Things "Specialists" Told You Couldn't Happen, That Happened

[Birdstrike]

The thread on the ovarian cyst rupture that lead to hemoperitoneum and shock, got me thinking. We need a thread on things specialists told us couldn't happen, that did happen. There's been many times consultants questioned me, doubted my instincts or just plain told me that what I was seeing and knew, was wrong, and then they turned out to be dead wrong.

Probably the most blatant and glaring example that comes to mind, was a guy who according to EMS told them he was having chest pain, then when they arrived and walked in the room, he clutched his chest and collapsed. They put the paddles on him, it showed V-fib and they shocked him back to sinus. By the time they got him to me he was awake and complaining of chest pain, again. I got an EKG right away and it was normal. Right before my eyes, he said, "I'm having chest pain," and again clutched his chest and got this crazy look on his face. We looked on the monitor and it showed V-fib. We shocked him and fortunately got him right back into sinus rhythm, again.

So, at this point, I'm thinking, okay, great. This guy is obviously having an MI, and not just any MI, but 'the big one' and the cool thing is, if we get him to the cath lab right away, this will be one of the cleanest 'lives saved' I've ever had in my career.

So I repeat an EKG; still normal (but who gives af, right? since people have non-STEMI, non-Q wave MIs all the time, and when I repeat the next ekg or two, the ST segments will obviouly go up, because this is the most obvious no-brainer MI I've ever seen in my life, and we’ll get him off to the catch lab.) So, we start the classic chest pain, stemi protocol and put a call out to interventional cards. Now mind you, this is day time. It's not 3 am and it's not everyone's favorite holiday, either. I'm anticipating virtually zero pushback.

About 60 seconds later, cards calls back and while I'm answering the phone, the guy goes into v-fib again and me and awesome-nurse pop him with juice again, saving this guy's life, AGAIN. Then, unf***ing-believably, the cardiologist starts lecturing me on “what MI's are, that this guy is obviously not having an "MI" and that it's obviously not an MI, because it's an arrhythmia and that the two have nothing to do with either other, and was I a ***** because I must have slept through the ‘What is an MI?’ lecture in residency.” He then tells me to call non-interventional cards.

Dumfounded, I call our non-interventional cards person who was even more pathetically worthless and tells me to call Medicine, because, "Anything could be causing this arrythmia and since it's 'obviously not a STEMI' to have medicine admit him." During this 60 seconds, the guy V-fibs again, and amazingly we get him back. Again.

At this point, I'm keeping my cool, because I know, that with one more EKG, the ST segments will certainly go up and then I can get ------bag of the century to actually take this guy to the cath lab and help me save this guy's life. So I repeat and EKG and '--ck! It's still normal!" So I break down and call the hospitalist, tell him the insane story I'm living and he's like, "Wtf? You want me to admit and refractory V-fib that's having an obvious MI?"

Yep, I say, and thankfully he's a stand up guy, unlike the insane gaslighting cardiologist on call, so he comes down to help me out. By this time, I've intubated the guy and have defibrillated him 7 times, SEVEN ----ing times! and back to sinus every time. He's got a strong pulse.

The hospitalist walks in the room and we're both, shaking our heads, disgusted at the insane world we live and work in right now. The nurse hands us another EKG and guess what it shows?

Take a wild ----ing guess what it shows?

Yep, a STEMI.

Imagine that?!?!?! /sarc

So, I tell him, "Dude your turn. If I have to call this ------bag cards crew one more time, I'm going to lose it and get fired. You call 'em."

He calls them and doctor-horrible-human-being takes him to the cath lab.

I go home in disgust.


Next day:

"Guess what? That guy had a 95% LAD."


Yeah, no ****, Sherlock!

A decade later, I still remember the patient's name. He walked out of the hospital 100% neuro intact. A clean life saved, despite a valiant effort from two cardiologist to gaslight me into letting him die.

Moral of the story: You’re just as smart, of not smarter than them. Stick to your guns.

---

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[shookwell]

Bilateral spontaneous simultaneous mac-on retinal detachment. The ophthalmologist told me that bilateral is always neurological. I told him that I read that in the book too but I'm standing here watching this guys retinas float around on sono.

He was good about it though, so even though I could tell he really didn't believe me on the phone, he came in and did the right thing for the patient once he saw that it was actually happening.

 

[dchristismi]

Maybe not as blatant as Bird's, but same gut feeling.


EMS brings in a STEMI.
Big ST elevations II, III, AVF. Reciprocal changes. Guy somewhat gray and ashen, uncomfortable, but sitting bolt upright in the occult-pneumothorax sort of way, looking a little off. Spidey senses tingling.

I call cardiology (who happens to be a stand-up guy unlike the cardiologist above) and says he's on his way because STEMI.
Guy's mediastium looks *maybe* a smidge wide on the portable, I roll the dice and personally escort him to the scanner.

Cardiologist shows up, and was, ahem, rather upset that I was boxing this guy's kidneys with my stupid CT scan when he Needed. To. Be. On. The. Cath. Lab. Table. Now.
Get him off the table. He doesn't need more contrast. The whole cath team is there now. He repeats his pleas to move this guy now. I believe he might have ordered the CT guys to stop because this was an obvious STEMI and dissections don't do that.


