It s 3 a.m. in the emergency department.
The radio crackles with yet another EMS patch in a very long night. We re en route to your facility with a 51-year-old male complaining muscular chest pain, advises the crew from this rural agency.
The emergency physician happens by the charge nurse as she jots down the information supplied by the paramedic: The patient noted pain while lifting a garbage can at his job an hour ago. He says he has had this before when his rib went out and a chiropractor fixed it. He refused an IV and walked to the ambulance. See you in 15.
(Expletive deleted), thinks the emergency physician. Fighting a losing battle with acute sleep deficit, the thoughts continue, For God s sake, why couldn t this guy wait until daylight? Sure the ED is the nation s health-care safety net. But, we don t have an on- call chiropractor.
This particular ED physician has demonstrated progressively less ability to adapt to night shifts with advancing age. When greeted by other night staff and asked How are you doin , doc? the common retort is, Not nearly as good as I will be doin at 7 am.
The ambulance arrives and, sure enough, the patient ambulates to his room in the company of the crew and the nurse. The emergency physician rounds a corner to observe a portion of this parade to the exam room with an undeniable tug of anger and resentment. There s no evidence of any distress at all.
This guy should be sent to triage and the waiting room, the doctor mutters to no one in particular.
In the patient s room, the paramedic reviews the history of the complaint with the physician. He says he s had this before, but this was the worst it has ever been. It was a sharp, stabbing pain in the left chest area. All he was doing was picking up a trash can. The man didn t want to go the hospital. We really had to convince him. But for a while, his pain was 10 out of 10, and that s what made him agree to come. The pain is a lot better now.
What did you give him? asks the doctor, already knowing the answer.
Nothing, replies the paramedic. He refused an IV.
Anything on physical exam?
Nope, totally negative, says the paramedic. Pulse ox was 98% on room and the 12 lead was unremarkable, too.
Are you sure this isn t just a work-comp deal?
Thanks, concludes the physician, with just a hint of sarcasm.
Eventually alone with the patient in the exam room, the doctor struggles to locate some empathy. The search proves fruitless. The patient is seated comfortably in a chair rather than on the bed. He s dressed in a T-shirt, jeans and a baseball cap. He says he just prefers to sit on the chair and stay in his clothes.
The medical history is indeed negative for any obvious significant coronary risk factors. In fact, he has no risk factors for anything other than simply being a middle-aged male. He has had this pain before, and it was successfully treated by his chiropractor. He has had no direct trauma to the chest in recent memory. The emergency physician s physical exam is also unremarkable except that the patient has very palpable tenderness in the left anterior and lateral chest area. Pushing on his chest seems to reproduce the pain.
Stifling yet another yawn, the physician mulls over the next steps.
It so happens that in this particular ED there has been a recent strong emphasis on increasing physician efficiency. In this department s perception, physician efficiency is directly correlated to the number of patients seen by a doctor per hour. Prolonged patient stays in the ED decrease the number of available beds for other patients and thereby decrease the patient per hour count. It turns out that a recent statistical analysis of this particular doctor s clinical activity placed the physician next to last in patients seen per hour. Needless to say, the doctor feels significantly increased pressure to move patients more quickly through the ED.
What would my super efficient partners do with this guy? the physician considers, and then answers. They would boot him out in a second. And I should too in the name of efficiency. But boot him to where? He lives 80 miles away. To the lobby?
The history provided by the paramedic of 10/10 pain now much improved just doesn t quite add up. The story of this chest pain is just a red herring, in all likelihood. But before completing the train of thought, the emergency physician tells the patient, Sir, since you re here, we should probably do a few tests just to make sure you re OK.
Doc, I got no insurance and no money.
A wisp of guilt stirs in the physician. It s true these tests are unlikely to find any pathology. They almost never seem to.
Well, I just think it would be safest if we look and can prove everything is all right.
How am I going to pay for this?
The doctor squirms, We have people in the hospital who can work with you and see if you re eligible for any kind of federal or state aid. Also, they will help you with an affordable monthly payment plan. ( Affordable — ha! the doctor actually thinks while speaking.)
Well, I don t know, but I guess if you really think it s necessary.
Cardiac enzymes, a chest X-ray, an electrocardiogram (ECG), and a D-dimer blood test are obtained. The ECG is completed first (see Figure 1).
The emergency physician takes a quick look at it. Hmmmm. Could be abnormal, but even if it really is abnormal and that s questionable it often doesn t mean anything.
I can still get this guy out relatively fast if everything else is OK.
Chest X-ray normal. Cardiac enzymes normal.
We re on a roll now, the physician smiles.
But the D-dimer is elevated. It s only a little elevated, but it s enough to break up the party.
Dammit, the doctor says to the nurse. I thought we might have this man done, but this result means we re stuck having to do a CT of the chest.
You ve got to be kidding, me. Let s just get him out of here.
I wish. But these two tests tie my hands. You know, in a way, the D-dimer isn t a total surprise, given the ECG. But the majority of these ECG abnormalities and D-dimer elevations are due to nothing immediately important or life-threatening, the physician says.
