WhiteCoat

Diagnosis by Retrospectoscope

The patient was crying and shaking her hands when she rolled through the doors on the ambulance stretcher. She had been sitting at work and developed severe chest pain. There was also a little shortness of breath thrown in because she felt as if someone was sitting on her chest. She said she had been upset over something that happened at work and was “stressed out.” The pain was right in the middle of her chest and felt a fullness in her neck. She was starting to get tingling in her fingers and thought that shaking her hands would help. Paramedics gave her aspirin and nitroglycerin which she said may have helped her chest feel better.
The nurse gave the paramedics a stink eye. “Come on, now. She’s 27 years old. She ain’t having a heart attack.”
Even though she wasn’t having a heart attack, the nurse still ordered an EKG. Doesn’t it figure. Something didn’t look quite right. Little bit of ST elevation in Lead I and aVL. May just meet criteria for MI. Also a little elevation in V1 through V3. Not the tombstones you typically see. Just a hint of elevation. And there’s some T wave inversion in the inferior leads as well. Since she’s 27, there’s obviously no old EKG for comparison.
“That’s concerning. She has some EKG changes that may be ischemic.”
The nurse was quick to counter. “Yeah, right. She needs some Ativan, not a cardiologist.”
“Well, you can give her some aspirin, some morphine, and a milligram of Ativan also. If nitroglycerin helped in the ambulance, give her another dose of that as well.”

EKG

Decision time. I’m moonlighting at a rural hospital and there’s no cardiologist available. Do I treat her like an 80 year old diabetic and fly her to the medical center 60 miles away? Or do I treat her for her anxiety and watch her? She technically meets the criteria for an MI, which puts you in a no-win situation. If you send her to the referral hospital and her pain goes away, everyone thinks you’re an idiot. If you keep her at your facility, on the outside chance there’s something serious that you didn’t act upon, you get tarred and feathered by everyone who looks at the case.

After receiving some morphine and Ativan, she’s a little out of it, but is still crying and having pain that she rates as a 4 on a 1-10 scale. I call the Metro General referral center and ask to speak to the cardiologist.
“There’s a 27 year old young lady with typical sounding chest pain and EKG changes that look ischemic. Can I fax you the EKGs to look at?”
“Family history? Smoker? Drug use? Other medical problems?”
“Nope. Nope. Nope. Nope. Can I fax you the EKG?”
“Hey, you’re there seeing the patient. I’m not. If you believe that the patient is having an acute MI, just send her here. What I say about the EKG doesn’t matter.” Actively avoiding looking at the EKG. In other words, “If I look at the EKG and say it looks like a 27 year old is having a heart attack, then I look bad. If I rely on your interpretation, then you get left holding the bag.”
Labs have come back and of course they’re all normal. Not even a little bump in the cardiac enzymes. Normal d-dimer as well. Chest x-ray looks fine. She is still crying in pain.
“Okay, let’s call the helicopter,” I told the nurse . “Grab some heparin and Plavix. We’re going to treat her as if she is having a heart attack.”
“Holy sh*t. Are you kidding me? She’s 27 years old.”
“Hey. Cardiac disease doesn’t discriminate. Let’s get this show on the road.”

I walked back into the room to talk to the patient. She was crying and talking on her cell phone.
“Your EKG looks like you may be having a heart attack. We’re going to have to send you to Metro General by helicopter.”
She stopped crying immediately.
“Holy sh*t. Are you kidding me?” I wanted to say “No, I’m serious as a heart attack” but cheap blog humor didn’t seem appropriate at that point. I explained to her what was going to happen and had her sign the necessary paperwork.
I went back into the office and completed her medical records which took about another 10 minutes.
I went back into the room, the patient’s mother was standing there. She looked at me and said “Can I ask you what is going on?”
“Sure. You probably heard the unexpected news. Your daughter has changes on her EKG that make it appear she is having a heart attack .”
“Hole-lee sh*t .”
I’m getting kind of sick of hearing that phrase by now.

About 20 minutes later, the helicopter crew was walking through the door. The nurse began giving them report. The patient was still having chest pain, so we repeated her EKG. It hadn’t changed from her initial presentation. The helicopter nurse gave me a quizzical look out of the corner of his eye. I gave the same quizzical look back at him.
Now I’m getting ticked off. Just be quiet and take your damn notes. You’re getting paid regardless of whether or not I know how to read an EKG.
They loaded patient on their stretcher and wheeled her back to the elevator leading to the helicopter pad on the roof.
As I heard the helicopter blades start spinning, I started to wonder whether or not I had documented the chart well enough to survive the inquisition by retrospectoscope that would be occurring the following day. We met all of our “quality” indicators including aspirin at time of arrival and EKG within 10 minutes. But how many people would still be sitting around the conference room table the next day asking what I was thinking?

Oh well, that part of the job. Everyone’s a genius once the diagnosis is known.

Just to rub it in, during my next shift, the nurse mentioned that she had seen the patient in the grocery store two days after we transferred her.

Such is the life of a pit doc, I guess.

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

14 Responses to “Diagnosis by Retrospectoscope”

  1. WhiteCoat says:

    Oh, I almost forgot to mention.

    A couple of hours after the patient was transferred, I get a call from the cardiologist at the Metro General.
    Great. Now that they’ve done another set of enzymes and a chest CT, they have some other diagnosis that I obviously should have considered.

    “Well, we took your patient to the cath lab.” I was actually glad to hear him say that. At least that gave a little more support for my decision since the cardiologists believed her story enough to cath her.
    “Let me guess, normal coronaries.”
    “No. Actually, she had a complete occlusion of her left anterior descending artery.”
    Holy sh*t! A widowmaker? Are you kidding me?
    “That’s what I said, too. This lady probably would have sat in our waiting room for quite a while. Good call on your part both in getting her right back into the department and in pulling the trigger to get her down here.”