It was something out of West Side Story, and the Jets and the Sharks were going to rumble in the scanner.

(Not to bring in any other biases, but this guy was at least 6' 6" and I am a rather petite woman. So there's that intimidation factor. I was also relatively new to this hospital and he'd been there forever. I'm also not much for confrontation...)




"See... look... his perfusion is so bad that the contrast is taking a long time... we have to get him upstairs. It's not even to the aor... oh."


Cardiologist sees the dissection the same time I did.

Whips out his phone, calls CV surg, looks at me, gives me a nod, bops me on the shoulder and walks out.


(This guy didn't do as well as Bird's... those sorts of saves are truly rare.)

I saw a torsed ovary once who had all negative tests other than a large cyst, +flow on doppler, the works. But she was miserable. So again I rolled the dice, called her private OB, insisted he come see her. He was very skeptical, but not an ass about it. My secretary called me the next day to pass along a cryptic message "He said to tell you that you were right." It wasn't nearly as adrenaline provoking as the above but a potentially nasty reminder than patients don't read textbooks.

 

[Birdstrike]

Maybe not as blatant as Bird's, but same gut feeling.


EMS brings in a STEMI.
Big ST elevations II, III, AVF. Reciprocal changes. Guy somewhat gray and ashen, uncomfortable, but sitting bolt upright in the occult-pneumothorax sort of way, looking a little off. Spidey senses tingling.

I call cardiology (who happens to be a stand-up guy unlike the cardiologist above) and says he's on his way because STEMI.
Guy's mediastium looks *maybe* a smidge wide on the portable, I roll the dice and personally escort him to the scanner.

Cardiologist shows up, and was, ahem, rather upset that I was boxing this guy's kidneys with my stupid CT scan when he Needed. To. Be. On. The. Cath. Lab. Table. Now.
Get him off the table. He doesn't need more contrast. The whole cath team is there now. He repeats his pleas to move this guy now. I believe he might have ordered the CT guys to stop because this was an obvious STEMI and dissections don't do that.


It was something out of West Side Story, and the Jets and the Sharks were going to rumble in the scanner.

(Not to bring in any other biases, but this guy was at least 6' 6" and I am a rather petite woman. So there's that intimidation factor. I was also relatively new to this hospital and he'd been there forever. I'm also not much for confrontation...)




"See... look... his perfusion is so bad that the contrast is taking a long time... we have to get him upstairs. It's not even to the aor... oh."


Cardiologist sees the dissection the same time I did.

Whips out his phone, calls CV surg, looks at me, gives me a nod, bops me on the shoulder and walks out.


(This guy didn't do as well as Bird's... those sorts of saves are truly rare.)

I saw a torsed ovary once who had all negative tests other than a large cyst, +flow on doppler, the works. But she was miserable. So again I rolled the dice, called her private OB, insisted he come see her. He was very skeptical, but not an ass about it. My secretary called me the next day to pass along a cryptic message "He said to tell you that you were right." It wasn't nearly as adrenaline provoking as the above but a potentially nasty reminder than patients don't read textbooks.

Infuriating, disgusting, and appalling that your cardiologist claims not to know aortic arch dissections can dissect down into a coronary and cause a real, concurrent STEMI

 

[Apollyon]

Maybe not as blatant as Bird's, but same gut feeling.


EMS brings in a STEMI.
Big ST elevations II, III, AVF. Reciprocal changes. Guy somewhat gray and ashen, uncomfortable, but sitting bolt upright in the occult-pneumothorax sort of way, looking a little off. Spidey senses tingling.

I call cardiology (who happens to be a stand-up guy unlike the cardiologist above) and says he's on his way because STEMI.
Guy's mediastium looks *maybe* a smidge wide on the portable, I roll the dice and personally escort him to the scanner.

Cardiologist shows up, and was, ahem, rather upset that I was boxing this guy's kidneys with my stupid CT scan when he Needed. To. Be. On. The. Cath. Lab. Table. Now.
Get him off the table. He doesn't need more contrast. The whole cath team is there now. He repeats his pleas to move this guy now. I believe he might have ordered the CT guys to stop because this was an obvious STEMI and dissections don't do that.


It was something out of West Side Story, and the Jets and the Sharks were going to rumble in the scanner.

(Not to bring in any other biases, but this guy was at least 6' 6" and I am a rather petite woman. So there's that intimidation factor. I was also relatively new to this hospital and he'd been there forever. I'm also not much for confrontation...)




"See... look... his perfusion is so bad that the contrast is taking a long time... we have to get him upstairs. It's not even to the aor... oh."


Cardiologist sees the dissection the same time I did.

Whips out his phone, calls CV surg, looks at me, gives me a nod, bops me on the shoulder and walks out.


(This guy didn't do as well as Bird's... those sorts of saves are truly rare.)

I saw a torsed ovary once who had all negative tests other than a large cyst, +flow on doppler, the works. But she was miserable. So again I rolled the dice, called her private OB, insisted he come see her. He was very skeptical, but not an ass about it. My secretary called me the next day to pass along a cryptic message "He said to tell you that you were right." It wasn't nearly as adrenaline provoking as the above but a potentially nasty reminder than patients don't read textbooks.