So why in the world do you have to waste our time and his money on a CT of the chest?
With this D-dimer abnormality, we have to look for a pulmonary embolism and the chest CT is the way we most commonly make the diagnosis. The D-dimer is increased when blood clots are present in any significant quantity. But the problem is that the D-dimer can be elevated for many other reasons besides blood clots in the lungs or the extremities. Surgery, old age, cancer, recent trauma, infections can also raise the level. A negative D-dimer, in someone at low risk for a PE like this guy, is helpful. A positive D-dimer is no help at all and generally leads to additional, unnecessary testing. But medical/legally, I now don t have a choice in this case.
So, you don t think he really has a PE, do you?
No, I don t. I think he has musculoskeletal pain, but I have to do the CT to follow-up likely meaningless abnormalities on tests I probably shouldn t have ordered in the first place.
When are you going to learn? huffs the nurse as she walks away.
I need what, doc? asks the patient suspiciously, still seated in the chair and fully dressed.
I really am sorry about this. But we need to do this fancy X-ray just to be sure the earlier tests aren t right.
I can t afford it and like I told you, I got a bad rib.
I realize that sir, but if by chance you had this blood clot, it would likely kill you.
The patient eventually concedes to the study and is taken to the scanner.
Radiologist is on the line, the unit secretary advises the emergency physician.
The radiologist says matter-of-factly, Your patient has a large left-sided pulmonary embolism with an area of infarcted lung.
The mortality from untreated PE is estimated to be 30%. The occurrence of clinically unsuspected pulmonary embolism incidentally discovered at autopsy ranges between 2 8%. In the past, the diagnostic confirmation of PE has been somewhat difficult. Recently, the development and availability of modern CT scanners has made the identification of these clots simpler.
The symptoms of PE classically include shortness of breath and/or sharp chest pain, but these are not always seen. Some patients can be nearly asymptomatic. Patients with larger PEs may be hypoxic as evidenced by low pulse oximetry. However, hypoxia is certainly not always present and was not in this patient.
Other tests that may be suggestive of a possible PE include the D-dimer and, occasionally, an ECG.
Sinus tachycardia is said to be the most common finding on the cardiogram, although not seen in this case. An S wave in Lead 1, a Q wave and a shallowly inverted T wave in Lead 3 (S1,Q3,T3) may be noted. If seen, this finding suggests acute cor pulmonale, or right-sided heart enlargement. Common causes of cor pulmonale include chronic obstructive pulmonary disease, tricuspid valve insufficiency, pulmonary hypertension and pulmonary embolism.
When an S1Q3T3 is present, I have yet to see the computer-generated reading pick it up. So when interpreting an ECG, the reader must specifically look for the abnormality. An S1Q3T3 certainly doesn t prove a PE is present. I ve had many patients with this finding ruled out for a PE and the ECG in these patients is unexplained. The presence of an S1Q3T3 merely raises the question.
Not surprisingly, right ventricular hypertrophy (RVH) may also be noted. This is likely due to increased workload of the right ventricle in the face of a moderate sized PE or any other cause of acute cor pulmonale.
Looking again at the ECG from this patient (see Figure 2), one can see that there is some RVH. The red marks on this copy highlight an obvious S wave in Lead 1 and a slightly inverted T wave in Lead 3. I can t really call a Q in 3, though. Note, again, the rate is normal and there is no evidence of sinus tachycardia.
Blood clots in the deep veins of either the arms or legs, called deep vein thromboses (DVTs), can travel to the lungs and lead directly to the formation of PE.
Patients at increased risk for PE include those with cancer, recent surgery or immobilization, pregnancy, absence of certain proteins (which help reduce abnormal clotting) and prior diagnosed PE or DVT.
This patient had no apparent risk for PE. Once a PE or a DVT has been diagnosed, an underlying cause must be considered.
What Can We in EMS Learn from this Case?
- Life would be easier if medicine and EMS was strictly a day job.
- We can expect to be humbled many times when caring for patients. In this case, almost everyone involved in this patient s care thought there was nothing significantly wrong with him (including the patient). I learn, and relearn, this lesson repeatedly despite 25 years of practicing emergency medicine. Diseases and trauma may present as wolves in sheep s clothing. When evaluating patients, consider the worst possible explanations for their symptoms.
- Patient refusals are always dangerous for the patient and an EMS agency. In this case, the crew did a great job of convincing a reluctant patient to be transported to the hospital, even when they themselves thought it was unlikely the patient had any serious illness.
- History provided by an EMScrew to a receiving hospital or physician can be critically important, as in this situation. The emergency department I work in has a policy that physicians will meet all ambulances. The policy has paid off on many occasions. In some facilities, it may not be possible for the doctors to meet every ambulance. However, concentrated efforts should be made to connect treating EMS providers with the receiving nurse at the minimum, so that the prehospital history can be shared and an organized, coordinated handoff of care can occur.
- If you re sick or injured in the middle of the night, you might want a different emergency physician than the one in this case.