    I nearly started having chest pain after that.

    Totally true story.

    Be honest, now. How many of you were thinking “Acute MI” after hearing this story?

  2. TH says:

    Having been in your boots (and working under similar conditions on a regular basis), I look at it in the same way we used to think about appendicitis: If you’re not getting a few normals out of what would otherwise be typical findings, then you’re missing something.

    Everyone wants certainty in their lives – patients, cardiologists, hospitalist…. it is the EM doc’s job to start bashing chaos into something that looks organized and sometimes we overcall things.

    Me? I’d’ve probably sent her with that EKG that looks like a 59 year old male smoker’s EKG.

  3. Bloodshot says:

    I’m no medical professional, but in any field you get them some times: Situations where you (almost) can’t win. If you manage to win after all, the sense of victory is very rewarding. :)

  4. Nick Genes says:

    Great writeup. You captured the challenge of pressing forward with a big workup, on a probably-ok patient, in the face of mounting skepticism from nurses, consultants, and sometimes even the patients themselves.

    Everyone is second-guessing you. The administration is going to review this case, either way. Best you can do is advocate for the patient and document your decision-making and concerns.

  5. hashmd says:

    You should be commended into not falling into “diagnostic inertia” just because the age, sex, lack of family history did not fit our preconceived ideas of what an acute MI should look like. You had the criteria in your hands, you kept the thought of the possibility in your head, AND YOU ACTED IN THE BEST INTEREST OF THE PATIENT! You saved her life. The medics, the public, maybe even the patient may not ever know that you did.

    But you know now. Relish it when the 99% of the false positives keep coming by.

  6. Dr boo says:

    Well done.
    We also had a 33 yr old woman 4 days post partum with chest pain. We thought it was a pulmonary embolus with some ecg changes and small trop rise. No cardiac risk factors….But turned out to be ischaemic heart disease with occlusion of a circumflex artery.

  7. Atypical says:

    My father had his first heart attack age 27. He was given a bypass of some sort and lived until he was 35, where another heart attack killed him. Healthy bloke, fit, outdoor worker. Just can’t win sometimes. Good on you for taking this woman’s symptoms seriously.

  8. moshe says:

    1) Is this her actual EKG or a similar one?

    2) based on Bayes theorem, evidence based medicine, likelihood ratios etc., she was most probably not having a heart attack, as her pre test probably was close to zero. Just goes to show that sometimes you gotta trust your gut and not a nomogram!

    • WhiteCoat says:

      That was her actual EKG.
      I agree that her pre-test probability was close to zero – which is what makes these cases so frustrating.
      One one hand physicians are chided for “shotgunning” and doing “unnecessary” testing. In 99,999 out of 100,000 cases, the cardiac workup in a patient like this would be considered “unnecessary” and “wasteful.”
      But the one time a physician misses the needle in the haystack, a patient dies and the physician gets blamed for not doing enough.
      It is a horrible double standard.

  9. DocHodson says:

    I’ve pushed TPA on the stroke equivalent of this before, when I was a resident. 27ish yo F, no sig PMH, rural hospital, Normal Non-Con Head CT, completely aphasiac, mute, right sided hemiparesis. Our neurologist said “complex migraine.” There wasn’t a darn thing that should have set her up for a stroke.

    I had a real, real debate, with the pro and con of TPA (and that is a can of worms I’m not opening); suffice to say, we pushed it, and then sent her to the tertiary center with the drip running, she got angio’d.

    Massive clot to left MCA.

  10. WhiteCoat says:

    Thanks for all the words of encouragement.

    Several people echoed the take-home points from this post:
    If you work in the ED, you’re going to be second guessed. Always. You’re going to be criticized for not making the right diagnosis. Always. Get used to it. That’s part of the job. Smile, nod your head, remember that everyone is a genius once the diagnosis is known, and realize that few people could do your job as effectively as you do. Then go back to work and save more lives.
    And when in doubt, try to do what is in your patient’s best interests.

  11. Ted says:

    Leads I, aVL, and V3 make me nervous, and the inferior lead changes sealed the deal. Maybe I’m oversensitive, but I looked at that EKG and reached for the phone to activate a “Code STEMI”.

    Did I mention that I’m off duty and reading this at home?

  12. Jeffrey says:

    Critical observations:
    “Something didn’t look quite right”
    “Pretest probability was close to zero” ≠ zero
    A symptomatic patient with a non-diagnostic ECG is no less likely to have ACS than an asymptomatic patient with the same ECG (Chase, M., et al, Academic Emergency Medicine 13(10):1034, October 2006).
    Important axioms:
    All things being equal; treat the patient not the test result (?medicine axiom)

    “In life, to be honest, I failed as much as I have succeeded.” (Dickie Foxx from” Jerry Maguire”)

    “In any moment of decision, the best thing you can do is the right thing. The worst thing you can do is nothing.” T Roosevelt

    This is why “google doc” will never replace the real thing…. Excellent example of avoiding bias and the representative heuristic and critical thinking.

  13. Dino says:

    Great job with this. Actually, aVL is extremely concerning and when you are considering a STEMI, ANY elevation in aVL has significantly higher specificity for STEMI than elevations in 2 contiguous leads. A case similar to this has been noted in one of Amal Mattu’s ekg books. What we do is hard and the diagnostic dilemma you perfectly captured is something we have all experienced.

Leave a Reply


three + 4 =

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Earn CME Credit