I had a similar case, but, out here in the boonies, it's all by telephone to the ivory tower. Guy has burning substernal pain, and STEMI on ekg. Cards at the big house was great. As we're talking, guy's pain migrates. He says, "it doesn't sound like a STEMI, but I'll accept the pt and straighten it out here". He suggested the chest CT, and, lo and behold, DeBakey I, Stanford type A. VERY happy I did not heparinize this guy!

He lived, but had a complicated post-op course, including a colostomy after mesenteric ischemia.

 

[deleted547339]

I had a similar case, but, out here in the boonies, it's all by telephone to the ivory tower. Guy has burning substernal pain, and STEMI on ekg. Cards at the big house was great. As we're talking, guy's pain migrates. He says, "it doesn't sound like a STEMI, but I'll accept the pt and straighten it out here". He suggested the chest CT, and, lo and behold, DeBakey I, Stanford type A. VERY happy I did not heparinize this guy!

He lived, but had a complicated post-op course, including a colostomy after mesenteric ischemia.

Eh, everyone gets so uppity about heparinizing these folks, but the first thing they do in the OR is give them a big bolus of heparin to get them on pump.

 

[Perrin]

A year or two ago, I had a little old lady with diffuse right sided abdominal pain. Looked at her scan and she had an intussusception. I called the surgeon, nice guy who was a surgery resident on my team when I was a med student. He tells me there's no way, but he pulls it up, agrees that's what it is. Radiologist calls me a little later and tells me she has an intussusception.

 

[Lawpy]

Good thread

 

[gro2001]

I have a few similar ones from residency.

One was this guy in his mid 40s who came in with the most BS chest pain story ever. He had some extremely mild and nonspecific chest pain that had since resolved, but really came in because he had two friends die of heart attacks recently and was worried. No other risk factors and no family history. We did an ECG and a trop, with the plan of repeating a second and discharging him. ECG was stone cold normal, but the first troponin was just a little elevated. I think it was 0.1 (with the upper limit of negative being 0.04). Still, figured this earned him an admission. Admitted him to hospitalist. No beds upstairs though, so he sticks around in the ER. A few hours later, he starts complaining of some mild chest pain. I repeat an ECG. It has a couple of contiguous 1 mm STEs and some reciprocal changes. I activate the STEMI team. The first year cards fellow shows up. She is standing at the foot of the bed, looking at the ECG. I am standing on the right side of the patient. She is hemming and hawing, questioning whether this really counts for a STEMI, and that it's not really a whole mm elevation... Literally as she say this, the guy goes pale, says "I don't feel so good...", loses consciousness, and is in Vfib on the monitor. Since I was right there, I start chest compressions immediately. As I am pushing on his chest, he is awake, looking around, moaning, grabbing at things. There was a problem with the defibrillator, so it took a couple of minutes to get a replacement. When its time to stop for a pulse check, he loses consciousness again since he doesn't have a pulse. We defibrilate him on the second pulse check, and he comes back immediately, asking "What the hell was that?" Has no memory of the event, but is very concerned that the cards fellow is now pale and staring at him wide eyed "What's wrong, doc?". I turn to the cards fellow and deadpan "I really think he might be having a STEMI though". She immediately starts consenting him for cath. I don't think she took her hand off his pulse all the way up to the lab.

The other was this one young pregnant woman who came in with first trimester bleeding. She had just had an ultrasound done a week ago showing an IUP. I did a pelvic and an ultrasound myself. Os closed, but I just can't see an IUP. I do think I see a heterogenous mass in the adnexa and some free fluid though. So she is bleeding, BP a touch on the lower side, I don't see an IUP, and there's free fluid. Would be silly to miss an ectopic that obvious, but there's this official ultrasound from a week ago saying she has an IUP. At this hospital we had to call gyn for a consult to get an official endovaginal ultrasound (part of a turf war they were having with radiology). I call and explain my predicament.

Gyn: "Sounds like she has a threatened abortion, you don't need me, just tell her to follow up in clinic."
Me: "I think she may have a ruptured ectopic though..."
Gyn: "She just had an US by an ob attending [emphasis hers] saying she has an IUP!"
Me: "I don't know what to tell you. Look, I saved the images, want to come down and see them?"
Gyn: "I have like a bagillion consults to do!"
Me: "Please come, I really need your help with this patient"

This went on for a good 5 minutes with the gyn resident telling me all the reasons she doesn't want to do the consult and all the reasons why she shouldn't have to. I would just respond with "please" and "pretty please". Eventually she said that "just because you asked nicely" she would come down and repeat the ultrasound if it would "make me feel better". A co-resident of mine who was sitting next to me during the conversation said "If I were her I would have come down just to shut you up".

Gyn resident shows up, goes in the gyn room. Doesn't come out for a few minutes. Gyn attending shows up, goes in the room too. When they come out, they are wheeling the patient out, gyn resident is on the phone with the OR. Gyn attending hangs back to say that she does in fact have a ruptured ectopic and to congratulate us on a good catch. The patient went on to drop her BP pretty significantly just before making it in to the OR, ended up in the SICU, but ultimately did well. Gyn resident did come down after the case and very publicly apologized for giving push back and thanking me for not giving her a hard time, saying I earned unlimited BS consult privileges with no more pushback ever. I like to think I didn't abuse that privilege.

