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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.

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*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.

Latest Interviews

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It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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