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Why I Sent A Guy With A Normal EKG To The Cath Lab

I sent a guy with a normal EKG to the cath lab.  Let me tell you my side of the story.

Dude was minding his own business when he started having crushing, substernal chest pain.  I see dude by EMS about 45 minutes into his chest pain.  He’s had the usual: aspirin, 3 SL NTG’s an IV, a touch of MS (I can abbreviate here, as it’s not a medical record) and is continuing to have pain.

He describes it like you’d expect (elephants have a bad rep in the ED), and looks ill.  Frankly, he looks like a guy having an MI.  Sweaty, pale, uncomfortable, restless but not that ‘I’ve torn my aorta’ look.  The having an MI look.

Every EM doc knows the look.  I didn’t ask about risk factors.

On to the proof: the EKG.  EMS EKG: normal.  ?What?  Yeah, maybe there’s some anterior J-point elevation, but not much else.  Our EKG: Normal. Read more »

*This blog post was originally published at GruntDoc*

Defensive Medicine: Fear Of Law Suit Or Fear Of Being Wrong?

A thoughtful and (dare I say it) balanced look at medical malpractice in today’s NYT:

Malpractice System Breeds More Waste in Medicine – NYTimes.com

The debate over medical malpractice can often seem theological. On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive. On the other side are those liberals who see malpractice reform as another Republican conspiracy to shift attention from the real problem. [...]
The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.

The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.

Read more »

*This blog post was originally published at Movin' Meat*

From The Heart: A Christmas Story

By Alan Dappen, MD

Twas days before Christmas and all through the house
The doctor was pacing, not telling his spouse.
“It can’t be my heart for it’s healthy and strong;  
I exercise, eat right and do nothing wrong.
I’m hurting, I’m worried, have lingering doubt
I guess that I really should check this thing out.”

I did and the doc said, “Sadly it’s true,
That nobody’s perfect and that includes you…”

So starts my tale about life’s infinite ironies. This past week, I, “the doctor,” became “the patient.” My story is classic, mundane, full of denial, of physician and male hubris that it merits telling again. Like Christmas tales, there are stories that are told over and over again hoping that lessons will be learned, knowing they might not. I was lucky. I was granted a pass from catastrophe and this favor was handed to me by my medical colleagues and all who supported me.

My story began six months ago while playing doubles tennis with friends.  Suddenly I felt the classic symptoms of chest pain. “This is ‘textbook’ heart pain,” I thought. “A squeezing/pressure sensation dead center in the chest.” Running for shots made the pain worse and stalling between points helped. My friends soon noticed a change in my behavior.

To my chagrin, they refused to keep playing. Instead, they wanted to call for help. Indignant, I informed them that the chest pain was caused by my binge-eating potato chips before the match – a fact only a doctor could know.  The sweating was clearly from playing. I was younger and healthier than anyone there.  The pain subsided while we relaxed and joked about “the silly doctor who thinks he doesn’t need help.”

In the next week, the discomfort returned often when I exercised, which I regularly do, including jogging, biking, swimming, and weekly ice hockey and tennis matches. Every activity provoked the pain. “Stupid acid reflux!”  I thought, contemplating giving up my favorite vice –coffee.  Keeping the secret from my wife was easy; she was traveling for business.

Over the next several days I started aspirin, checked my blood pressure (BP) regularly, drew my cholesterol, rechecked my weight. All were normal. Finally I plugged myself into an electrocardiogram (EKG), with the “nonspecific changes” results not reassuring me. I went to a colleague for a stress echocardiogram, and passed. “See!” I congratulated myself. “It was just reflux.”

For five months, all went well, with no memorable pain. But on December 10 “the reflux” came back. On the sly, I restarted aspirin, pulled out the home BP monitor again, and considered cholesterol-lowering drugs “just in case.”

Saturday night into early Sunday morning I played ice hockey. This time the pain was worse.  With my team short on substitutes, I played the entire game.  I dropped into bed exhausted and pain free at 2 a.m., only to be nagged throughout the night with persistent discomfort. I nearly slept through a morning meeting with a medical colleague at Starbucks. To avoid increasing my “reflux” pain, I passed on coffee.

By noon, a feeling of overwhelming inadequacy enveloped me. I withdrew, and my wife, Sara, asked what was wrong. I had to confess to her – and myself – of the reality of the pain in my chest. Sara coaxed my answers from me with non-judgmental techniques learned from years of experience.

“What advice would you give a patient calling you with these symptoms?” she asked.
“If it was anyone else, I’d send them to the ER,” I responded, wanting to stall longer. “I want to check my EKG at the office.”

Once there, she helped me with the wires, hooked up the machine.  She turned the screen toward me with the interpretation to read: “anterior myocardial infarction, age undetermined, ST- T wave changes lateral leads suggestive of ischemia.”

“Stupid machine,” I thought, “there must be something wrong with it.” I insisted Sara redo the EKG. The second reading was the same.  I leaned my head into my hand, not willing to believe what I saw.  “Sara, let’s do it one more time…please.”

She asked, “What would you tell your patient to do?”

“Call 911.”  I said quietly. The words hung there.  At last I handed her the keys, saying, “Drive me to the ER.”

So went the gradual erosion of my denial, emerging into a new reckoning. After a catheterization, the cardiologist used a stent to open my 95% blocked coronary artery. Despite all I did to ruin my chances, modern medicine delivered me a “healthy” heart. This holiday season I got a second chance.

Eating healthy, exercising regularly, sleeping well, being happy, praying regularly, even being a doctor does not save us from the inevitable… sooner or later we are all patients. Healthcare is a critical social asset that must be done right, must be affordable, must offer as many of us in America a second, even a third chance. May we all be thoughtful and willing to compromise to achieve this end.  Amen.

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