 

[deleted547339]

A year or two ago, I had a little old lady with diffuse right sided abdominal pain. Looked at her scan and she had an intussusception. I called the surgeon, nice guy who was a surgery resident on my team when I was a med student. He tells me there's no way, but he pulls it up, agrees that's what it is. Radiologist calls me a little later and tells me she has an intussusception.

That’s surprising that a surgeon wouldn’t have seen or heard of that before. Usually they have a leading edge cancer or some other reason.

 

[Psai]

That’s surprising that a surgeon wouldn’t have seen or heard of that before. Usually they have a leading edge cancer or some other reason.

Saw one in the ED a year ago in an older guy.

 

[deuist]

I have had 2 women with ruptured hemorrhagic ovarian cysts with free bleeding internally. In both instances the OB came in and took the patient to the OR without fuss.

Adult with no prior surgeries with intussusception. The surgeon only took the patient to the OR the next day.

Posterior STEMI. The cardiologist told me that it wasn't real and said that he would only take the patient to the cath lab to prove me wrong. I was right.

Bilateral angle closure glaucoma. I had to transfer the patient since I don't have ophtho. The receiving doc thought that my tonopen was malfunctioning. The ophthalmologist at the other facility agreed that the patient had bilateral angle closure from topamax usage.

 

[southerndoc]

Bilateral angle closure glaucoma. I had to transfer the patient since I don't have ophtho. The receiving doc thought that my tonopen was malfunctioning. The ophthalmologist at the other facility agreed that the patient had bilateral angle closure from topamax usage.

Wh-wh-what? I never realized Topamax could cause this. :O

 

[thegenius]

Bilateral spontaneous simultaneous mac-on retinal detachment. The ophthalmologist told me that bilateral is always neurological. I told him that I read that in the book too but I'm standing here watching this guys retinas float around on sono.

He was good about it though, so even though I could tell he really didn't believe me on the phone, he came in and did the right thing for the patient once he saw that it was actually happening.

Which was what? Pt go emergently to the OR to tack down the retina?

 

[thegenius]

I saw a torsed ovary once who had all negative tests other than a large cyst, +flow on doppler, the works. But she was miserable. So again I rolled the dice, called her private OB, insisted he come see her. He was very skeptical, but not an ass about it. My secretary called me the next day to pass along a cryptic message "He said to tell you that you were right."

I've had this too. Large complex cystic structure like 8 cm round, + flow on doopler. Pt needed multiple rounds of IV narcotics just to bring her pain to a 5. Gyn was skeptical despite me telling him that I've had multiple gynecologists tell me that you can have ovarian torsion with blood flow. He was nice about it though. Saw the patient and took her to the OR.

Next day I read the operative report "visualization of left ovary confirmed torsion...."

 

[Perfect Hair Day]

he would only take the patient to the cath lab to prove me wrong.

#nonmaleficence

 

[zero0]

So are cardiologists just jackasses or are they disproportionately represented on here because cc of chest pain is so common?

 

[bravotwozero]

Probably the latter. I had a cardiologist in residency who would say all the time that he would ‘give up his cardiology practice’ if a patients reproducible chest pain was the result of acs or an MI, despite documented evidence to the contrary.


Sent from my iPhone using Tapatalk

 

[deleted547339]

So are cardiologists just jackasses or are they disproportionately represented on here because cc of chest pain is so common?

Little of both.

They see a different patient population than we do and seem very antiquated when it comes to EBM. As an example, I teach all of my students about the positive and negative predictive signs for ACS. Reproducibility may have a negative predictive value, but not significant enough to rule out acs. When you’re up on the literature and have a condescending cardiologist going on what their textbook says a classic presentation, you’re going to butt heads.

Mine was a cardiologist telling me he “doesn’t believe in avr”. I told him that I would happily quote him in the chart and reminded him of the guidelines.

 

[Apollyon]

10% of MIs have reproducible cheat pain. One out of 10. Some of these cards guys are really choosing the wrong hill on which to die.

 

[bravotwozero]

I think it says 30% in tintinalli?...

 

[Apollyon]

It is more than zero. To fight against that seems foolhardy.

 

[RustedFox]

2012.
First year out of residency.

Old, buttery man has chest pain. EKG shows LBBB which he has had before, but with serious discordance.
Old Man Cardiologist says to me on the phone: "There's no way you can tell an MI if there's a left bundle."
"Ever heard of Sgarbossa criteria?"

He accused me of "making it up".
No joke.

Cath'd. 100% LAD.

Thank Christ that old bastard has retired.

 

[RoyBasch]

Mine was a cardiologist telling me he “doesn’t believe in avr”.

I hate that my liability and the outcomes of my patients depend on people like this.

 

[lucid_leprechaun]

Alcoholic cirrhotic with leg swelling, bullae, pain with palpation and movement at ankle. Radiologist: plain films effectively rule out necrotizing soft tissue infection. Meta-analysis: 50% sensitive, CT 80%. Radiologist: No you’re wrong, the definition is air on plain films.

 

[gro2001]

So are cardiologists just jackasses or are they disproportionately represented on here because cc of chest pain is so common?

I don't think cardiologists are jackasses. Or at least any more so than docs of any other specialty, including EM.

