[sidebar]ILLUSTRATION/PAUL JUESTRICH; PHOTOs shutterstock.com[/sidebar]
Quick-thinking emergency physician becomes a fan’s health care safety net during a cardiac emergency at a hockey game
You never know when the person sitting a few rows from you might save your life.
Bill Streb, a 71-year-old retired Xerox Corporation executive, certainly didn’t expect to encounter a life-or-death situation when he decided to accompany his son to watch the Los Angeles Kings play the Anaheim Ducks in a preseason hockey game at the Staples Center. Mr. Streb, who describes himself as “the most healthy person in my family,” experienced a cardiopulmonary arrest during the third period of the game.
Fortunately for Mr. Streb, emergency physician Sujal Mandavia, MD, FACEP, group vice president at TeamHealth Emergency Medicine’s West Group in Glendale, California, and a faculty member at the University of Southern California in Los Angeles, was also attending the game. Dr. Mandavia noticed Mr. Streb’s cardiac distress and leapt into action, providing immediate medical attention and ensuring that Mr. Streb made it to the emergency department to receive lifesaving care.
Dr. Mandavia and Mr. Streb recently sat down with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, to talk about the events of the game and how the experience has affected their lives.
KK: Where were you sitting, Bill?
BS: I was sitting in the lower section, about 15 rows up from the ice. My son and his wife have season tickets. His wife was a bit under the weather, and they gave me a call and asked if I’d like to go instead.
KK: Sujal, where were you sitting in relation to Bill?
SM: I was behind Bill and over a few seats.
SM: Probably six or seven feet.
KK: Getting right to the point, Bill, you suffered a cardiopulmonary arrest. You said you would be regarded as the healthiest sibling in your family. How did you feel prior to this event? Did you have any suspicion?
BS: We had gone to Ventura, which is about 50 miles north of us, had a seafood lunch in which I ate things I usually don’t eat—New England–style clam chowder and fish and chips—and then had a normal dinner before going to the game. During the day, I did not feel anything. Somewhere in the beginning of the first period, I started getting what I thought was indigestion, though the indigestion was rather different than before because it was a lot stronger. In the break between the second and third period, I believe, I even went to the first-aid station and got some Tums for my stomach.
KK: Did you tell them that you had some indigestion and you needed Tums?
BS: Yes, I told them that I needed Tums before I signed something that said I received the Tums.
KK: So you’re receiving Tums, and in no way did you or anyone else feel like you had a heart condition that day?
BS: No way at all. I did speak with my oldest son, Michael, who was there with me, and I told him it was really stronger than I’ve ever experienced and a little bit higher. It was above the breast plate on the top part of the plate, and it went from one side all the way to the other. My normal heartburn would be mostly on the right side only. About nine years ago, I’d actually had enough of it that I went in and had a stress test. The stress test showed nothing at all.
KK: Bill, it’s human nature to explain away important symptoms because we don’t want anything bad to be happening. What led you to the point of saying, “Despite the fact that this is entirely different than anything I’ve experienced before, I’m going to decide that this is indigestion”?
BS: I actually never entertained that it was a heart issue at all. I’m sure if I had been home with my wife and told her what I had, she would have mentioned it. Every time I got indigestion, she said, “Are you sure it’s not your heart?” and I’d say, “Yeah, it’s the same as I always have. I’ll go take some medicine, and it’ll be done.”
KK: Did you just wake up at the hospital, or did your condition get worse and did you have other symptoms?
BS: I was watching the game. I was feeling my chest, and it was hurting. I was thinking that I was ready to go home, but let’s see how much time is left in the game. I looked up to the scoreboard, and I think it was 5:41. Almost immediately after noticing that, I began getting really lightheaded and dizzy. The next thing I knew, I woke up in the emergency room, and somebody was jamming something down my throat.
Bill just didn’t look right. At the time, he wasn’t unconscious, but I noticed that Bill’s son was speaking with him, and he wasn’t really responding….Then, about three to four seconds later, I looked back to Bill, and I saw him take an unusual agonal breath, and that’s when I knew what was going on there. —Sujal Mandavia, MD, FACEP
KK: Tell me, Sujal, how you were aware of this? Did you have to move the hot dog and popcorn vendors out of the way? How did this play out?
SM: I was at the game with my wife, Kelly. I looked over, and Bill just didn’t look right. At the time, he wasn’t unconscious, but I noticed that Bill’s son was speaking with him, and he wasn’t really responding. I don’t know if Michael noticed right away because he was still watching the game. Then, about three to four seconds later, I looked back to Bill, and I saw him take an unusual agonal breath, and that’s when I knew what was going on there. I jumped over the seats, and Michael and I got Bill down into the row, which was not easy. I probably have never given somebody bystander CPR, or CPR in a clinical setting, as quickly. We were in the right place at the right time, and there was recognition pre-arrest. You probably had CPR started within literally five to seven seconds of having your cardiac arrest.
