Precordial Thump

Working as a senior resident at our Level I Trauma Center, I was caring for a 50’s year old male patient who presented with chest pain. He had a very concerning story for ACS (Acute Coronary Syndrome) with numerous risk factors such as diabetes, hypertension, hyperlipidemia. His EKG did show some ST changes, but not enough to qualify for a cath lab activation. Within 5 minutes of being in the department, I had already paged cardiology. The interventional fellow called me back and reviewed his EKG on the EMR. They were unimpressed and asked that we wait for his troponin to return. As I was ordering a heparin bolus and drip, I overhead a tele alarm and looked up to see a concerning rhythm on the main monitor in front of the resident’s documentation area. Thankfully, this patient was in Room 10, which was right behind my desk. As I entered his room, I saw V-fib on his monitor and found him pulseless and apneic. I hit the code button above his bed and, without thinking, I punched him as hard as I could with the ulnar aspect of my closed fist. I started CPR and waited for the team to arrive. Within seconds, the code cart was at his bedside. We attached pads and shocked him with 200J. I continued CPR and on the first pulse check, he was back in a sinus rhythm. He was awake but still looked like death. I looked up to see his 10-year-old daughter standing at his bedside. She was trembling uncontrollably and twice as pale as her father.

I left his room and called the fellow back. They took the patient immediately to the cath lab. The fellow came down two hours later and told me he had a 100% occlusion of the LAD that was stented and he was doing well. I went home that night riding the high of a lifetime. This was one of the cases where I actually felt like my actions saved a life. It’s funny to think that ER physicians don’t often save lives, but it’s true. While we make a difference in thousands of lives every year, seldom are we in the right place at the right time to save a life. I continued to think about that case countless times over the following years. I have since graduated from residency and work part-time at that same hospital. I am still friends with the attending (Dr. AE) who was on that day 5 years previously. I have often reminded Dr. AE of my precordial thump. I would joke, stating that it was my Thor-like strength that revived the patient. With a fist like Mjölnir, I struck life back into his dead body. I was son of Odin. He would laugh alongside me, but never corrected me in my thinking.

Five years after graduating from residency I was drinking with that same attending at a bar. We ordered whiskeys and were waiting for them to arrive. We again started talking about that 50’s year old man who almost died. This time, however, he corrected me. We discussed how it wasn’t the precordial thump that saved him, but the electrical cardioversion. I laughed it off and showed him my bicep, again joking that it was my hero strength that saved him.  Dr. AE then got very serious and told me that there had been a complaint filed about his care. His 10-year-old daughter thought I was frustrated at losing her father and punched him out of anger. She had told her mother, who filed the complaint. Dr. AE had to go to a multi-disciplinary meeting and describe that his senior resident was performing the now out-dated practice of the precordial thump. No charges were filed and the family was happy with the explanation (they were also elated at the fact that he walked out of the hospital neurologically intact 4 days later).

I would be lying if I said I hadn’t thought about Dr. AE and my conversation at that bar innumerous times over the following years. I had been so enthralled at my abilities to save this man’s life but didn’t think to take the time to explain his care to the family. How could I have been so stupid? Since that night in the bar many years ago, I have come to several conclusions. Firstly, what we do is a gift. We may take it for granted, but caring for human beings and their families is an honor and we are lucky to be given the chance to do so. Secondly, we must take the time to explain what we are doing to those who are present. This is the worst day of their lives. They deserve to know what we are doing and why. Thirdly, the bonds we make in medicine last forever. Those who we work with are family. They laugh with us and cry with us. They have felt the power of medicine and understand that with great power comes great responsibility (sorry for the superhero references here people).

My final realization came to me only recently. Dr. AE didn’t tell me of the family’s complaint until recently. He saw an enthusiastic young physician who was excited to have saved a life. He knew that bringing up the complaint would only crush me. I was too young in my career to handle it. He was there to pick up the pieces like every attending should be. He was my mentor and my friend.

I have since stopped performing precordial thumps. Like much of medicine, this practice has been proven to be useless. I now take more time to involve those who are closest to my patients. I also still drink with Dr. AE. And yes, we still joke about that day. Sometimes all we can do is joke. We ride the highs so that we can survive the lows. Medicine can be exciting, but it is also unforgiving and can bring you to your knees.

Speaking of superheroes, I will leave you all with a quote by the late Dr. Peter Rosen. He was a superhero and changed the face of this specialty. He once said, “I did something useful with my life. I worked in the ER.”

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Dr Erik Adler

Emergency Medicine Doctor. Trained in Colorado. Hobbies include snowboarding, mountain biking, camping, and hanging out with his wife, daughter, and two dogs.