We have a relatively low threshold to consult cards, or fax them the ECG for an opinion, or even activate the STEMI team. This is as it should be, because while we can't be 100% sensitive and have to be reasonably specific, we are still expected to act as a more sensitive (rather than specific filter). Part of this is that nothing invasive is going to happen to the patient just because I chose to pull the trigger on the consult/activation. The cardiologist on the other hand has to pull the trigger on an invasive, labor intensive procedure, with a non zero complication rate. So it makes sense that they have to act in a way that makes them a more specific test than we are. Add to that egos on both sides, an often emotionally charged situation for everyone involved, possible system/logistic barriers (activate the cath lab at night and a bunch of people have to start driving in from home) and you've got a prime situation for conflict.

Another component of this is that a lot of the time, particularly at academic institutions, the primary contact point between the EM team and the cardiology team is the cardiology fellow. The unenviable position of the fellow is to pretend to be the expert in something they can not possibly be an expert in yet. A first year cards fellow may have been an internal medicine resident just a few months ago. While I totally respect their training, it's just going to be the case that an experienced EM attending will usually have seen a wider variety of uncommon presentations than a first year cards fellow. Often both the EM attending and the cards fellow are not aware of that disparity during their initial interaction.

And finally, at least at a couple of the institutions I am familiar with, there is a certain expectation of cards fellows to be the bad ass that doesn't over react to symptoms or even objective findings. This is what leads to comments on elevated troponins along the lines of "we don't start worrying until they are way higher" or "these elevations are really under 1 mm" and "doesn't sound cardiac" to something that clearly does.

 

[NITRAS]

It is more than zero. To fight against that seems foolhardy.

Actually, I disagree. (I'm a hospitalist btw). You should discharge people that have a diagnostic uncertainly of very low (1-3%), I shouldn't give you slack for people that have pretty low diagnostic uncertainly of like 5%-10%.

If you admit everyone who might have ACS, you could admit everyone who comes in. You are going to miss people. If you aren't, you are practicing poorly and causing more harm than good because admitting people comes with risk.

Sorry to sideline the thread, very entertaining thread.

 

[Zebra Hunter]

I’ve always called BS on that 15% of MIs have reproducible chest pain. I’ve seen hundreds of MIs, I can’t remember ever having a patient with reproducible chest pain who had a STEMI, ischemic EKG changes, or bumped trop. Do some of these patients report tenderness when I press their chest? Sure, but when I ask them to specify whether it feels the same as the chest pain that brought them to the hospital, the answer has been universally “no”. Thats not to say I wouldn’t believe an EKG or troponin if their answer was “yes”, but the face validity of that statistic, in my experience, is lacking.

 

[deleted859535]

Actually, I disagree. (I'm a hospitalist btw). You should discharge people that have a diagnostic uncertainly of very low (1-3%), I shouldn't give you slack for people that have pretty low diagnostic uncertainly of like 5%-10%.

If you admit everyone who might have ACS, you could admit everyone who comes in. You are going to miss people. If you aren't, you are practicing poorly and causing more harm than good because admitting people comes with risk.

Sorry to sideline the thread, very entertaining thread.

So, I'm a conservative guy, but I don't want to admit everyone under the sun. But to stick with ACS as an example, if there's a ~10% pretest probability of someone having a major underlying disease which is (a) life-threatening, (b) functionally impairing and (c) highly litigated, I am going to err towards admitting them every day of the week. Being careful isn't practicing poorly, and I don't need anyone's slack for being concerned about solely taking responsibility for a one in ten chance of a major "miss." I have noticed that I have not had a single one of these patients discharged from the ED by the admitting service once they've seen the patient.

Back to the thread: I have had two Wellens syndrome cases that were blown off by the cardiologist with the response of "so?". Both of them had major disease on their cath reports the following day.

 

[Zebra Hunter]

So, I'm a conservative guy, but I don't want to admit everyone under the sun. But to stick with ACS as an example, if there's a ~10% pretest probability of someone having a major underlying disease which is (a) life-threatening, (b) functionally impairing and (c) highly litigated, I am going to err towards admitting them every day of the week. Being careful isn't practicing poorly, and I don't need anyone's slack for being concerned about solely taking responsibility for a one in ten chance of a major "miss." I have noticed that I have not had a single one of these patients discharged from the ED by the admitting service once they've seen the patient.

Back to the thread: I have had two Wellens syndrome cases that were blown off by the cardiologist with the response of "so?". Both of them had major disease on their cath reports the following day.

Are you saying they didn’t believe it was Wellens or that you were upset they didn’t take them to the cath lab immediately? I ask because Wellens syndrome doesn’t need emergent PCI unless their chest pain is returning. Wellens is a sign of reperfusion.

 

[kjamess]

Back to the thread: I have had two Wellens syndrome cases that were blown off by the cardiologist with the response of "so?". Both of them had major disease on their cath reports the following day.

They blew it off, but still were concerned enough to cath them the next day

 

[Birdstrike]

Do some of these patients report tenderness when I press their chest? Sure...

You just defined "reproducible chest pain," perfectly. That was the place to stop.

Do some of these patients report tenderness when I press their chest? Sure, but when I ask them to specify whether it feels the same as the chest pain that brought them to the hospital, the answer has been universally “no”.

Now, you've changed the definition to your own. But that's not how this works. Look what you did.

