S Y N O P S I S
Saturday evening, March 1 1997, I phoned my parents. The ringing stopped, someone had picked up the phone, but no one spoke. Finally, I said "hello," after which I heard my mother respond with a very weak "hello." By the sound of her voice, I knew something was wrong. "Mom, are you ok?" I asked. There was no response. I said "Mom, why donít you call me back after you feel better. I heard her say in a very weak voice, "all right." It was the last time I spoke with her. She was having a heart attack. Her dying voice will haunt me the rest of my life. While it was unexpected, it was not a total surprise. My motherís family has a history of coronary artery disease. Her younger sister had a heart attack a number of years ago. Her younger brother has had quadruple arterial bypass surgery, and more recently had plaque removed from a carotid artery. My mother was diabetic for 27 years, which adds significantly to her coronary artery risk profile. Her HDLs, often referred to as "good" cholesterol, because it removes excess cholesterol from cells and helps transport it back to the liver, were 22, less than half of what is normal for a woman. My mothers age (75), sedentary life style, and overweight condition also contributed adversely to her risk profile.
My father informed me that mom had been wearing a nitroglycerin patch during the day, but was instructed to remove it at night. He was afraid she had removed it prior to my phone call. I was unaware that she was using prescription nitroglycerine, but I knew that she had been complaining of being "short-of-breath" for some time. Her diabetes had caused damage to the sensory nerves in her hands and feet (neuropathy), causing her pain, numbness, muscle weakness of the legs, and difficulty walking. I assumed her "shortness-of-breath" was due to her lack of exercise. I was also aware that she had had tests recently at a cardiology diagnostic center, and was concerned about the results of these tests, but the results were in and they were negative.
On March 3, 1997, I began to try to piece together what had happened. What kind of tests did mom have at the cardiology center, and why didnít they show the arterial blockage I presumed she must have had? I telephoned the Lebanon Cardiology Center to find the answers to these questions. I was told she received a Holter Monitor EKG and a non-stress Echocardiogram. I was surprised. I donít have a medical background. What little I knew about heart disease was due to general knowledge acquired from reading newspapers and magazine articles etc. Yet, that, and a little common sense suggested to me her primary-care physician, Robert L. Barton M.D. had failed to order the most likely test my mother needed, the one I believe probably would have saved her life, a stress test. Virtually all of my mother's risk factors pointed to coronary artery disease as her greatest risk. Neither the Holter Monitor, nor the non-stress echocardiogram, was designed to detect coronary artery disease. Even though I did not know him personally, I had always assumed that my parentís physician would do a better job than I could at insuring their medical well being.
At the time of my mother's passing, for personal reasons, I was unable to pursue the issue further. As soon as I was able, I began to research the medical circumstances and details of my mother's death once again. In February of 1999 I acquired copies of my mother's medical records from Medical Care of Lebanon County (Pa). By that time Dr. Barton had sold his practice and was then and still is employed by Medical Care of Lebanon County, practicing at the West Cornwall Family Health Center just outside of Quentin, Pa. A review of those records combined with what I already knew could be summarized in the following paragraphs.
Dr. Barton was well aware of my mother's family history of coronary artery disease (CAD) and he had been treating her diabetes pharmacologically for many years. My mother routinely had glucose and/or blood lipid tests prior to most appointments with Dr. Barton, and thus there is an adequate list of data available from which to draw statistics. In the five years preceding her death, my mother's cholesterol had risen from an annual average 257 to an annual average 328 mg/dl. At the time of her death, her most recent blood lipid report showed her cholesterol level at 363mg/dl. The American Heart Association puts out a flyer, which in general correlates a 2-percent change in heart attack risk for every 1-percent change in cholesterol level alone. In the same period her annual average triglycerides level rose from 410 to 982 mg/dl. Triglyceride levels are a significant risk factor for CAD, particularly in women. In addition, using Dr. Barton's records, I counted 8 symptoms of impending heart failure, including chest tightness, shortness-of-breath, dyspnea-on-exertion etc., beginning more than 1 year prior to her death. In that same period, Dr. Barton twice prescribed nitroglycerine in one form or another. Nitroglycerine is prescribed specifically to prevent and treat angina pectoris, a symptom of CAD. Despite my mother's obvious symptoms of CAD and her associated risk factors, it does not appear that Dr. Barton saw a need for her to see a cardiologist or schedule a stress test. In fact she had not had a stress test since January of 1993 when she was hospitalized for reasons unrelated to heart disease. She would not have had one then, were it not for the decision of a cardiologist associated with the hospital to schedule one.
It was my mother who finally took the initiative. With her blood as thick as syrup (cholesterol and triglycerides are both fats in the blood), and with rising blood pressure and concern she might have a heart attack, she phoned Dr. Bartonís office requesting to see Dr. Barton, on February 5, 1997, the date of my fatherís scheduled appointment. According to the medical records, her blood pressure had risen further. She left Dr. Barton's office that day with two new medications for high blood pressure and finally, an appointment for tests at the Lebanon Cardiology Center scheduled for February 11, 1997.
