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AAME/RSA 2010 Resident Editor
Originally Published: Common Sense September/October 2010
Last week, Jerry got the scare of his life. Jerry is a 48-year old mechanic who is in good health. His parents are healthy, and he recently got a “clean bill of health” during his annual check-up. Over the weekend, he helped his brother move across town. Monday morning, he woke with tightness in his chest. He described it as a “spasm” and thought that he might have pulled something while he was lifting the sleeper sofa. But someone in his neighborhood had a heart attack recently, and Jerry’s wife persuaded him to go to the ED to get it checked out.
A generation ago, Jerry’s family doctor would probably have told him that he had a muscle strain. He would have left with some Motrin and feel better. Not so on this particular day. The nurse who greeted Jerry noted his chief complaint of chest pain and quickly called over a tech who helped Jerry take off his shirt and attached him to a cardiac monitor. He was given four baby aspirin to chew on. He was brought to a treatment room where a young doctor came in and asked a series of questions about his chest pain while a second nurse drew several vials of blood and then sent him off for x-rays of his chest.
Hours passed. Finally, the doctor in charge, we’ll call him Dr. M, came in and told Jerry that everything looked OK so far, but that he needed to stay overnight for some more tests.
Jerry didn’t want to stay. He had already missed his son’s lacrosse game; he didn’t want to miss his daughter’s choir performance too. Dr. M told him that he could still be having a heart attack, and that sounded scary. So Jerry dutifully stayed the night. The next morning, he found out that he hadn’t had a heart attack. That was good news, but his ordeal wasn’t over yet. Dr. M told him that they still could not be sure what was causing his chest pain or that there weren’t problems with his heart. “You should see your primary care doctor to follow-up on this,” Dr. M cautioned. “He’ll probably want to order some more advanced tests.”
Jerry went home, far from reassured and more confused than ever. If he didn’t have a heart attack, what could it be? The discharge instructions just said that he had a diagnosis of “chest pain.” But isn’t that a symptom, not a diagnosis? His chest was still a little sore—it got worse after his kids pounced on him when he got home—should he be worried about this? Is it OK to keep working, what with crawling under all those cars? Is he going to be OK?
Emergency physicians are taught to always think about the most dangerous things that our patients could have. Headache? Most likely it’s something benign, but we need to think about subarachnoid hemorrhage. Back pain? Probably it’s something chronic, but we always ask about continence and assess for saddle anesthesia and such to make sure it’s not cord compression. Chest pain? Even in a patient who probably pulled a muscle, we do have to think about dissection and MI.
It’s the nature of our job to make sure that we assess for potentially life-threatening conditions. It should also be part of our responsibility to provide our patients with a diagnosis. Too often, we focus on the “rule-out” of the really bad stuff: the head bleeds, the strokes, the appys. When we find that our patients don’t have these (admittedly quite bad) diagnoses, we are relieved. We tell our patients that they don’t have something terrible, and for a second, they are relieved too. Then, they wonder what it is they actually have. To treat a problem, it helps to figure out what the problem is. It’s part of our duty to provide a diagnosis of not just what patients don’t have, but what they have, and to tell them what to do about this less-than-life-threatening condition.
“How can I do this? We’re really busy; I can’t sit down and go over every single thing on the differential and what to do about that! Besides, we often can’t offer any diagnosis at all.”
I would argue that there often is a diagnosis or a “most likely” diagnosis. The key is to involve our patients in the thought process. Tell your patients what you are thinking. Involve them in your thinking through the differential and the decisions about what tests to do. We can say that tests so far show it is unlikely you have this terrible life-threatening condition. Based on your symptoms and physical exam, we think it is most likely this diagnosis. This is what you can expect in your symptoms based on the natural history of your disease. This is what you can do about it to alleviate the symptoms. This is why you should follow-up with your PCP, and here are danger signs to look for that should prompt you to come to the ED. Our patients are our partners, and it’s part of good care to provide them an answer that guides their treatment.
In Jerry’s case, think about how differently he would have felt if Dr. M had involved him in the decision-making from the beginning. His symptoms starting after the moving and feeling like “spasms” and his lack of significant risk factors might not have even prompted a workup for ACS in the first place. Instead of being frightened about the risk of a heart attack, Jerry could have been involved in the decision-making from the get-go and could have avoided staying for lab work. At the very least, he could have been told after the two sets of x-rays AND stress test that his diagnosis was not just “chest pain,” but musculoskeletal chest pain. He could have been told that the pain could worsen in the next 24-48 hours, but that it was safe to resume work and exercise. He could take ibuprofen 600mg every 6 hours with food to help with the pain. He should see his PCP to follow-up in a week if symptoms persist, and to come back to the ED if he has warning signs of something worse (i.e., crushing chest pain, shortness of breath, etc). If he had been given a diagnosis followed by these explicit instructions for treatment, Jerry would have gone home sooner, happier and far more reassured.
Patients come to their doctors to feel better. Let’s make sure that even in the busy, often uncertain and unfortunately litigious environment of the ED, we strive to figure out not just how to rule out the bad stuff, but to provide patients the answer of what is actually causing their problems. Let’s put the focus back on diagnosis.