You admitted straight up, that "some" of your patients with MIs come in with reproducible chest pain. And when they hit the door, neither you, nor anyone else knew whether they were having an MI or not. Then when you got confirmation of the MIs, after having an EKG and enzymes, you went back (in your head) and undid the 15% that had the reproducible chest pain and convinced yourself it actually wasn't "reproducible pain" because now that you had this other information that no one ever has at the outset. You can't retrospectively "rule out" reproducible chest pain at presentation, based on a cath report that comes from the future. If you could, you'd have sent them all home without any of that.

That's the whole point. When these conversations are happening, the confirmation isn't yet there one way or the other, at the time the consultant is telling the ED doc they don't need any confirmatory tests, because "After all, it's reproducible pain!" and can't be an MI.

I've never seen a greater example of hindsight bias.

I suggest you walk down in the ED, start seeing patients 1,000 patients per year with "chest pain," then with your physical exam alone, rule out all 1,000. You send all those patients home, that have "reproducible chest pain." No tests, no enzymes, no heart cath and no stress tests. You don't need them. You're that good. You said it yourself. Stake your career on it. Better yet, stake your life on it. Not the patient's, but yours. Then we'll see how confident you are.

But you would never do it. Because you can't be cavalier about "reproducible" chest pain. Because you already said "some" of your MIs have it. And you can't get cocky about it, until you have your retrospectoscope, and you walk in the next day with your stress test results, your 3 sets of enzymes and your heart cath report, and courageously declare, beating your chest valiantly on horseback like the robed warrior-guy at Medieval Times, in a deep, authoritative echoing roar, that you've ruled out reproducible chest pain on admission.

 

[Zebra Hunter]

You just defined "reproducible chest pain," perfectly. That was the place to stop.


Now, you've changed the definition to your own. But that's not how this works. Look what you did.

You admitted straight up, that "some" of your patients with MIs come in with reproducible chest pain. And when they hit the door, neither you, nor anyone else knew whether they were having an MI or not. Then when you got confirmation of the MIs, after having an EKG and enzymes, you went back (in your head) and undid the 15% that had the reproducible chest pain and convinced yourself it actually wasn't "reproducible pain" because now that you had this other information that no one ever has at the outset. You can't retrospectively "rule out" reproducible chest pain at presentation, based on a cath report that comes from the future. If you could, you'd have sent them all home without any of that.

That's the whole point. When these conversations are happening, the confirmation isn't yet there one way or the other, at the time the consultant is telling the ED doc they don't need any confirmatory tests, because "After all, it's reproducible pain!" and can't be an MI.

I've never seen a greater example of hindsight bias.

I suggest you walk down in the ED, start seeing patients 1,000 patients per year with "chest pain," then with your physical exam alone, rule out all 1,000. You send all those patients home, that have "reproducible chest pain." No tests, no enzymes, no heart cath and no stress tests. You don't need them. You're that good. You said it yourself. Stake your career on it. Better yet, stake your life on it. Not the patient's, but yours. Then we'll see how confident you are.

But you would never do it. Because you can't be cavalier about "reproducible" chest pain. Because you already said "some" of your MIs have it. And you can't get cocky about it, until you have your retrospectoscope, and you walk in the next day with your stress test results, your 3 sets of enzymes and your heart cath report, and courageously declare, beating your chest valiantly on horseback like the robed warrior-guy at Medieval Times, in a deep, authoritative echoing roar, that you've ruled out reproducible chest pain on admission.

...okay

Edit: Also, I’m an ER doc

 

[kjamess]

I don't think cardiologists are jackasses. Or at least any more so than docs of any other specialty, including EM.

We have a relatively low threshold to consult cards, or fax them the ECG for an opinion, or even activate the STEMI team. This is as it should be, because while we can't be 100% sensitive and have to be reasonably specific, we are still expected to act as a more sensitive (rather than specific filter). Part of this is that nothing invasive is going to happen to the patient just because I chose to pull the trigger on the consult/activation. The cardiologist on the other hand has to pull the trigger on an invasive, labor intensive procedure, with a non zero complication rate. So it makes sense that they have to act in a way that makes them a more specific test than we are. Add to that egos on both sides, an often emotionally charged situation for everyone involved, possible system/logistic barriers (activate the cath lab at night and a bunch of people have to start driving in from home) and you've got a prime situation for conflict.

Another component of this is that a lot of the time, particularly at academic institutions, the primary contact point between the EM team and the cardiology team is the cardiology fellow. The unenviable position of the fellow is to pretend to be the expert in something they can not possibly be an expert in yet. A first year cards fellow may have been an internal medicine resident just a few months ago. While I totally respect their training, it's just going to be the case that an experienced EM attending will usually have seen a wider variety of uncommon presentations than a first year cards fellow. Often both the EM attending and the cards fellow are not aware of that disparity during their initial interaction.

And finally, at least at a couple of the institutions I am familiar with, there is a certain expectation of cards fellows to be the bad ass that doesn't over react to symptoms or even objective findings. This is what leads to comments on elevated troponins along the lines of "we don't start worrying until they are way higher" or "these elevations are really under 1 mm" and "doesn't sound cardiac" to something that clearly does.

