Emergency Room Follow Up
I am very glad to see all the thoughtful comments on the last "Tales From the Emergency Room" post. I was inspired by your comments to post this follow-up, because I think there is a critical misunderstanding about the abilities of medicine to diagnose illnesses among those who have to be the recipients of that care.
Medicine is not black and white. There is no "x + y = z" to diagnosis. When faced with a diagnostic challenge a practitioner of medicine must take a thorough history, including all the details of the present illness, as well as the person's past medical and surgical history, and current and recent medication use (prescription and over the counter). He or she then synthesizes all this information and places it in the context of the "odds" of various things being wrong. Let's take a common example, chest pain (CP). As I approach the room in the ED with the CP patient I have a "differential" list in my head. A differential list is all the possible causes of chest pain I can think of: heart (ischemic heart disease/heart attack/angina), lung (congestive heart failure, pneumonia, blood clot, tumor, pneumothorax, pleurisy, dissecting aneurysm), musculo-skeletal (contusions, costochondritis, rib fractures), and GI (reflux, heartburn, esophagitis, ulcer, gastritis, referred pain from the gallbladder or pancreas).
When I go into that room I notice a few things right off:
Another one: 17 year old with 24 hours of chest pain that started after eating pizza quickly while at work at the pizza joint. Now feels that it hurts to swallow. No prior history of stomach problems, no significant heartburn in the past. Has also been away at camp and exposed to lots of other teens, and has a minor cough. Chest x-ray is normal and pain gets better with some Maalox mixed with lidocaine (a numbing agent), suggesting that there is a problem in his stomach or esophagus. My diagnosis: esophagitis, basically inflammation in the esophagus (swallowing tube between mouth and stomach), possibly after injury to the esophagus from hard pizza crust eaten quickly. Plan-home on antacids and acid-blocking pill, follow up with own MD. But if not better, then what? The patient is a little over weight, has a little chest wall tenderness but it Does the person actually have inflammation in the stomach or a stomach ulcer? Does the person actually drink alcohol with friends on the weekends, but won't admit it in front of mom? Is it really muscle pain from sports activities at camp? If my medicine doesn't work, the patient will be back to their own MD and "back to the drawing board" in terms of having a correct answer.
Third one: over weight mid-30's year old woman on birth control pills with sudden chest pain and increased heart rate; non-smoker, recent cross-country flight with layover of 1 hour in Philadelphia before changing planes. Asked for wheelchair ride between gates due to "pulled muscle" in her right calf that caused her to walk too slowly; she was afraid of missing her connection. No personal of family history of blood clots or clotting disorders; positive elevated D-dimer in her blood work, chest CT positive for blood clot in left lung. My diagnosis: pulmonary embolus (blood clot in lung) secondary to long plane trip, being overweight and on birth control pills. Admit to hospital until improved on blood thinners.
So the last patient is pretty clear-cut, but the other two are not. In this field you must put together a set of potential explanations, figure in the odds, test for the most likely scenarios, and then "pick a path and go down it," as my first mentor used to tell me. But there is always a chance that one can be wrong, and that is why follow up, with your own health care provider who knows your personal and family history well, is so important. This is the single biggest problem in medicine today in my opinion: people are uninsured or under-insured and thus they don't think they can have a personal health care provider. Many don't realize that there is someone in their community who will take care of them, or there is an option in the nearest large city. It takes some effort, but finding someone to have a relationship with, and getting established with them, is a much better source of care than you can get in the ED, unless it is a true emergency.
Stay cool and out of the midday sun.
~ Laurie
Related Topics: Technorati Tags: emergency medicine, chest pain
Medicine is not black and white. There is no "x + y = z" to diagnosis. When faced with a diagnostic challenge a practitioner of medicine must take a thorough history, including all the details of the present illness, as well as the person's past medical and surgical history, and current and recent medication use (prescription and over the counter). He or she then synthesizes all this information and places it in the context of the "odds" of various things being wrong. Let's take a common example, chest pain (CP). As I approach the room in the ED with the CP patient I have a "differential" list in my head. A differential list is all the possible causes of chest pain I can think of: heart (ischemic heart disease/heart attack/angina), lung (congestive heart failure, pneumonia, blood clot, tumor, pneumothorax, pleurisy, dissecting aneurysm), musculo-skeletal (contusions, costochondritis, rib fractures), and GI (reflux, heartburn, esophagitis, ulcer, gastritis, referred pain from the gallbladder or pancreas).
When I go into that room I notice a few things right off:
- age (less than 40 vs. over 40), because a young person doesn't usually have heart attacks, dissecting aneurysms, angina, or CHF, but is more likely to have GI tract or musculo-skeletal problems.
- level of current distress and other clues, such as a low blood oxygen level or being short of breath, which pushes me in the direction of heart or lungs.
Another one: 17 year old with 24 hours of chest pain that started after eating pizza quickly while at work at the pizza joint. Now feels that it hurts to swallow. No prior history of stomach problems, no significant heartburn in the past. Has also been away at camp and exposed to lots of other teens, and has a minor cough. Chest x-ray is normal and pain gets better with some Maalox mixed with lidocaine (a numbing agent), suggesting that there is a problem in his stomach or esophagus. My diagnosis: esophagitis, basically inflammation in the esophagus (swallowing tube between mouth and stomach), possibly after injury to the esophagus from hard pizza crust eaten quickly. Plan-home on antacids and acid-blocking pill, follow up with own MD. But if not better, then what? The patient is a little over weight, has a little chest wall tenderness but it Does the person actually have inflammation in the stomach or a stomach ulcer? Does the person actually drink alcohol with friends on the weekends, but won't admit it in front of mom? Is it really muscle pain from sports activities at camp? If my medicine doesn't work, the patient will be back to their own MD and "back to the drawing board" in terms of having a correct answer.
