Case 37
Alcohol use disorder and pacemaker replacement
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Brief Past Medical History
The patient was an elderly Caucasian man with alcohol use disorder and hypertension, status post coronary artery bypass graft surgery who had a pacemaker put in approximately two years prior.
Recent Events
Approximately 6 months prior, the patient developed a metallic taste in the mouth, prompting him to have his water supply evaluated.
Approximately 4 months prior, the patient went into renal failure, had a dialysis shunt put in and began dialysis.
Approximately 3 months prior, he fell off a chair, was admitted and found to have bulging discs.
The family remained concerned about the metallic taste, prompting evaluation of the pacemaker during the admission.
The hospital found it was “corroded.”
They removed the pacemaker and debrided the site.
At that time, a temporary external (replacement) pacemaker was placed.
The temporary pacemaker was left in place for three weeks.
The patient was hospitalized to exchange the temporary pacemaker with a permanent (internal) pacemaker.
He remained in the hospital for two weeks and then was discharged to rehab.
In rehab, he immediatedly decompensated, was re-admitted to the hospital and died.
He was thought to have had a heart attack in the two weeks prior to death.
The history is provided by the family.
Discussion Questions
1. Summarize the history.
2. Why were two pacemakers put in?
3. What do you think of the story that the metallic taste was due to a “corroded pacemaker”?
4. Why do you think the patient had a metallic taste?
5. What evidence in the history supports your answer?
6. What is the difference between a history provided by the family and a history provided in a medical record?
7. How strongly do you feel the family believed the pacemaker had corroded? What’s your evidence?
8. Do you think each of the patient’s procedures (removal and replacement of pacemaker) was necessary? Why or why not?
9. What do you think is the likelihood there was a medical error in this case?
10. Do you there any part of the history might have been inaccurate?
11. What are early symptoms of kidney failure?
12. Do you see any ethical considerations in this case so far?
13. Some families will pressure clinicians to take certain steps. Some clinicians can pressure themselves to comply with what they think a family wants. What kinds of threats or pressures can clinicians experience from families? Alternatively, what kinds of internal pressures can clinicians experience to “please” a family or comply with what they think the family wants? If these internal or external pressures result in an unnecessary procedure, where is the breakdown in training? How can clinicians strengthen themselves in these situations? How might these issues apply in this case?
14. How might the second surgery have been avoided while also addressing the family’s concerns about the metallic taste?