This is a reasonable post. From someone frequently on the other end of these conversations, some of the initial reactions you'll get is possibly based on prior experience with the EM provider. If it is from someone you know is really good/thoughtful, then you'll take everything they say at face value no matter how atypical/unlikely the presentation sounds. On the other hand, if its someone who cries wolf for seemingly every patient and constantly activates, then admittedly I'm more likely to be skeptical if the presentation is sketchy with alternative diagnoses (though always will do due diligence).

The opposite occurs as well. In my young career I've been the one to point out cholecystitis x2, aortic dissection x1, massive PE x2, IPH x1 and mesenteric ischemia x1 for ED patients who are "clearly having ACS!!!!". And missed STEMIs that were signed off by EM attendings have been an unfortunate occurrence as well.

We understand you are built for sensitivity and uncommon presentations most certainly do occur (we see it more so on the inpatient side) which is why my group will err on the side of caution in high stake situations and never rely on one factor. But the reality is that the overwhelming majority of BS will prove to be BS one a full workup is completed (from experience in 90+% range). This informs some of the confident opinions you'll get from cardiologists, but we are not infallible and I always assess atypical presentations in the full context especially when an alternative diagnosis isnt readily apparent. There are a lot of nuances that we have to deal with after the fact (this is where specificity comes in) that affect patient management in the intermediate to long term, so cardiologists will have that in mind during initial interactions.

As far as 1st year fellows go, they wont be acting alone and typically run these situations/EKGs by the on call attending. They get reamed for NOT calling if its a borderline situation (attending deals with the liability after all).

 

[Birdstrike]

...okay

Edit: Also, I’m an ER doc

..okay. The post was directed at people that criticize ER docs retrospectively.

Edit: Still though, if you "call BS" on "15% of MIs having reproducible chest pain," then why don't you just push on their chest, and send them home?

You're saying on one hand, the talk of reproducible chest pain in MI patients is silly and you "call BS" on those who take it seriously, while on the other hand, calling BS on yourself calling BS on it, so much so, that you still order an EKG, enzymes and admit patients for stress tests and heart caths. Which is it?

 

[Zebra Hunter]

..okay. The post was directed at people that criticize ER docs retrospectively.

Edit: Still though, if you "call BS" on 15% of MIs having reproducible chest pain, then why don't you just push on their chest, and send them home?

You’re implying I don’t do that. They all still get EKGs and delta troponins, and then I send them on their way for the clear cut chest wall tenderness.

 

[Birdstrike]

You’re implying I don’t do that. They all still get EKGs and delta troponins, and then I send them on their way for the clear cut chest wall tenderness.

EKGs and troponins do not rule in, or rule out, musculoskeletal causes of chest pain.

 

[Zebra Hunter]

EKGs and troponins do not rule in, or rule out, musculoskeletal causes of chest pain.

Shoulda stuck with your original reply of “Okay. Cool.” I’m tired of this back and forth.

 

[Birdstrike]

Shoulda stuck with your original reply of “Okay. Cool.” I’m tired of this back and forth.

Fair enough. I'll admit, I was being a little trollish in the last couple of posts. I don't know why, but I thought you were a hospitalist or cardiologist coming to this thread to do the old "I'm a hospitalists, I'm smarter than you, I can rule out MI at the beside" schtick, I've heard so many times. I mean, I know you're not a hosp/cards person seeing your screen name now from seeing you post a million times, but I read your post fast without really looking at it. So, I apologize for being a little trollish there. I just can't stand the retrospectoscope second-guessing stuff, after someone has all the results downstream. I'm the first one to defend any ED doc against that. It drives me nuts. I'm sure what you're doing with your patients as an EP, in the ED, is perfectly fine.

 

[UKEMdoc]

Our cardiologists have previously called us out for admitting too many BS chest pains so they decided to come to the ED to show us how to avoid admissions.
They went up by 50%

 

[Birdstrike]

Our cardiologists have previously called us out for admitting too many BS chest pains so they decided to come to the ED to show us how to avoid admissions.
They went up by 50%

Lol. Awesome. That's exactly it. All of a sudden, it's not so easy.
Best post of the thread.

 

[WilcoWorld]

You just defined "reproducible chest pain," perfectly. That was the place to stop.


Now, you've changed the definition to your own. But that's not how this works. Look what you did.

You admitted straight up, that "some" of your patients with MIs come in with reproducible chest pain. And when they hit the door, neither you, nor anyone else knew whether they were having an MI or not. Then when you got confirmation of the MIs, after having an EKG and enzymes, you went back (in your head) and undid the 15% that had the reproducible chest pain and convinced yourself it actually wasn't "reproducible pain" because now that you had this other information that no one ever has at the outset. You can't retrospectively "rule out" reproducible chest pain at presentation, based on a cath report that comes from the future. If you could, you'd have sent them all home without any of that.

That's the whole point. When these conversations are happening, the confirmation isn't yet there one way or the other, at the time the consultant is telling the ED doc they don't need any confirmatory tests, because "After all, it's reproducible pain!" and can't be an MI.

I've never seen a greater example of hindsight bias.

I suggest you walk down in the ED, start seeing patients 1,000 patients per year with "chest pain," then with your physical exam alone, rule out all 1,000. You send all those patients home, that have "reproducible chest pain." No tests, no enzymes, no heart cath and no stress tests. You don't need them. You're that good. You said it yourself. Stake your career on it. Better yet, stake your life on it. Not the patient's, but yours. Then we'll see how confident you are.

