Unbelievable
A 60 year old gentleman presented to the ER with shortness of breath which he described as "gasping for air," intermittent palpitations, and a vague heaviness in his chest of about 3 hours duration. His symptoms had resolved by the time he arrived in the ER, and his vital signs and ECG on arrival were normal. Fortunately, he already had an established Cardiologist at our facility. Once the initial set of cardiac enzymes came back negative, I asked the unit secretary to call him. For admission, of course.
The patient had been worked up extensively in the past for paroxysmal atrial fibrillation, and his cardiac catheterization two years ago at another facility reportedly showed normal coronary arteries. Nonetheless, it seemed like a straightforward admission, particularly at 4 am. Hardly anyone is awake enough, hardheaded enough, or foolish enough to argue against such an admission at 4 am. So I thought.
"I have a 60 year old man with chest pain" is usually all you have to say, and it's a done deal. That is the presentation that is considered the most slam-dunk of all admissions. The no-brainer. The Best Possible Patient for an ER doc to ever have: a level 5 with a cookie-cutter workup and no controversy except "does he need the ICU or can he go to telemetry?" So I expected.
Instead, I received a 10 minute lecture from a Cardiologist about the evaluation of chest pain in the Emergency Department. At 4 am.
"You drew cardiac enzymes? Why would you do THAT? You don't think he's having an infarction do you? DO YOU? What do you think the warranty should be on a normal heart catheterization? You guys draw way too many enzymes!!!!!!!!"
"Not everyone with chest pain is having an infarction. Don't you ever THINK? Aren't you a doctor? Don't you ever try to figure out what else they might have? A robot could just draw enzymes and admit everyone to the chest pain unit."
And so on. As I sipped my coffee and listened to his rant, I wondered how many Cafe Grandes he had already consumed this morning to get him so agitated.
"What is it going to take to make you comfortable that he can go home?" he asked.
"An observation bed and a negative stress test," I offered hopefully.
"Well, I'm not going to do that. I just cathed him. He's probably just having intermittent arrhythmias. Call his electrophysiologist and see if he wants to adjust his medication. Is the patient comfortable going home?"
I didn't know. The thought never crossed my mind to even ask him.
The electrophysiologist didn't want to adjust the medications. The patient decided to follow the recommendation of his Cardiologist. I offered to find another Cardiologist to admit him, but the patient declined. He felt better.
I felt worse.
The patient had been worked up extensively in the past for paroxysmal atrial fibrillation, and his cardiac catheterization two years ago at another facility reportedly showed normal coronary arteries. Nonetheless, it seemed like a straightforward admission, particularly at 4 am. Hardly anyone is awake enough, hardheaded enough, or foolish enough to argue against such an admission at 4 am. So I thought.
"I have a 60 year old man with chest pain" is usually all you have to say, and it's a done deal. That is the presentation that is considered the most slam-dunk of all admissions. The no-brainer. The Best Possible Patient for an ER doc to ever have: a level 5 with a cookie-cutter workup and no controversy except "does he need the ICU or can he go to telemetry?" So I expected.
Instead, I received a 10 minute lecture from a Cardiologist about the evaluation of chest pain in the Emergency Department. At 4 am.
"You drew cardiac enzymes? Why would you do THAT? You don't think he's having an infarction do you? DO YOU? What do you think the warranty should be on a normal heart catheterization? You guys draw way too many enzymes!!!!!!!!""Not everyone with chest pain is having an infarction. Don't you ever THINK? Aren't you a doctor? Don't you ever try to figure out what else they might have? A robot could just draw enzymes and admit everyone to the chest pain unit."
And so on. As I sipped my coffee and listened to his rant, I wondered how many Cafe Grandes he had already consumed this morning to get him so agitated.
"What is it going to take to make you comfortable that he can go home?" he asked.
"An observation bed and a negative stress test," I offered hopefully.
"Well, I'm not going to do that. I just cathed him. He's probably just having intermittent arrhythmias. Call his electrophysiologist and see if he wants to adjust his medication. Is the patient comfortable going home?"
I didn't know. The thought never crossed my mind to even ask him.
The electrophysiologist didn't want to adjust the medications. The patient decided to follow the recommendation of his Cardiologist. I offered to find another Cardiologist to admit him, but the patient declined. He felt better.
I felt worse.
