Just when your evening can’t get any worse, two of your stellar EM residents come up to you and inform you that the internal medicine team is trying to “block” yet another admission. This is the 5th attempt at refusal today. The patient in question is acidotic, thrombocytopenic, altered, and bleeding from around the PICC line that was placed while he was in the hospital last week. He was recently discharged after a brief hospital admission for urosepsis, and is supposed to be receiving parenteral antibiotics and intravenous fluids through this precarious line. His wife brought him in because she was worried he looked worse, and she was concerned that the home health nurse couldn’t get his antibiotics infused through the malfunctioning PICC. After you listen to the internal medicine resident’s reasoning for refusing admission, “We just discharged him…he doesn’t look that bad to me…he can follow up as an outpatient…and the hospital is full…” you kindly show him how every blood test performed from the ED is abnormal and many of them have a “critical value” notation next to the result. In addition, the patient hasn’t been able to receive any of his IV therapy at home because the PICC isn’t working. There’s no way to argue with your logic or with the numbers in front of him, so he finally concedes to do the right thing for the patient. You marvel at just how far the paradigm has shifted. When did it become so in vogue to become an obstructionist?

altYou are thankful that the next three patients presented to you seem relatively straightforward.  All three patients have a chief complaint of chest pain.  All three of them have enough risk factors that they deserve an evaluation for ACS in your department tonight.  And with your ED’s chest pain protocol, you don’t have to use your powers of persuasion to get a consultant to care for the patients.  You finish examining the first two patients, and agree with your residents that they have stories concerning for potential cardiac ischemia.  When you get to the third patient, you realize he isn’t as straightforward as anticipated.  

The third patient is a 65 year-old fit and muscular male, sitting upright in the stretcher.  Yes, he has left sided and substernal chest pain radiating to his left shoulder.  He does note that it is exacerbated by working out, and yes, he does have a history of hypertension and hypercholesterolemia. The only thing that doesn’t make sense is how he is holding his arm across his body. Instead of the typical Levine’s sign, the patient is holding his left arm across his upper abdomen with the elbow bent at 90° and his hand is resting near his right upper quadrant.  When questioned about this, he notes that his chest hurts if he tries to extend or abduct his shoulder.  You palpate along his chest wall and ask him some more detailed questions about what brought about his chest pain today.  As you are talking, you perform a quick bedside ultrasound of his left chest.

altYou obtain a couple of diagnostic images from scanning his left chest wall (Figure 1 and Figure 2). What do you see? What is causing the patient’s chest  pain?

See next page for case conclusion.



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