Chest pain is where protocol driven medicine breaks down

On the theme of knowing when and when not to follow the diktats of emergency medicine, one of the greatest challenges for a practicing ER doc is chest pain. Missed MI is still the biggest driver of malpractice costs, and last I hear, ER docs still send home something like 2% of patients who are having MI or unstable angina. Not good. So over the last decade we’ve gotten all these chest pain observation units and rapid rule-out protocols and early stress tests and all sorts of protocol-y goodness to fulfill every ER doctor’s goal of never sending home an MI.

And it’s good, and works. At least, for most cases. Consider if you will:

Mr Smith is 58 years old. He smokes, and was diagnosed with hypertension and high cholesterol several years ago. He is treated with medicines for these, but is not particularly compliant about taking them. He has a strong family history of accelerated cardiovascular disease, with a father who died of an MI in his 40s and a younger brother who has had a CABG. He presents with 24 hours of stuttering chest pain. It is episodic, lasting 2-10 minutes, dull, midsternal, without radiation or associated symptoms. It occurs sporadically both at rest and with exercise. On arrival, his ECG and troponin are normal, and he rates his pain as 5/10.

So this is a pretty straightforward case, isn’t it? Slam dunk, admit to Card Tele, rule out & stress test. See? Protocol-driven medicine is fun and easy.

Oh, I forgot to mention something:

Mr Smith has previously had two MIs, has five stents in place, and says the pain he is having today is exactly the same as the last time he had an MI.

That gets your attention, doesn’t it? I just ramped up my level of concern quite a bit. In this case, I am probably calling a cardiologist to see the patient in the ER and starting him on heparin and a nitro drip.

But I also forgot to mention a couple of other details:

Mr Smith had his last cardiac cath eight months ago, showing patent stents. His stents are three years old. He had a negative nuclear stress test three months ago. He also has a crippling anxiety disorder and has visited the ER for chest pain twelve times over the past year. He has been admitted seven times, ruling out each time.

Oh. Well, that does change things, doesn’t it?

This is where protocol-driven medicine breaks down. Chest pain observation units are great for undifferentiated chest pain. but for someone with well-known, recently studied disease, they are less useful. Mr Smith is a real patient — I changed nothing from the patient I saw yesterday. And I see a Mr Smith every single day I work.

The academic emergency physician will say, rightly, that I should treat the third Mr Smith exactly the same as the second one, because you cannot know when his noncardiac chest pain is noncardiac and when it is cardiac. A risk-averse doc will assert that he just admits any patient like this, because he does not want to run the risk of ever ever getting sued. But that is not practical or sustainable in the real world. I only have so many beds in the obs unit! There are only so many times you can admit someone for observation without objective evidence of active disease before you have to admit it’s pointless. No matter where you personally set that threshold, there will be a patient who will visit you in the ER more than that.

I recall in residency a guy with known CAD who visited the ER for chest pain 550 times in a three-year span. We kept his ECG on the wall for easy comparison. After a while we stopped treating him with nitro and just gave him orange juice, which fixed his chest pain. But I digress.

If you work in an ER, someday you are going to send home a patient who presented with chest pain with a history of CAD. If you don’t, then you are a crummy doctor with no clinical judgement. It’s bad medicine and a poor stewardship of resources to admit every patient with chest pain. The difference between a good ER doc and a bad one, between an experienced physician and a robot, is acquiring the judgement to know where to draw the line, and how to do so safely.

I sent Mr Smith home, after talking to his cardiologist, observing him for six hours with serial ECGs and troponins, and arranging next day follow-up in the cardiology clinic. In this case, for this person, that seemed reasonable. For other patients, some of them do get admitted, depending on a million sometimes subjective variables — how many ER visits, when they were last studied, how old the stents are, how the patients look, how bad their disease has been, how long the pain has been going on, etc etc etc. There’s no good protocol for that.

Someday I am going to be wrong. In fact, I have been wrong, though with care there have been no bad outcomes. I can live with that — you have to be able to live with that if you are going to survive long working in the ER.

This is the art of medicine. This ability to recognize patterns, to integrate a lof of variables and clinical data points and come out with an accurate, back-of-the-envelope estimate of risk, that is the hallmark of a true physician. It somes with time. We all start off as algorithm-driven neophytes and some never seem to progress beyond that point. But for the Mr Smith I see every day, who doesn’t want to be admitted to the hospital again (he never does), but he also doesn’t want to die, he really values having a “good doctor.”

“Shadowfax” is an emergency physician who blogs at Movin’ Meat.

