This article in the USA today discusses the stories of 2 men with heart disease, one of whom died, and one of whom did not. Both presented to the ER. One got sent home and was dead 24 hours later. The other was admitted ot the hospital, no diagnosis of heart disease was made. 2 days later a different doctor performed a catheterization and found extensive heart disease including occlusion of bypass vessels from 11 years prior.
My thoughts on the article…first of all, they make ER doctors look like idiots. Second of all, the first ER doctor was an idiot for sending the patient home. An ER visit cannot absolutely rule out heart disease or even a heart attack due to the nature of testing available in the ER and the natural course of a heart attack. Full evaluation requires admission to the hospital, serial cardiac enzymes and the appropriate diagnostic tests such as a stress test or cardiac catheterization.
Because stress tests can have a high number of false negatives as in the case of the 2nd patient, certain groups should skp that test entirely and have a catheterization performed as the first test. The second patient in this article did not get a catheterizataioni during his stay. If he had not run into a different cardiologist in the hospital he may not have had the subsequent life saving care that resulted when the cath showed 80-90 % stenosis of his arteries.
The doctor who cared for the first patient, the one who died, claims he was not having a heart attack at the time of presentation, that his symptoms which brought him to the ER that night were unrleated ot his heart condition, and that he died the next day from “chronic heart disease”. Total Bullshit in my opinion.
Sure anything is easy in hindsight, but an older gentleman with a history of heart disease presenting with chest pain is having what is called “Acute Coronary Syndrome”, a catchall for pain related to underlying heart disease. More specifically, he was having unstable angina…no heart attack is in progress, but he is having symptoms of angina whcih are either new or different than before. He was appropriately ruled out for having a pulmonary embolism or aortic disection, but his disposition should have been admission to rule out unstable angina.
So while the USA today article makes us look like fools, maybe it will help me end my endless arguments with patients about why I would like them admitted ot the hospital. In fact, maybe I’ll start carrying a copy of this article with me to show to them when they insist on going home.
I was never a big fan of any of the cop shows, except Hill Street Blues. Especially not that NYPD Blue style. The balding guys with cheesy moustaches, brown suits and a clipboard…acting all tough with a New York accent as they grill the crime suspects in a dimly lit room.
Well, let’s just change the scenery a little bit. From a dimly lit interrogation room to a slightly better lit hospital room. New York accent to Pittsburgh accent. Crime suspect to crime victim, at least until proven otherwise.
I sat at his bedside with a boatload of lidocaine and a #11 scapel blade. Since the poor guy survived the ordeal of being shot twice with a shotgun, the least I could do was try to pop out as many of the pellets as I could easily get. Not the type of souvenier most people want to take home from what he thought would be a “gentleman’s argument.” All of it over a girl.
“She’s not even that good looking,” he snickered at the detective.
It was better than being a fly on the wall.
It turns out that with the combination of a satellite dish donated and installed a few years ago, an old dell computer, and a sporadically operating gas generator, that the internet comes to life here in rural San Jose de Negrito, Yoro, Honduras.
I have set up a group blog that we are trying to post to several times per day. I am, however, resisting the overwhelming urge to check personal email…it just ruins things to be distracted by stuff from home.
The generator only runs when we need it for patient care (lights, nebulizer’s, EKGs, construction), and doesn’t stay on just for the computer. So about 5 minutes a day per person if we’re lucky.
Follow along here for some vivid detail about our trip.
Last weekend was a 4 lap cyclocross race. I got lapped during my 2nd lap while the experts were on their third. I thought they were going to pull me off the course at the end of that lap so I rode it as hard and fast as I could. My legs were ready to fall off, my lungs burned and I was nauseated. I crossed the start line and no one said anything, except “one lap to go”. Crap. I suffered through one more lap that was mentally anguishing, but physically, it had already been spent.
Today was #3 in the series, a hilly 2 lap 5.5 mile course. The experts started maybe 10 minutes ahead of the rest of us, so guess who got lapped by the experts as she was descending the hairy hilly loggy rooty downhill? that’s right, me. I stepped off the trail about every 200 yards to let a pair of riders pass, then rode a bit, stepped off, drank, rode, off, drink, ride, off, drink, ride, etc,etc. I was mentally finished and my legs felt like sticks of lead from the lifting and running this past week. “One lap to go” simply rattled inside my brain and I pulled off into the grass to watch the real riders finish.
Doc Shazam will be in Honduras for the next 2 weeks. Unfortuneately, no “searching for nemo” reports this time unless I can sneak it on on the first weekend. Regular updates are unlikely…but possible, so check in occasionally.