Some many months ago, I was doing an on-call with my senior, Dr B. I was then called to the Casualty urgently to see a middle-aged man with acute chest pain. Myocardial infarction (medical jargon for heart attack) was one of my several differential diagnoses. His ECG was borderline for MI. After discussion with Dr B, we decided not to thrombolyse the patient.
A bit lost now?
Just to give you a crash course on MI. When someone has a coronary, one or more arteries in his/her heart get blocked by a blood clot. As a result, the heart muscle supplied by this artery becomes starved of nutrients and oxygen, and dies. If an ECG is performed during the attack, it will show a certain change called ST elevation. The treatment for MI is a powerful clot-busting drug to dissolve the clot. This procedure is termed thrombolysis. Basically the sooner the drug is being administered, the more healthy heart muscles can be salvaged.
Back to my story. As it transpired, the man did have a heart attack. One of the cardiac nurses (rather unhelpfully) put in a risk management form against the both of us. I was requested to submit a formal report regarding my (lack of) action. Fortunately I was vindicated.
Unfortunately history repeated itself last Friday. I was once again doing on-call with Dr B. A middle-aged lady with yet another borderline ECG. The only difference this time was she strongly and repeatedly denied ever having any chest pain. She was brought in after fainted on a bus. We didn't thrombolyse her because the evidence for MI was rather weak. Subsequent investigations however showed she has had a MI.
I'm sure someone somewhere will very soon put in a risk managment form against me and Dr B.
The problem is: Medicine is never as straightforward as it seems to be! Not every patient, every case would comply with textbook medicine. In fact we hardly ever see such a patient. Working on the shopfloor, seeing real patients with their ever unique presentation of disease, is different from learning a particular medical condition in the textbook. At the end of the day, I am the one who has to make an assessment of the situation, and then initiate a treatment plan which I think is most appropriate. Not the nurses, not the consultant, and DEFINITELY not the fatcat managers.
Hindsight is always a more superior tool. But when I'm seeing a patient there and then, I can only do what I believe is best for my patients.
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4 comments:
I beg to differ. I have seen hundreds of female suffering with acute heart attacks, and they almost always complain of severe chest pain.
The only people who are more likely to have a 'silent' heart attack are the diabetics. Even then it's highly unusual.
Okay, but that has been a concern of people who are concerned with women's health (as a "special" field of human health) - that women's heart attacks often go unnoticed because we don't have the same symptoms as men.
I'm sure you don't have time to read women's magazines, but we're being told that it's likely ER people would not recognize a heart attack in a woman. And here is an instance when it happened. It's frightening.
This is from onthebreeze.blogspot.com - I'm on a "posting as anonymous" form for some reason.
Studies have repeatedly shown that young females with chest pain are less likely to have heart attack. Again, I can testify to this through my own experience.
Perhaps you have been reading too many women's mags.
I can assure you that most docs know what they are doing. Patients are not losing out, because the diagnosis of heart attack is clinched by ECG changes (ST elevation). All patients who attend A&E with chest pain and/or breathlessness will get an ECG. Hope I have explain myself well enough.
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