KK: Did you do one rescue of CPR?
SM: I did one rescue of CPR. I’ll be honest; I probably went past 30 cycles before mouth-to-mouth was initiated because I knew that was not what was going to save Bill’s life at the time. There was a lot of attention, and there were other bystanders who were willing to help. What I needed to do was get them organized and into roles rather than let chaos occur. There was another bystander who was kind enough to help and did mouth-to-mouth while I continued the CPR. I called for the defibrillator right away, saw that it was v-fib, and shocked Bill. He actually got an immediate pulse back but did not regain consciousness.
KK: Let me ask you a personal question, Sujal. It sounds like you would prefer to do compressions over ventilations, and there was some reluctance to do mouth-to-mouth. Have you noticed this kind of hesitancy to commit in other relationships in your life?
SM: Now that Bill and I have gotten to know each other, I would do the mouth-to-mouth first and then start the compressions.
KK: Wow, that’s just weird. Bill, you couldn’t have had CPR done by a nicer guy.
BS: You are correct with that.
KK: How much care was delivered right there by the seats?
SM: We were working in between the seats and in between the rows where the popcorn falls.
KK: Was there an intubation attempt there, IV started, or medications? What else transpired right there at the facility?
SM: Bill was not intubated because he was actually breathing spontaneously; he had supplemental oxygen. An IV was started, but he didn’t actually require any medications because he did have a pulse at that time. I know that there is a paramedic unit within the stadium at every game, but that’s actually for the players. We had to wait for the emergency medical services [EMS] system to bring a paramedic unit that would transport and take care of Bill.
KK: Did the players stop?
SM: Play didn’t stop. Part of it was there wasn’t awareness, and unless there is an event on the ice, they won’t stop play.
KK: Sujal, did you go to the hospital with Bill?
SM: No, I didn’t. As you’ve been in these situations before, there were a lot of folks who got involved; there was a cardiologist and everyone else coming out of the woodwork. I knew that by that time, my work was done, and I felt comfortable with how Bill was going to be handed off to the EMS system.
KK: Sujal, how has this changed your life, if it did in any way?
SM: It has given me a whole different level of appreciation for the simple things we can do in cardiac arrest. The other piece of it is it truly humanized that experience in a way that I do not think I’ve had the opportunity to see before. Sometimes I’ve been able to follow up with patients, but I’ve never shared the connection with a patient in the way I have with Bill.
KK: Bill, what are a couple of ways that this has changed your outlook on things?
BS: There are a couple of things. One, my other sons are going to get some tests done with a little more urgency than they were before to make sure that they do not have similar problems. Prior to my event, the only person in the family who has had anything was my grandfather who, at 65, passed away from a heart attack. There is no other person with heart disease on either side of my family. I now look at every day as a gift because I had the v-fib once at the Staples Center and twice more in the emergency room, so I had it three times in total. My middle son says, “That makes you a zombie because you died three times.” My youngest son is actually a radiologist, and he says, “No, you didn’t die because death is brain death, and you didn’t come anywhere near that.” Now we look at every day with a little more appreciation.
KK: Some people talk about seeing lights, some say it’s physiologic, and some say it’s more spiritual. Did you have any of that experience?
BS: No. My sister asked if I had seen the light, and no, I did not see anything.
KK: Did you just have one stent, or did you have multiple stents?
BS: There were three places that were blocked. The stent was actually in the back side of the heart, and it was 100 percent occluded. I had one at 70 percent and another at 30 percent. We’ll see my cardiologist a week from Tuesday, and we are supposed to be scheduling a nuclear stress test to see if we need to do anything else with those other arteries.
KK: Did they stent the 70 percent lesion or not?
BS: No, just the 100 percent. Then they put me on high dosages of Lipitor, 80 mg, to see if we could drive it down and have the actual plaque dissolve.
KK: Sujal, when did you follow up with Bill?
SM: I had known where Bill was going to be transported because of the STEMI [ST elevation myocardial infarction] network that we have here in Los Angeles. I provided my contact number to one of the hospital administrators, who was able to pass it on to probably the nurse manager in the ICU, who then got it to Bill. Bill called me two or three days later.
KK: We [emergency medicine] are the safety net of the health care system. Sujal was your personal safety net.
BS: I need to know where he sits from now on when I go to the games.