Continuing the cardiac theme…
In residency, oh-not-so-long-ago, chest pain was way up there on my list of favorite chief complaints. And that’s because it was so easy. Virtually anyone who came to the ER with chest pain was admitted. Maybe if you were 20 and had been bitten on the chest by a bug you’d find your way out of there, otherwise I got a quick history, looked at your chest x-ray and EKG, looked at your enzymes, typed “medicine consult” next to your name on our computer system, and poof you magically disappeared upstairs.
Things have changed since I left, however. The general public would likely be shocked by how much we wing it in the medical community. Despite wheelbarrows full of research coming out on a weekly basis, all in all there is very little “evidence based medicine” available to practice. And so, since a true gold standard often doesn’t exist, you instead have to resort to your best judgement or, if the problem is common, practice within the confines of “local standards of care.”
And I have found the standard of care here to be much less conservative. What before was an automatic admission is now a discharge to home. Most of the rub is with the ACC/AHA level 4’s, which is essentially a patient with pain that is not classic for a heart attack, a normal or near-normal EKG, and normal blood work. Long before I arrived, the docs in my group have typically been managing them as outpatients via close follow up with cardiology the following day.
And really I can see where they are coming from, particularly the cardiologists. From both evidence and experience, I know that the percentage of my level 4’s that rule in (for a heart attack) is very small, and the percentage of those that have a significant arrhythmia justifying their telemetry (electrical cardiac monitoring) is extraordinarily small. So couple the odds stacked against anything bad happening with the general pain in the butt it is to admit a patient, and it’s pretty clear why I’m being asked to send these patients home.
Unfortunately, this also shifts all of the liability from their shoulders to mine, and even though the likelihood of a bad outcome is minute, when you see tens of thousands of patients with chest pain over a career, you will inevitably send home a few to die.
But you can’t just admit everybody, and I believe the missed heart attack rate remains constant at around 3% or so despite ER chest pain units and more aggressive admitting practices. I suspect the bulk of the folks who are missed are like the patient below, who present so atypically that the diagnosis is never considered. Because it’s common knowledge: if you don’t think of the diagnosis you’ll never make it.
In the meantime I’m just trying to do the best I can within the confines of my local standards of care. I admit my level 4’s on Fridays and Saturdays when next day follow up is unavailable. I often run mini rule outs, drawing a second set of cardiac enzymes 3-4 hours after the first, much to the chagrin of the nurses who aren’t used to seeing this from the other, older docs in the group. And for the patients that are capable, I try to explain this entire thought process to them, giving them the risks and benefits, and allowing them to share in the responsibility of making a disposition.
And when they go home I hold my breath, hoping the other shoe never drops.
June 29, 2007 at 5:03 pm
I’d do more of those 4-hour rule outs. Seriously, it will frost your shorts how many of those will rule in (maybe 1 in 20 or 30 — too many for comfort). Until we got a chest pain unit, we did a 4-hour rule out on everybody with risk factors. No, there’s no evidence behind it, but it seems to filter out some of the higher-risk cases, I think.
Make it department policy and you’ll have even more protection from liability. When someone goes home and croaks, you can claim that you followed your institution’s standard of care — you may be wrong but you weren’t negligent.
June 29, 2007 at 7:51 pm
Well, as far as 4 hour rule outs are concerned, the plaintiff’s attorney can say, “well, obviously you felt the patient is at risk for a heart attack because you bothered to do a 4-hour-rule-out, but this is not standard of care.” So I think if you have suspicion, then do the real rule out, else do what you’ve been doing and document things. Practicing defensive medicine doesn’t do anything but drive up healthcare costs.
June 29, 2007 at 8:46 pm
I think this is very interesting. I’m a rising second-year (it’s almost July!!) in a ED residency program in a very conservative state. Like 10/10, we admit almost everyone with chest pain that doesn’t have another good source (like clear respiratory stuff, not like anxiety or GERD, although a few young and healthy people with those slip out the door). We don’t have a ED-based CDU, so it’s a medicine/hospitalist admit. It wasn’t like that at all in the two other states I worked in as a medical student (one of which had an ED CDU without in-ED stress testing and one without a CDU) – they were very good about leveling people, getting more than one set of enzymes, and discharging those low-level patients who didn’t rule in. Personally, I liked the less conservative approach better – but we also don’t have that many low-level patients here. What we do have (and what I wish there was a better solution for) is a lot of people with chronic angina and known 40% disease who keep having chest pain and get admitted all the time!!! I understand why, unstable plaques and all, but our cardiologists have a thing about “non-obstructive” = “noncardiac” chest pain and like to give us trouble.
June 30, 2007 at 10:00 pm
I love CP when it is a STEMI or other clear cut EKG changes, otherwise we are just out there gunslinging it. On the softy stories I will explain to the patient my best guess at probabilities and give them three options:
1. Most risky — go home now
2. Middle ground — check a second set in the ER
3. Most conservative — admit.
If they want option 1 or 2 I document the discussion and concurrance of the patient in the medical decision making. If the admitting doc gives me grief about option number 3 I just say that the patient wants 100% assurance that it is not cardiac.
I consistantly have one of the lowest admission rates in the group because many patients are willing to take more risk with their lives than the physician will.
July 2, 2007 at 7:45 am
I, like Sara, work at a hospital where we admit most of our chest painers with ANY risk whatsoever. (Speaking of, Sara…do I know you? If so, you probably know what HIBGIA means…)
I’ve had to argue with multiple services about the 4 and 6 hour rule out scenarios. They are for LOW RISK only. They are NOT for the “79 year old, presyncopal, history of NSTEMI which felt JUST LIKE THIS.”
We don’t have a CP unit, but we do have a “Day Hospital” for the low risk, pain free ones. At the other hospital we rotate through, there is a Chest Pain Decision Unit which the cardiologists run (their decision). I got CHEWED OUT one night when attempting to admit a low risk patient (prob panic attack)…the Cardiologist said “why don’t you call it what it is? When are you guys going to take responsibility for your own f+*#ing patients?”
My problems with that? I WAS taking responsibility…by ruling her out. I would LOVE to have an ED-run rule out unit…but HIS group insisted they run it. I STILL would have brought her in if it was our unit.
Anyway…enough ranting
July 2, 2007 at 10:06 am
The thing is, ID, the group of patients I’m talking about probably rule in about 5% of the time, so the suspicion is there, but the de facto standard of care set way before I got here is to by and large manage them as outpatients.
The “evidence” isn’t there yet for the 4 hour rule out, but like the saying goes there are also no randomized controlled studies showing you’ll die if you jump out of a plane without a parachute.
So while I completely agree that it won’t save me in court, as of today I think (hope) that a 2nd set in the low risk group will drop the post test prob even lower when trending down, and will pick up some of the 5% that would have otherwise gone home when trending up. And two extra blood tests is nothing compared to the cost of a cardiac workup, and certainly is cheaper than an admission.
Is there a greater disconnect between any two specialities than EM and Cards? I guess after 10 years of seeing most of your rule outs rule out you just get fed up with admissions, while the ER doc is there in the room with the patient and the family, always fearing a return visit with CPR in progress and knowing that missed MI represents the #1 source of litigation against the speciality.
August 4, 2007 at 4:36 am
Panic Away
This brought me back from the Brink!
August 6, 2007 at 6:13 am
Panic Away Fast
This helped me out of those DARK PLACES.
August 6, 2007 at 7:12 pm
Panic Away
This helped me out of those DARK PLACES.
March 19, 2008 at 7:37 pm
Panic Away
Stop Panic Attacks for Good