A patient's tragic tale didn't add up

The patient, in her early 20s, had red hair, pretty features and a disarming sincerity. When I first met her in the cardiac care unit, she told me that she had been on a flight from Helsinki, Finland, to Detroit, where her grandmother lived, when she developed palpitations and dizziness. Finding her pale and sweaty, a flight attendant had taken her to the back of the plane to lie down. The plane's automatic external defibrillator, she said, had revealed a potentially life-threatening arrhythmia.

When the plane landed at LaGuardia Airport for a short layover, the patient said, she hailed a taxi and asked the driver to take her to the nearest hospital. The airline had arranged for an ambulance, she said, but she had refused it. "They wanted three paramedics in the ambulance instead of two," she explained. "I don't have that kind of money." I told her that given the nature of the emergency, she would not have been responsible for the charges. "See, I didn't know that," she replied matter-of-factly.

She went to Flushing Hospital Medical Center because that is where the taxi driver took his own family when they were sick. Doctors there, after hearing her history, inserted a central intravenous line below her collarbone. They gave her some heart-stabilizing medications, monitored her for several hours and then transferred her to my hospital for further evaluation.

I asked about her medical history. She told me that her family suffered from an unknown blood disorder that caused premature heart attacks. Her mother had died at age 33. Three maternal uncles had died in their 30s and 40s. Her cousins were all dead. The first, Sarah, died at age 18. Sarah's brother died at age 22. John, Josh and Matthew all died in their 20s. Apart from her grandmother, my patient was the last one in her immediate family who was still alive.

I inquired about the medical work-up in Finland. She told me she had had a heart attack in her early 20s, necessitating angioplasty of a major coronary artery. She couldn't recall whether she had ever undergone an electrophysiology study. When I asked for permission to obtain medical records from hospitals in Helsinki, she refused. "There are confidentiality issues," she explained.

I performed a physical exam. Her blood pressure was 120/80: normal. Her lungs sounded clear, and her heartbeat was regular and normal. I noticed a long scar along the right side of her back, where, she told me, she had previously had lung surgery. "A blood clot was choking off part of my lung," she explained, another consequence of the blood disorder.