To me it is clear my mother had coronary artery disease. Her blood lipid risk factors (high cholesterol, high triglycerides, low HDLs) pointed to it, her diabetes pointed to it, her family history pointed to it, and her symptoms (angina, shortness-of-breath when walking etc.) pointed to it. On January 7, 1997 Dr. Barton prescribed nitroglycerine to relieve my motherís angina. Angina pectoris occurs when the arteries, under stress (exercise), become constricted due to narrowing of the walls from plaque build-up, and are not able to carry sufficient oxygen to the heart. Nitroglycerine is thought to improve oxygen flow by relaxing the muscles of arteries, thus allowing them to dilate. So what kind of test do you specify for someone who has the obvious symptoms of CAD? One acceptable answer is a test that measures blood flow, through the coronary arteries, to the heart, under stress, commonly referred to as a "stress test". Yet Dr. Barton, on February 5, 1997, less than one month after prescribing nitroglycerin to relieve my motherís angina, a symptom of CAD, referred her to the Lebanon Cardiology Diagnostic Center, specifying a Holter EKG, and a non-stress echocardiogram which included a Doppler echocardiogram and color flow. In all, tests costing $1,270, and none of them designed to determine if CAD is present.
There are a number of tests given to determine if CAD is present. A stress EKG is a test performed when someone walks on a treadmill while his or her heart is monitored on an EKG machine. A stress echocardiogram and a stress thallium are similar tests, which can sometimes provide more accurate information than the stress EKG. A cardiac catheterization is the most accurate test for assessing whether CAD is present, however this is an invasive test. In my mother's case, since she would have had difficulty exercising, one of the pharmacologic stress tests would have been the logical choice. Such tests were available locally on February 11, 1997. On the other hand the Holter monitor is often used to check for arrhythmias, and the echocardiogram is valuable for studying disorders of the heart valves, but neither is considered an appropriate test for CAD.
Cause Of Death. My motherís death certificate lists the cause of death as Ventricular Fibrillation due to Myocardial Infarction. Ventricular Fibrillation is an arrhythmia. It is a condition in which disordered electrical activity causes the ventricles to contract in a rapid unsynchronized uncoordinated fashion. When this occurs, little or no blood is pumped from the heart. Myocardial Infarction means there is death of some of the muscle cells of the heart as a result of a lack of supply of oxygen and other nutrients. This lack of supply is caused by closure of the coronary artery that supplies that particular part of the heart muscle with blood. According to the Heartpoint Information Center, this occurs 98% of the time from the process of arteriosclerosis (hardening of the arteries) in coronary vessels. There is little doubt my mother had arteriosclerosis, a result of long term unchecked diabetes and ultra high cholesterol and triglyceride levels. Her heart attack was simply the result of these conditions. My mother had gone to see Dr. Barton on February 28, 1997, to review the results of the Holter EKG and echocardiogram. At that time, she was finally given an appointment to see a cardiologist. Her appointment was scheduled for March 5, 1997. She did not live long enough to keep it.
It's a terrible experience to lose a loved one. We all must go through the experience sooner or later. Later is always preferable. My parents and I have always been close. I am an only child. What only adds to the sense of loss is the knowledge that this tragedy should have been prevented if my mother had had a cardiology test commensurate with her coronary risk factors and symptoms, or had been referred to a cardiologist when Dr. Barton diagnosed coronary artery disease. We depend on doctors to be able to evaluate conditions and test results that we are not trained for. My mother and father, and patients in their age group are especially dependent on doctors in this regard, as aging increases the frequency of medical needs. My mother was literally a ticking bomb. She could have had a heart attack at any time. The American Heart Association distributes a flyer and questioner titled, "First Heart Attack Risk Test," a copy of which, ironically, I obtained in Dr. Barton's office. With the flyer as a guide, I computed mom's risk of having a first heart attack using applicable medical record data from the last year of her life. A score of 4 or more indicates an above average risk of a first heart attack. The higher the score the higher the risk. For each of Mom's 6 blood lipid tests, her score was a minimum 15, on occasion 16, out of a maximum possible score of 17.
It would appear there was no shortage of opportunity for Dr. Barton to take remedial action in my mother's case. From and including the date on which Dr. Barton initially prescribed nitroglycerine and prior to her death a little more than a year later, my mother saw Dr. Barton 9 times. I strongly believe that if we can't depend on physicians, for whatever reason, to recognize the obvious signs of heart disease and take appropriate and timely action, we must find other ways to protect the public from this deficiency. When a physician cannot be depended upon to perform at the level of a physician, he or she is a risk to the community and should not have a license to practice medicine. I believe my mother would be alive today if my parents had gone to a hospital emergency room instead of Dr. Barton's office in early February of 1997, I'm confident my mother would have been given a proper cardiology test. While that alone is not a guarantee of survival, at the very least, she would have had a fair chance. Likewise, had I known the level of my mother's blood lipids, I would have made sure she had a stress test, not in February of 1997, but on her first utterance of the term "short-of-breath."
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