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  • Anonymous

    Kirk: Mr. Spock, have you accounted for the variable mass of whales and water in your time re-entry program? 
    Spock: Mr. Scott cannot give me exact figures, Admiral, so… I will make a guess. 
    Kirk: A guess? You, Spock? That’s extraordinary. 
    Spock: [to Dr. McCoy] I don’t think he understands. 
    McCoy: No, Spock. He means that he feels safer about your guesses than most other people’s facts. 
    Spock: Then you’re saying, 
    Spock: It is a compliment? 
    McCoy: It is. 
    Spock: Ah. Then, I will try to make the best guess I can.

  • JenniferL

    My favorite crooked insurance company scam (and please include Medicaid and Medicare)  is retrospective denial of emergency room evaluation of acute chest pain, whic proves negative for MI.

  • ninguem

    And you’ll be sued no matter what you do.

    Standard of care will be whatever you didn’t do.

  • Tricia

    And then there is the patient who will rule out, leave the ED, and VF arrest within the hour.
    For one day, it would be nice to have a profession where right and wrong, do and don’t do are always clear and where results logically follow actions.
    But, just for one day.

  • Anonymous

    “ER docs still send home something like 2% of patients who are having MI or unstable angina. Not good.”
    okay.. so what miss rate is acceptable? it sounds like you are saying nobody having an mi or usap should ever be sent home. this is a very irresponsible stance to take when society’s money is at play. time and again we are told there is no way to guarantee someone’s chest pain isn’t cardiac. absence of classic risk factors? normal ecg? negative biomarkers? nope, still could be acs. the only way to never send home an mi or usap is to admit everyone that presents with chest pain or some potential anginal equivalent. excuse me, on-call doc? i have a 19 year old with reproducible chest pain i need you to admit. why? because i can’t ever send home an mi/usap. you can say that’s a bad example but what’s the youngest mi you’ve ever seen? mine is 22. i’ve had someone with a negative cath 2 weeks prior rule in upstairs the day after i admitted him.

    what we need is for our academic leadership to rigorously study this and define an acceptable miss rate, and then define that miss rate as standard of care. 2% sounds too high. maybe 1%? regardless, if you are missing fewer than that number you are actually not sending enough patients home. much as i dislike algorithm medicine, chest pain is one area where it might be a good idea, because we will never get it right every time no matter how great we are at the “art of medicine.”  might as well get it wrong every once and a while and have it be the algorithm’s fault. if you deviate from the algorithm and admit someone, you don’t get paid. if you stick to the algorithm and someone has an adverse outcome, you cannot get sued.

    …in my dreams.

    • Margalit Gur-Arie

      What if you deviate from the algorithm and admit someone and it turns out you were right and the algorithm failed in this instance? Do you still not get paid?

      What if you stick to the algorithm and have a personal miss rate greater than the algorithm predicts? Can you get sued then?

      • Gil Holmes

        The algorithm was always wrong if it gets the wrong answer and the patient is harmed. There was some factor that made the patient not fit the algorithm. That is why there is ALWAYS a deviation from the ‘standard of care’ in malpractice cases.”Yes, doctor this algorithm/prtocol/guideline is great, but Mr Smith didn’t meet the entry criteria for the algorithm/protocol/guideline because of this {very minor sideline issue that isn’t actually relevent}. Therefore you committed gross negligence and malpractice and killed this kind-hearted 53 year old grandfather who volunteered at the animal shelter every Saturday’

      • Anonymous

        question 1: yes, you do not get paid.

        question 2: that represents a statistical aberration and no you cannot get sued for that. this of course implies that the algorithm has been proven to be externally valid in the practice environment of that physician.

        this is a meaningless discussion, as american society has deemed the acceptable miss rate of all diseases to be zero. tough to care about what things cost when one is not footing the bill.

        • Margalit Gur-Arie

          Does this make any sense to you?

          You don’t get paid for making the right call, and you don’t get sued for consistently making the wrong calls? Or perhaps this is a good illustration why you cannot really have a deterministic algorithm calling the shots, while you only follow instructions and deal with difficult manual labor?

          • Anonymous

            in an ideal world the cost of things in health care would be transparent and reasonable, and people would pay directly out of pocket to have the art of medicine applied to their individual situation. but that ship has sailed.

            the point i’m trying to make is that any blunt instrument that gets implemented to contain costs will not work if there is ANY fine print or gray area.

      • Anonymous

        sorry, missed your third question.

        yes i need to be there because as an emergency physician i see other complaints besides chest pain. i’m assuming whatever computer or unskilled worker you are planning on having run the chest pain algorithm couldn’t, say, handle a difficult airway.

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