It’s been a very busy week on call — made more challenging by getting over a cold. Like buses, I hadn’t had one for years and then two arrived in quick succession. The most irritating feature of this latest one was the nocturnal cough. It reached the point where I was (quite rightly) banished to the spare bedroom because I was keeping my wife awake. It has been a sharp reminder of something I normally take for granted: good health. When you’re used to feeling well, you don’t really notice it. But the moment it’s disrupted — even by something as mundane as a cold — you realise just how much it underpins everything. Exercise has been curtailed (although I’ve done bits and pieces and followed my own advice from a recent blog), but the biggest impact has been on sleep. I’ve always needed plenty of sleep, and coughing through the night — combined with being on call — has been challenging. Thankfully, over the past 48 hours, I’ve finally felt back to normal. Proper sleep. Proper exercise. A lovely round of golf with my son. A gym session this afternoon. Normal service resumed.
One case this week stood out — a reminder that no matter how long you’ve practised medicine, there will always be something new to learn.
I’ve been a doctor for over 25 years and have seen thousands of patients with collapses. This particular lady, in her 70s, was normally fit and active — a regular golfer. She had hypertension, which we were managing, and had developed some breathlessness. I prescribed what is, in effect, a weak diuretic — an excellent blood pressure medication. She subsequently experienced a couple of “funny turns,” significant enough that we implanted an implantable loop recorder. For context, in many patients we use ambulatory ECG monitoring, but where symptoms are severe or very sporadic, an implantable loop recorder — a small device placed under the skin with a battery lasting several years — can continuously monitor heart rhythm and automatically record events.
Two weeks later, she had what initially appeared to be a cardiac arrest at home. Her son performed CPR.
When she arrived in hospital, we urgently interrogated the loop recorder. Surprisingly, there was no evidence of any significant heart rhythm abnormality. At first, we questioned whether there might be a device malfunction — but there wasn’t.
Then her blood results came back.
Her sodium level was profoundly low — at a level where patients can become confused, have seizures, or even slip into a coma.
All diuretics can lower sodium. It’s not uncommon to see mild reductions. But in 25 years — and having prescribed diuretics many thousands of times — I have never seen such a precipitous drop in sodium. In retrospect, we do not believe she had a cardiac arrest at all. The episode was almost certainly a seizure caused by severe hyponatraemia (low sodium).
Brain imaging was normal. The heart rhythm was normal. The culprit was biochemical.
It was a powerful reminder: even after decades in medicine, you will encounter things you have not seen before. It was humbling — and educational. Avoiding that particular medication in her case in the future should prevent any recurrence.
The other striking theme this week has been the number of cases I’ve seen in which illicit drug use lay behind serious heart problems.
Cocaine, in particular, is profoundly toxic to the cardiovascular system. It can cause intense spasm of the coronary arteries — the blood vessels supplying the heart — abruptly cutting off blood flow and triggering a heart attack. It can also lead to coronary artery dissection, where the layers of the artery wall split apart. Both can be catastrophic, and tragically it may be the first time someone has taken the drug — or the thousandth. Intuitively I would have thought most cocaine use is in young adults, but I’ve seen two cases this week of people in their 50s coming to harm as a result of this drug.
We also continue to see the consequences of intravenous drug use. When drugs are injected — often into large veins in the groin — bacteria from the skin or from contaminated equipment can enter the bloodstream. Once circulating, these bacteria have a tendency to settle on heart valves, leading to infective endocarditis.
The valves can develop infected masses (vegetations), begin to leak severely, or be structurally destroyed altogether. Treatment is complex. High-dose intravenous antibiotics are required, often for weeks, and not infrequently surgery is needed to replace the damaged valve.
The difficulty, of course, is that if the underlying drug use continues, replacement valves can become re-infected. These infections can also throw off fragments — emboli — which travel elsewhere in the body. If the infection is on the right-hand side of the heart, these emboli often lodge in the lungs, causing infected clots. If on the left-hand side, they can travel to the brain, causing strokes or even encephalitis.
It is sobering medicine. Preventable disease, often in younger individuals, with consequences that can be life-altering or fatal.