Its interesting seeing the debate regarding getting troponins, vs not depending on the "description " of the pain . Heres the thing. I do not even care about how anyone describes their pain anymore. It really makes no difference in my decision making.Maybe its because I am 5 years out of residency, or that I have seen to many missed MI 's. .... but the reality is we have to understand several things when approaching these patients
1. WE ARE NOT PRACTICING MEDICINE ANYMORE
The reality is we stopped practicing evidence based medicine long ago , in America we are practicing "DO NOT MISS ANYTHING EVER " medicine. I don't care if you see 1000 low risk chest pain patients that end up being nothing, and 1 dies. guess what your were a 99.9 % "good"doctor , here's your lawsuit. You will not be able to use the defense of how "unlikely " this event is based on presentation etc ever. no one will care. You will be dragged through the coals. Once you realize this then you can proceed to step 2 . So take your HEART SCOR E, PORT SCORE , TIMI SCORE and shove them up your **s, as this will not save you .
2.HISTORY DOES NOT RULE OUT MI ...
I don't care whether your pain is "burning" "pressure like" sharp " etc.. IT DOES NOT MATTER , as soon as there is chest pain on the chart your job is to RULE OUT emergency . Description , character, location, duration, is will not rule out MI . Also if you have spent anytime talking to the populace you will realize PEOPLE CANNOT ACURETLY DESCRIBE ANYTHING . This along with the subjective variation of how people experience pain , etc . mean that there is literally nothing anyone can tell me that will matter as to ruling out emergency . History is useful in RULING IN chest pathology but you cant count on it for ruling out MI , PE or any of the serious chest pathologies.
3. YOU WILL NEVER REGRET ORDERING A TROPONIN
I never understood why some people will literally argue with themselves on whether to get a troponin or not. Even to the point where people will order other labs on a chest pain patient and purposefully not get a troponin . We were taught this in residence (ie troponin means you have to get another one, admit, rule out etc. ) That is bull. I guarantee you no one was ever sued for NOT getting a troponin. even a negative troponin x1 will help in that the jury and lawyers are NOT Medically people. they will not understand ruling out , trop length , etc etc. What they will understand is that there was a test that can tell whether you are having a heart attack and you didn't order it . THe reality is most of your chest pains will be getting ekg, chest xray . they will be in the ER for several hours(at least in my shop) in that time you could have easily gotten a troponin, helped your liability AND increased the billing of the chart. Also troponin doesnt just rule out MI , but most importantly is the difference between a mild pericarditis, and dangerous myocarditis, heart strain in PE , pericardial effusion, all can present with elevated troponin in an otherwise young person.
4. DONT DIAGNOSE NONEMERGENCIES
I don't care if a person has, gerd, pleurisy , gastritis, . I will not be diagnosing them with any of these. I may tell the patient, and treat them . but on the chart I will only diagnose CHEST PAIN. etc. Noone will ever come back and tell you how great a doctor you were for diagnosing GERD costochrondritis. The only time you will ever here about these type of patients again are when you missed a diagnosis, chart review or something went wrong. Having the diagnosis of GERD , after the patient died of a heart attack will lend you in a lot of trouble. Normal people and lawyers dont understand that your there are not test to identify GERD , or pleurisy and that just you best guess on what the person had. . Patients also take this a then decide they dont need to come back when things get worse or change because "the doctor told me what I had"
5. Repeat visits for the same thing get upgrade workups.
yes I know its annoying, but stop thinking about it , stop trying to rationalize it . If a person comes in multiple times, whatever workup they got last time, increase it. 1st time chest pain ek, 2nd tme labs, 3rd time ct chest and admission. Same thing with abd pain . I dont care whether the patient belly is completely perfect, they come in a second time and weren't scanned the first , they surely will get a scan the second time. Not only will it make the patient think you "care" which is a big factor in lawsuits. but it shows the jury and lawyers that you took their complaints seriously and thought of other things.
So just understand that when your are making your decision .I am not saying get a trop in every patient, yet understand you will be judged on it if you miss something.
You will miss an MI at some point. You will only miss an MI in a low risk patient. You will likely be sued at some point in your career. Think about what you would like your chart to say when it happens, and how you would like it do defend you.
PS sorry for the misspelling and grammar errors, I am lazy, on shift, and don't really care to proofread