungs, but she was too sick for us to send her.” So the team decided to do something unusual. “We used a bedside ultrasound to look at her heart and saw evidence of a blood clot in her lungs,” Dr. Safdar says. Few hospitals have the equipment or training for this.
Based on this information, Dr. Safdar gave Hofmann the thrombolytics, a TPA (tissue plasminogen activator) to break down the clot. Then she worked to raise Hofmann’s blood pressure to a safe level and put her on a breathing machine because she was still struggling to breathe. The clot was so large that it had filled both of her lungs and was pushing into her heart.
“The highlight here was how fast she was able to receive an accurate diagnosis and life-saving therapy within 10 minutes of her arrival,” Dr. Safdar says. “The mortality of a blood clot that size is 80 percent, and the prognosis increases within minutes.”
Hofmann says she feels grateful for the speed and quality of the care she received. “The doctor has said to me that she was sorry that she had to be so aggressive,” Hofmann says. “Well, if she wasn’t so aggressive, then I wouldn’t be here.”