Seems like I’ve been on a real run of chest pain patients lately. Which is fine — it’s part of the gig. I did have a very interesting pair the other night. They were seen in sequence, right next to one another, in room 7 and room 8. They were both totally healthy women in their mid-fifties. And they were both over-the-edge, crazy, crawling-out-of-the-gurney anxious.
Anxiety is an awful red herring in the work-up of chest pain. People who are having an anxiety attack often if not always manifest some chest pain (pressure, tightness, whatever) as a prominent symptom of their anxiety. On the other hand, someone having a heart attack who is experiencing chest pain will also be anxious — and for good reason!
I probably see ten patients with simple anxiety for every one patient I see with “real” chest pain, so just by probabilities and pattern recognition an ER doc might easily dismiss the anxiety cases, just blow them off. Which would be a real mistake, since when you blow off these cases you absolutely will miss things.
So you have to pick and choose what you will work up and how far you will chase the zebras. Most of this you are going to do by Bayesian analysis: looking at the patient’s age and general state of health, incorporating some basic data like ECG, blood tests, and how well the patient’s history fits with classic patterns of disease. So the 25-year old who is hyperventilating and hysterical because her boyfriend was hitting on another girl probably will get minimal work-up, whereas the septuagenarian with a history of diabetes who has an elephant standing on his chest is a slam-dunk admit.
Those are the easy cases — the extremes of probability. We joke that it’s the cases in the middle that are why we get paid the big bucks. These two cases were real doozies as far as figuring out what to do with them. The first patient was, as I mentioned, about 55 and completely healthy. She had this sharp pain that had been migrating all over her chest for several days. It was not exertional, nor was it associated with shortness of breath, fever, cough, etc. She sometimes felt it between her shoulder blades, and sometimes it was worse with a deep breath or movement. It was a very fleeting pain, and clearly seemed related to some situational stresses she was having at work.
ECG, labs and chest x-ray were completely normal, as was her exam. The pain in the back did catch my attention: that can be a historical element associated with Aortic Dissections, a vascular catastrophe in which the aorta basically tears itself apart. So I did a CT scan on her to evaluate the aorta, which was normal. After a standard cardiac observation was completed, she went home with some xanax.
The second patient was even stranger in her presentation. Her complaint was listed on the triage note as “chest pain” but she started telling me about this tooth that had been bothering her, and she had bitten down on something and it had gotten much worse. The tooth pain was radiating over the top of her head and also down her neck into her shoulder and back. She was so anxious that she could barely get out a coherent sentence and she would hyperventilate herself into vomiting. She complained that after vomiting she felt a burning pain in her mid-chest, which was why she was billed as “chest pain.” It sounded pretty clearly esophageal.
As I took in this history, I wondered whether I should even work this up at all as chest pain, but the ECG and troponin had already been done (from triage) so I decided to roll with it. She also had a normal exam, and felt much better after some ativan. She slept through most of the night shift after that. I would rouse her from time to time, and other than a deep conviction that she had something terribly wrong, she actually seemed to feel much better. Never complained of any more pain. I considered scanning her, but mindful of the one “wasted” un-indicated CT I had just done on room 7, I was feeling a little gun-shy. I hate to shotgun tests, and this one seemed even less useful than the previous. Eventually, I figured that “you just cannot scan everybody,” and I put her in for the cardiac observation and discharge protocol, like the other woman.
By now, you probably can see where this is going. The next morning, when the patient’s observation period was done and she was set for discharge, she still didn’t feel right. Fortunately, an alert nurse spoke up and asked the new doctor on shift to re-evaluate the patient. He did, and really didn’t see anything much different, but out of a general sense of “I should probably do something,” he ordered a CT scan. And it showed:and
Yes, she had a Type A aortic dissection. Quite lethal when not treated. My partner reported that when he got the call from the radiologist, he got all sweaty and weak in the knees, it was so unexpected. Fortunately, the diagnosis was made and she went to the operating room for repair.
I’ve reviewed this case with our medical director, and his words were, “If I had taken care of this patient, she would be dead, because I doubt I would have even kept her for observation.” I don’t feel that it was a “miss” so much as a “Damn! Who’d've thunk it!” But still, the irony is maddening that I had two weird, anxious ladies and I picked the wrong one to scan. Crap.
There are a number of good learning points to take from this “near miss,” however.
1. Listen to the nurses. In my opinion, the hero of this story is Kathy, whose gut told her something was wrong and she brought it back to the doc. Woe unto the physician who blows off a nurse in this context. Whether or not you miss this case, if you disregard their advice, it’s all the less likely that he or she will be willing to stick their neck out and ask for a re-evaluation in the future. Nurses are so much closer to the patients that their input will save your ass if you’re smart enough to listen.
2. Beware sign-outs. Most ER docs are reluctant to get involved with a patient dispositioned by a previous doc. I get it — who wants to re-open Pandora’s box? But like it or not, they are your responsibility, and sometimes a fresh pair of eyes/ears are all that is needed to unlock the puzzle.
3. Keep an open mind. In this case, I admit that I was a little annoyed at this patient for her strange behavior, and just for the injustice of the universe at subjecting me to this sort of thing, and that bias would have made it difficult to really re-evaluate her with an open mind. I hope I could have, but I’ll never know in this case. My partner was able to do so, and that made the difference between getting the diagnosis and missing it.
4. Dissections are strange beasts. I’ve seen several now, and none of them had the classic presentation. I’ve learned to respect the isolated neck/back pain, and, on reflection, the incredible anxiety tone of almost every dissection I have seen is a remarkably consistent feature. Having a high index of suspicion is essential.
5. D-dimers are useful to screen for dissections. I did not originally order a d-dimer on this patient, but it was positive in retrospect. It appears that the majority of cases of dissections do have a positive d-dimer, which makes sense when you think about the physiology of the study. While the correlation does not seem to be strong enough to use d-dimer solely as a test to exclude dissection, it does appear to be useful as part of a rational strategy to determine which patients you might choose for further investigation.
*This blog post was originally published at Movin' Meat*