Labels: patients
posted by scalpel at 2:03 PM
22 Comments:
You did everything right. Hope you documented his doc's refusal to admit against your judgement.
Betcha his cardiologist was thinking of one thing: "Will insurance reimburse for caution?"
laziness... the cardinal sin of medicine, and why WE run the CPU at the Mecca.
In reality (which has nothing to do with American Medicine) the patient probably didn't need a medical admission, but we can't practice medicine for the patients in this country, we have to practice it for the lawyers. This patient would have been sent home in non-litigous healthcare systems, and done fine. I admit 20 year olds with chest pain (Usually after I CT-PA them) but give me a job in Canada, and I send home the 60 year old so he can follow up with his doc.
If the cardiologist had come in and evaluated the patient himself, would you feel any better about him? Or would you continue to feel about him the way that you and your EM colleagues feel about me when I go into the ED to evaluate a patient?
Of course, you are right in this case, and he is wrong. But I wish you hadn't used the expressions "slam dunk", and "cookie cutter". These are precisely the approaches that cause the problems for my patients and me. For example:
2 year-old with vomiting and diarrhea, and good history for infectious gastro. 5-10% dehydration on exam. Line, labs, and KUB? Why? Especially as the best EBM counsels against it?
With your 60 year-old with chest pain, it's a different story. MI until proven otherwise.
best,
Flea
word verification = litrz, what crack mom's have, or the detritus in a big-city ED waiting room
I only felt upset with him because of the condescending manner that he talked to me, and his apparent lack of understanding of the practice of emergency medicine. I agree that he was probably right, because if I really disagreed I would have been more forceful in my argument.
I never mind when a doc comes to see his own patients in the ER. In fact, I respect them most of all. There just aren't that many who still do that.
My cookie cutter treatment for kids with gastroenteritis involves oral Zofran and a pedialyte popsicle, not an IV or x-ray.
I'd be happy to have you in the ED at my hospital. Keep up the good work!
The long island nurse said it all. You did everything right. Last month my friend's husband (my friend is a hospital unit secretary) was having chest, and he was discharged from our local ER. My friend was very upset. She said she knew that something was wrong, and while she was driving her husband to another hospital, he had a major MI in the car. We must always listen to our inner voice when it's telling us that something is wrong with our patient.
MJ
Why did the cardiologist care whether or not you did an enzyme test? He wasn't paying for the damn thing, was he?
What a dick.
I have no idea what the "warranty" is on a cardiac cath. All I know is my husband had 5 vessel bypass less than 6 weeks after a normal stress so I'm less than 100% impressed with them and yes, I know his experience is unusual.
The cardiologist must know this particular patient really well and obviously the patient trusts him.
I've seen a 30 year old man who was having an ST-elevation MI 3 days after his "normal" stress test.
I've been sued after discharging a 50 year old woman with mitral valve prolapse and symptomatic premature ventricular contractions whose last normal cath (of three) was 6 months prior to her visit with me (and 6 months and 2 hours prior to her untimely death from cardiac arrest). She had a 95 % left main coronary artery blockage on her autopsy.
So I'm not much impressed with the warranty on heart catheterizations or stress tests.
So here's the problem with the American Healthcare system. We all have stories of "that guy who had a stress or a cath and dropped dead 3 weeks later". But because of these rare examples, or what we see on "Oprah", we over-treat and admit everyone to cover our Butts. There is so much momentum to admitting everyone "just in case" that if we eventually un-did the Lawsuit mentality we would have trouble practicing common sense medicine, becuase we are so far from it now.
"I've seen a 30 year old man who was having an ST-elevation MI 3 days after his "normal" stress test."
"So I'm not much impressed with the warranty on heart catheterizations or stress tests."
Scalpel there is a HUGE difference between a negative "stress test" (Bruce protocol I assume) and a recent negative cardiac catheterization (though two plus years since the cath in a patient with classic symptoms would catch my attention). Sorry the guy was a prick, but I can't tell you how many times I have had to go to the ER to discharge recently cath'd patients because the ER doc was afraid of his own shadow. I know it is the legalistic BS society we live in, but the CYA takes away from the patients who really need my care.
"Scalpel there is a HUGE difference between a negative "stress test" (Bruce protocol I assume) and a recent negative cardiac catheterization"
Perhaps. Perhaps not. As with many things, huge is in the eye of the beholder. ;]
See my latest post.
