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:
- 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.
Then I get the story: 51 year old woman with not 'typical, heart-related' chest pain presents with waxing and waning discomfort all day, which she describes as "I just didn't feel right" and "I was restless, like I couldn't get comfortable, and a little short of breath." She is a smoker with high cholesterol and anxiety disorder and whose brother had a heart attack at under age 50. First heart enzymes are in the abnormal zone, but not high enough to suggest a heart attack. EKG is normal x's two; D-dimer (a measure of blood clots) is normal. The odds are that this is not pain from her heart, but she has too many risk factors to ignore and will spend the night in the hospital having serial heart enzymes just to make sure her heart is ok. My diagnosis: atypical chest pain, admit to rule out heart as source. Once that is cleared she'll face the diagnostic dilemma of, "if not heart, then what is it?"
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
P. J. Plauger, Computer Language, March 1983
Related Topics: Technorati Tags: emergency medicine, chest pain
