One afternoon a few years back, my second patient of the shift was a 60-year-old female, June P, who had an extensive ED resume. Over the years, she had been seen frequently by all of my partners and her internist Dr. K, with varying complaints, including chest pain, abdominal pain and headache – often without a clear diagnosis. She had numerous workups including thallium stress tests, CT scans of abdomen and head, and enough diagnostic blood drawn to feed the cast of two more Twilight sequels. That day, her triage complaint was chest pain.

I picked up the chart with the anticipatory annoyance that often overtakes docs who assume they won’t be able to constructively have a diagnosis for a “frequent flyer.” I obtained her exhaustive history of chest pain and toward the end noted that this pain was different than her previous episodes. It was higher in her chest and seemed to be worse with exertion.

First troponin and EKG were unremarkable. I called Dr. K to admit for non-specific chest pain. He told me she’s a bit of a hysteric and he was reluctant to admit her but he knew my mantra on these patients: if you want to discharge her, please come in and arrange it. He said he’d be along to see her after completing several more patients on rounds.

About 15 minutes after that call, she went unconscious and was in v fib. I applied the paddles, and first shock converted her to NSR. She awoke a bit confused but alert and stable. Amiodarone was started and she was moved to a critical care space. A few minutes later, Dr. K arrived at the nurse’s station, and I detailed the episode. He paused and said, “Whatever you do don’t tell her what happened. She’ll just blow it out of proportion.”

Later that day, we had another code, an 82-year-old man collapsing on the green after sinking a putt on the 18th hole at the local municipal course across the street from the hospital. Considering 33 minutes of asystole via EMS, I elected to pronounce him DOA. As I looked around at the male tech and two female nurses assisting me, I said, “At least this man got his second choice of where he wanted to be when he died.”

The younger nurse, maybe 20 and recently graduated, naively asked, “What was his first choice?” I smiled and the others in the room began to laugh as she blushed.

It always fascinates me how we are wired to see the different meaning of an event. A recurring theme in my column relates to how the EP can be the central player in complex situations where multiple specialists may assume the roles of the blind men trying to examine an elephant and describe it based on an individual piece of anatomy. With ACS, EPs can often see a picture beyond a heart and a fetus.

There’s an old Hindu teaching: within a crowd watching the procession of a living saint, there stood a young monk and a pickpocket. As the saint passed, the monk saw a link to enlightenment, happiness and contentment, the pickpocket only saw the saint’s pocket.

This month’s article on “ACS in the Pregnant Patient” focuses on bridging essential clinical care between obstetrics and cardiology. We hope this will aid the EP in acute care management and stimulate leadership in assuring that hospital protocols address this issue, allowing efficient, high quality care when these patients hit the ED.