Scalpel:
re: "Perhaps. Perhaps not. As with many things, huge is in the eye of the beholder. ;]"
I am sorry but I don't understand. With cardiac catheterization there is visualization of the coronary arteries with relative (or lack of) stenosis and/or occlusion. There is no "eye of the beholder". There either is or is not stenosis/occlusion. If you think a negative bruce protocol stress test and a clean coronary catheterization results in the same amount of uncertainity....you need to read up on your cardiology.
I was pretty cocksure about my Cardiology knowledge until I saw the patient in the post I referenced above. Despite her recently confirmed "normal coronary arteries" she developed a 95% left main lesion six months later, which contributed to the apparently ischemic ventricular arrhythmia which killed her.
I know that it shouldn't have happened, but it did. You can live and die by statistics all you want, but I'm not going to subject any more of MY patients to the numbers game.
Oh, yeah....and autopsy provides even greater visualization than cardiac catheterization.
Scalpel:
Look I don't care if you don't believe me. Talk with your cardiology collegues about cardiac catheterization and the rates it picks up CAD. If you can't understand that freshly cath'd patients are lower risk (which again this patient may not have fallen into) than you might as well admit every single patient that walks through your ED. Chest pain, R/O MI, HA, R/O meningitis or SAH, kiddies with fever, just in case etc etc etc. We can go on and on. If you admit everyone, you may not get sued. But I within two years, every subspecialist would back out of call (I know I would).
I understand and agree that cath is more sensitive and specific than EST + MIBI in the evaluation of CAD.
I don't agree that a normal cath gives a failsafe warranty (of any duration) against SCD or MI. Most MIs occur from what were considered to be "noncritical" lesions. A cath that shows "only" mild diffuse disease or "only" a minor blockage is not going to affect my decision regarding admission of a symptomatic patient.
As I mentioned in the "second lawsuit" post, the risk tolerance of a Cardiologist is higher than that of an ER doc. How many missed MIs are YOU comfortable with?
I never said it was a "failsafe warranty". The only certain thing in life is that none of us is getting out alive:). If you want to admit everything that could possible go wrong than be my guest. I will thank my lucky stars I work with ER docs who's first thought isn't CYA. I have seen first-hand excessive CYA has resulted in loss of whole subspecialties on the call schedule. You tell me is that better?
goodnight.
If you were able to compare me to my colleagues, you would find that I am far from the most risk-averse among us. When it comes to chest pain, however, it's difficult to justify trying to be a hero. Our tests to stratify risk just aren't that good, and chest pain is a warning sign of what often kills people who come to ERs.
It all depends where you draw the line. I personally don't tend to admit the 25 year old female with costochondritis if her ECG, enzymes, and CT are negative. Some ER docs do. Maybe most do, but I doubt it. I doubt you will even see such a patient, but they are being admitted all over the country as we speak.
The Chief of Cardiology at my last facility laughed at me and hung up when I tried to admit such a patient early on in my career. It is cheaper to admit 1000 such patients for observation than to pay one lawsuit, however.
Plaque ruture still can be the cause of an acute MI, even if there was 'normal' cath 2 years ago. That's why you can have a normal stress test 2 weeks ago and a 95% left main today.
And apart from that, the PND ("waking up gasping for air") is congestive heart failure until proven otherwise.
A work up was in order.
I've recently had a similar experience, albeit with a family practice attending. A 90 year old female with HTN,DM, and both parents with CAD, presents with palpitations and chest pain for 3 days, seen in the ED last week for same. Last week, cursory work up done and patient sent home. (Personally, I wished she would have stayed that visit.) Anyway, attending began to lecture me about treating patient's symptoms, which I did. She was dehydrated and her heart rate was 121 initially, but improved with fluids. I did some other basic workup stuff: CXR (neg) and Head CT (my attending wanted this, also neg). I was told to call back to the primary attending when workup was completed. I did and then received a lecture of that this is probaly nothing and she does not need admission. "So this patient presents with I need to be admitted?" was the response I got. I reminded him of her risk factors, his reply was that she has those risk factors everyday. He finally stated he did not want to argue any further and would admit.
Personally, I do not think I did anything wrong and was going to admit to a cardiologist if the primary did not admit. The patient is 90 and presented a week earlier with same symptoms, she went to see her primary the day after that visit, and zantac was prescribed.
I guess everyone has their own definition of risk tolerance. If this was my grandmother, I would want something done.
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