Published in the April 2015 issue of Today’s Hospitalist
IT’S A ROUTINE CALL from the ED doc: “60-year-old guy with chest pain, pretty atypical, cardiac enzymes normal, EKG and chest X-ray look OK. How about I write some chest pain unit orders and you can see him when you get around to it?”
In a medium to large hospital, a hospitalist group can get literally dozens of such calls a month. If the patient has risk factors for venous thromboembolism, you check for that. But unless the D-dimer or V-Q scan is positive, you’re basically thinking of ruling out coronary artery disease.
So is the hospital, which has probably had a chest pain unit for years where patients can be monitored on telemetry until their cardiac enzymes can be checked a couple of times and they can get a test for CAD. If patients pass all their tests and are pain-free, you will probably discharge them before the end of their 23-hour observation period. Just hand them a script for ibuprofen or Pepcid depending on whether they sound more like musculoskeletal pain or reflux esophagitis, right?
Unfortunately, the list of problems that cause chest pain is a long one. And some of the most deadly “I’m thinking dissections “are also much rarer than heartburn or heart attack. How do you spot those in time to keep your patient from becoming a statistic?
Looking for trouble: the H&P
Even if it’s your third chest pain of the day, the patient’s description of his symptoms is your first clue that this is not a routine event.
Only half of patients with aortic dissection have the classic “tearing” pain that starts out substernal and moves to the back or lower chest. Ask a few questions to check for other red flags: pain that started here and moved there, neurologic symptoms, relief only with narcotics in a patient who doesn’t seem like a drug-seeker.
And if the pain radiates to the back, you need to get very suspicious. At the bedside, you can check for murmurs and bruits “and also for a difference in blood pressure between the two arms. Don’t let the chest X-ray reassure you too much; the mediastinum may not be wide or the aorta tortuous in the early or even later stages of a dissection.
“But I’ve never even seen one!”
Sure, aneurysms of the proximal aorta are rare. And maybe you haven’t even heard of a case since you finished residency. You may have to get your experience second-hand, spending time with patients who had aneurysms repaired in the past and getting them to tell you what it felt like back then.
And go back and look at your textbooks, even older ones; treatments and diagnostic tests may change, but symptoms and physical findings don’t. Aneurysms are right there under “vascular emergencies,” and they can kill a patient quickly. Mortality rises with every hour after onset of pain, and unless you’re in a facility with cardiovascular surgeons available 24/7, you will need extra time to get patients transferred for the treatment they need.
You may get lucky if you order a chest CT to rule out a PE, then get a panicked phone call from the radiologist asking which surgeon you want. But that CT has to be ordered stat, not left until morning while you give the patient some Lovenox “just in case it’s a PE.” If you’re still suspicious and the patient has renal insufficiency, ask the radiologist if an MRI or more detailed echocardiogram could replace a contrast CT.
Call the surgeon even before the patient goes to CT. He may be annoyed if the test is negative, but he knows that minutes count here. Dr. Surgeon can even help get your patient pushed in front of others waiting for a scan because he realizes how fast things can get worse.
“Please tell the jury … “
I took an online risk-management course offered by a national company that employs both ED physicians and hospitalists. In adult patients, the course pointed out, the four situations most likely to produce lawsuits when things go bad are abdominal pain, headache, sepsis and (you guessed it) chest pain.
My medical-expert practice isn’t very busy, but I’ve had three “count them, three “cases in the last year about patients whose aneurysms dissected and killed them while doctors were busy treating them for something else. In two cases, the patients had atypical chest pain and poorly controlled hypertension; the third patient would never have been diagnosed as anything except an MI if there hadn’t been an autopsy. That proves that even very good ED doctors and hospitalists can be misled.
The long and short of not only aneurysms but of many other medical problems is this: You can’t get too complacent about “routine” cases or think that you’ve seen enough patients to be able to relax your vigilance. A busy hospitalist sees rare diseases and conditions far more often than an office doctor.
The good news is that we are in a far better position to get patients the care they need. Look beyond the routine, evaluate patients’ complaints in detail and you may end up a hero.
Stella Fitzgibbons, MD, has been in practice since 1984 and works as both a hospitalist and an ED doctor. She also provides expert-witness assistance in malpractice cases.