I was looking forward to Independence Day as I eased into my Tuesday shift. My work as an emergency physician for the past 30 years has had its excitement, but this day started out as an ordinary one at the small rural hospital one-and-a-half hours from my home.
It was 12:30 p.m. when this text came across my phone from my husband: “Not feeling great. Does this look OK? Call when you can.” There was an attached pdf file labeled ECG. (See photo.)
My 55-year-old husband had never told me that he didn't feel well, even when he was obviously ill. Needless to say, I was concerned and took a moment away from my patients to open the attachment. The single lead I tracing clearly showing ST depression put me in hypermode.
I immediately called him to inquire about his symptoms, and he said he was just feeling a cramp in his back. (A reminder that cardiac pain can be any pain from nose to navel.) He had been playing pickleball several times a week, and this day had been especially hot. He said he had had no pain during exertion, but had a cramping sensation in his upper back on the way home. He said it felt just like the muscle cramps he frequently got in his legs, which it was in a way.
He had no chest pain, shortness of breath, nausea, vomiting, arm pain, lightheadedness, or palpitations. He was, of course, sweating because of the heat index and thought nothing of it. He said he had laid on the floor in an attempt to alleviate the persistent pain, and that got my attention.
He had purchased the newest edition of the Apple Watch Series 4 with ECG capability two weeks before and thought enough to obtain a tracing. He had no history of any heart problems or previous ECG changes, and given the presentation of pain following strenuous exercise, it was clear to me that the ST depression likely represented acute ischemia and he needed to go directly to the cath lab. I called to speak with the emergency physician, who was kind enough to allow me to send the pdf.
My husband was taken right back, and he described his emergency team as a pit crew. The ECG confirmed my suspicion of a STEMI (see photo), and he was off to the cath lab 10 minutes later for his stent. He had a commendable door-to-balloon time of 33 minutes.
As a medical director, I had to attend all those tedious meetings as we worked to eliminate minutes from door-to-balloon time after immediate PCI became the treatment of choice for STEMI. Now I was grateful for that work. I think my husband's time to reperfusion was shortened because the tracing told me to send him directly to a hospital with cardiac catheterization capability, and I was able to forward it to the EP there who could assemble his care team more quickly.
I am thankful that he recognized that the cramp could be something serious and thought to use the Apple Watch's technology. He said the hardest part was sitting quietly while recording a clean tracing; it took him three tries before he had one without a lot of artifact.
His cath showed a 100% right coronary artery occlusion, which was opened by angioplasty and clot extraction. Two stents were then placed to cover the distance of the narrowing. His post-procedure ejection fraction was 55%, and he has done well working through cardiac rehab.
Saving Patient Lives
We told our story to medical staff, family, and friends, and many were amazed at the availability of this technology. Two of our neighbors went immediately that day and purchased the watches, and several other friends have since done the same. I hope there will be a more general application of this amazing technology, but there are barriers to its use.
As my husband's cardiologist said, “Let me get this straight: Buy an Apple Watch, marry an emergency physician, survive a heart attack. Got it.” The application was designed to detect atrial fibrillation, and I have treated several patients with AFib RVR, who presented with, “My Apple Watch told me I was in AFib.”
I understand Apple's reluctance to promote the early detection of myocardial ischemia as a feature of the watch, but I see an immediate benefit for those with the skills to interpret the tracings. During in-flight medical emergencies, for example, where there is typically limited or no equipment available, this technology could provide important data for those attending the patient. I only realized several days after the dust (and my head) had cleared from the initial shock that my husband could have sent various leads just by transferring the watch to other limbs or placing it on several locations across his chest to obtain precordial tracings.
I credit the Apple Watch for its part in improving my husband's outcome. An event like this has a way of reordering one's priorities and imposing time for reflection. The thing that has stuck with me is how exciting it is be a physician in this time when all around us are medical technologies being developed at light speed that will make our lives and our patients' safer.
Dr. Eipperthas worked as an emergency physician in the Cincinnati area since 1992. She served 11 years as a critical care physician on the sidelines with the Cincinnati Bengals, but recently moved to a rural practice in southeastern Ohio where she said there is more time for communicating with patients and their families, perfecting the art of medical translation, and fielding questions about her husband and his Apple Watch MI.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.