Third one: over weight mid-30's year old woman on birth control pills with sudden chest pain and increased heart rate; non-smoker, recent cross-country flight with layover of 1 hour in Philadelphia before changing planes. Asked for wheelchair ride between gates due to "pulled muscle" in her right calf that caused her to walk too slowly; she was afraid of missing her connection. No personal of family history of blood clots or clotting disorders; positive elevated D-dimer in her blood work, chest CT positive for blood clot in left lung. My diagnosis: pulmonary embolus (blood clot in lung) secondary to long plane trip, being overweight and on birth control pills. Admit to hospital until improved on blood thinners.
So the last patient is pretty clear-cut, but the other two are not. In this field you must put together a set of potential explanations, figure in the odds, test for the most likely scenarios, and then "pick a path and go down it," as my first mentor used to tell me. But there is always a chance that one can be wrong, and that is why follow up, with your own health care provider who knows your personal and family history well, is so important. This is the single biggest problem in medicine today in my opinion: people are uninsured or under-insured and thus they don't think they can have a personal health care provider. Many don't realize that there is someone in their community who will take care of them, or there is an option in the nearest large city. It takes some effort, but finding someone to have a relationship with, and getting established with them, is a much better source of care than you can get in the ED, unless it is a true emergency.
Stay cool and out of the midday sun.
~ Laurie
My definition of an expert in any field
is a person who knows enough
about what's really going on to be scared.
is a person who knows enough
about what's really going on to be scared.
P. J. Plauger, Computer Language, March 1983
Related Topics: Technorati Tags: emergency medicine, chest pain
5 Comments:
1 more thing to think about when investigating chest pain is the possiblity of cocaine abuse in some cases. otherwise, this is exactly what I look for when triaging patients at work.
I have hypothyroidism and discovered I was being medically over dosed. I felt unwell, sweating profusely, some left chest and left arm discomfort, went to ER, and checked out okay and feel it was due to my thyroid condition.
Thyroid conditions need a lot more attention.
Personally, I find it obnoxious that many doctors don’t follow up on their patients. I have had numerous problems with doctors (especially with Kaiser) that seemed to believe that simply telling me to “eat right” would make me lose weight, and they refused to believe that I was exercising and eating right because I look overweight. After really pushing for diagnosis, I’ve finally done a bunch of tests and reached the preliminary diagnosis of PCOS, but this is after 5 years of battling with doctors and arguing that it wasn’t just a case of a “fat lazy person”.
Finally I have a good idea of how I need to eat, but I haven’t gotten everything figured out yet. Birth control pills apparently make my blood pressure get high (although I’m normal while off of them).
In the past, doctors seemed very happy to just push medication on me without taking a very detailed history, and many of the doctors that I was paired with didn’t even speak English very well! Not only was I trying to deal with medical scrutiny based on how I look, but I also had to cross language and cultural barriers in the 15 or less minutes that I was allotted in the doctor’s office.
I’ve had so many problems, that I’ve had to become a crusader for my health and the health of others. Many of my friends avoid going to the doctor like the plague because they know they’ll be treated like stupid animals when they’re there, and often, I’ll have to research symptoms myself (which is dangerous, considering that I don’t have much medical training), and encourage people to go to see doctors when it looks like it could be dangerous.
I’ve had horrible pains at night from time to time, but rather than go to the emergency room and deal with the treatment, I just tell myself that if it doesn’t go away in an hour that I shouldn’t even bother. I’d rather wait around at home than sit in an emergency room that is clogged with people with no insurance and no money and still be in pain for hours while waiting for one haggard doctor to tell me to lay off the cheeseburgers. It’s horrible to hear someone who barely even knows me say “you shouldn’t be this fat” or “you shouldn’t look like this for your age”. They make judgmental remarks about my body and it not only hurts my feelings, but it also ignores the basics of varying body sizes and shapes.
I want to be treated like a human being, not like some grotesque cadaver to be prodded around cursorily and then diagnosed, dismissed, and shunted down the assembly line to pick up an astronomical bill.
If I wanted to be told that I’m fat and lazy, I’d buy a woman’s magazine instead of pay high premiums for shoddy doctor care.
The emergency centers do their very best to acommodate the population in which they are already at a disadvantage to handle. Staffing and resources are just not there to care for every person the moment they walk through the door. This is why there is triage. The priority cases get seen first, Im sorry thats just the way it has to be. So, unless you come to the emergency center Not Breathing...there might be a small wait. But dont worry, you will be seen by a board certified physician.
It is a misconception that all emergency centers are crammed with the uninsured and poor. Most recent studies indicate that the emergency centers are being utilized most by mid-income, insured individuals out of convienence. Their doctor may be on vacation, for example, so the next best place where you can come in any time of day is...THE ER.
What is not known by many is that those slivers, sutures in the fingers, and itchy rash could all probably...depending on severity...be done in an out-patient urgent care center. This might help relieve some ER congestion if all people were aware that there are urgent care centers for those non life-threatening ailments. Then, there would be some space and a little more off the Doc's plate, so there is more time for you, when it comes to figuring out exactly why it feels like a hot knife jabbing through your intestines.
Hi, excellent commentary all around; thanks for reading and taking the time to reply.
To the person who mentioned cocaine-that's true, thanks for the comment. We recently cared for a man in his early 40's with a ruptured cecum/perforated viscous. ED doc, surgeon, and I were puzzled about the unusual location of the rupture, but ultimately the full story arrived on the table. The gentleman had an ischemic bowel from cocaine use.
Laurie
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