Chest Pain and Answers

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“It started about an hour ago,” he stammered. Sweating profusely and taking deep, splinted breaths between sentences, he described a great chest pain story. “Yeah, I’d say it’s like a… a…a crushing pain right in the middle, like an elephant’s standing on me.” He asked for morphine, which I didn’t hesitate to provide. It wasn’t until about 15 minutes into his workup – when he began cursing at my suggestion that we “wait a minute before we give any more pain meds” – that I began to suspect this eloquent, well-dressed man might just be drug-seeking. A normal workup and a more detailed chart review confirmed this hunch, but also revealed something much more fascinating: Over the course of a few years, this man had been to our ED about a dozen times – an excellent actor, he repeated the same story each time. Yet each time he presented, a completely different plan was pursued. Same man, same story, same professed risk factors, completely different plans. My drug-seeking patient had inadvertently become his own randomized controlled study.

It’s just easier to blame lawyers and algorithms.

Character though he was, my patient didn’t reveal as much about himself as he did about the providers in our ED. During previous visits, one doctor admitted him to telemetry for serial troponins. Another discharged him after only an EKG, while yet another pursued ACS, an aortic dissection, and a PE. Often he got aspirin, sometimes aspirin and heparin, sometimes neither (to his credit, he did somehow always manage to get morphine). More interestingly, the more I thought about it, the more I realized none of these doctors were wrong. Each plan was defensible. Yet how could it be, in our era of litigious and evidence-based medicine, that something as straightforward as “chest pain, rule out ACS” could be pursued along so many different paths?

This question is even more remarkable in light of how constricted we often feel as emergency room doctors. The phrase “I don’t really want to chase X, but our hands are tied, so let’s just go ahead and order the Y,” is, unfortunately, part of our ED colloquium. We often lament the unnecessary workups we feel we have to pursue for patients perceived as low risk, but here I was staring at a patient’s chart that screamed, “Do what you want! Some very good doctors chose very different paths, and they all make sense!”

The answer, as I see it, is that our litigious and evidence-based instincts kick in only after we have already decided on the path we’re going to pursue. For example, once we’ve decided that we’re concerned about a PE, we feel compelled to pursue it. We complain about it, lament our disputatious society and medical literature, kick and scream, and curse the lawyers and algorithms. But if we were never really concerned about a PE to begin with, neither lawsuits nor guidelines should scare us into working it up. We only felt compelled to pursue it because we actually are concerned about it. Thus if we’re really being honest, we are our own worst enemies. It is our own consciences that force our hands, making us pursue undesired workups; it’s just easier to blame lawyers and algorithms.

My patient ended up being discharged, with NYPD encouragement, sooner than initially expected (that’s another story), but the episode resonated. While my patient was obviously not truly a randomized controlled study, and there may be many interpretations of his chart review, I took a lot away from the experience. Even as veteran attending physicians lament that we young doctors are slaves to algorithms, and as we young doctors complain that we’re all slaves to the lawyers, my malingering thespian tried his best to prove us all wrong. We are all slaves only to our own judgments, doing what we believe we have to do for our patients – even if sometimes we don’t like to admit it.

Farzon Nahvi-MD

Farzon Nahvi-MD

Bellevue/NYU Medical Center, New York City, NY
Farzon Nahvi-MD

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