But you would never do it. Because you can't be cavalier about "reproducible" chest pain. Because you already said "some" of your MIs have it. And you can't get cocky about it, until you have your retrospectoscope, and you walk in the next day with your stress test results, your 3 sets of enzymes and your heart cath report, and courageously declare, beating your chest valiantly on horseback like the robed warrior-guy at Medieval Times, in a deep, authoritative echoing roar, that you've ruled out reproducible chest pain on admission.

I don't see @Zebra Hunter as being guilty of the retrospective fallacy that you're accusing. I don't need serial troponins before I can ask "is that chest tenderness the same pain that you were worried about?"

edit: nevermind - I posted before reading the resolution that you two subsequently came to.

 

[WilcoWorld]

Our cardiologists have previously called us out for admitting too many BS chest pains so they decided to come to the ED to show us how to avoid admissions.
They went up by 50%

That pretty well sums up the issue.

 

[Birdstrike]

I don't see @Zebra Hunter as being guilty of the retrospective fallacy that you're accusing. I don't need serial troponins before I can ask "is that chest tenderness the same pain that you were worried about?"

edit: nevermind - I posted before reading the resolution that you two subsequently came to.

There's absolutely nothing wrong with an ER doc diagnosing chest wall pain and sending that home. That's the system working how it's supposed to work. That's very different than a hospitalist or cardiologist questioning an EP downstream claiming if only it was them in the ED they could rule people out at the bedside and 100% of their admits would rule in, implying that's how EPs should be able to do it and giving them hell for every admission. I blew through @Zebra Hunter's post too quickly, assuming it was written in that vain, by a hospitalist. My bad.

 

[Apollyon]

Actually, I disagree. (I'm a hospitalist btw). You should discharge people that have a diagnostic uncertainly of very low (1-3%), I shouldn't give you slack for people that have pretty low diagnostic uncertainly of like 5%-10%.

If you admit everyone who might have ACS, you could admit everyone who comes in. You are going to miss people. If you aren't, you are practicing poorly and causing more harm than good because admitting people comes with risk.

Sorry to sideline the thread, very entertaining thread.

There's kind of a very long gulf between what I posted and what you did. Say we have two patients: first is a 25 year old female, smoker, with right sided chest pain, burning in character, nonradiating, no SOB, and pain is not reproducible. Second is a 58 y/o black male, 4 risk factors, burning pain, squeezing, rad to L arm, SOB, took 3 NTG before coming in, some relief, and the chest wall is tender on the left. Are you going to discharge the second pt?

I'm just saying that hanging your hat on reproducible pain ruling out cardiac causes might miss something.

 

[Birdstrike]

You are going to miss people.

Why should EPs accept "missing people" as the norm?
I don't think they should have to accept that, right out of the gate.
You want them to accept the reality of "missing people" because when you come down to see the patient, you're not going to "miss them." You're going to admit them. But you want someone else to do the missing, for you. Otherwise, you'd march down, and say, "Awesome. Easiest consult of the day. Obvious chest wall pain. And guess what, I get paid just the same as a hard admission. Great!" and click discharge. But 99 out of a hundred times, the hospitalist comes down, sees the patient, goes through a detailed evaluation, the bravado collapses, and they admit the patient because they know you can't rule people out at the bedside.

 

[Birdstrike]

There's kind of a very long gulf between what I posted and what you did. Say we have two patients: first is a 25 year old female, smoker, with right sided chest pain, burning in character, nonradiating, no SOB, and pain is not reproducible. Second is a 58 y/o black male, 4 risk factors, burning pain, squeezing, rad to L arm, SOB, took 3 NTG before coming in, some relief, and the chest wall is tender on the left. Are you going to discharge the second pt?

I'm just saying that hanging your hat on reproducible pain ruling out cardiac causes might miss something.

Reminds me of another few patients:

28-year-old female. Was exercising, developed crushing substernal chest pain, vomited and got short of breath. Was evaluated. EKG, CXR normal. Sent home. Why?

Cuz "28-yr-old females don't have heart disease, you idiot." "BS chest pain," right?

Came back later: ST segment elevation MI. Enzymes up.

Cath: Normal!

Diagnosis: Coronary vasospasm



13-yr-old male, came to my ED. Chest pain. Non-specific. No resp symptoms, no trauma. No PE risk factors. No early familial MI history, Kawasaki's, Marfan's or anything else weird. Chest x-ray, ekg, and home, because "kids don't get heart disease," right?

Nope.

I ordered a troponin and it was high. Not borderline, but very high.

Myocarditis. Transfer from satellite tiny-ED to tertiary Peds center.

 

[NITRAS]

Why should EPs accept "missing people" as the norm?
I don't think they should have to accept that, right out of the gate.
You want them to accept the reality of "missing people" because when you come down to see the patient, you're not going to "miss them." You're going to admit them. But you want someone else to do the missing, for you. Otherwise, you'd march down, and say, "Awesome. Easiest consult of the day. Obvious chest wall pain. And guess what, I get paid just the same as a hard admission. Great!" and click discharge. But 99 out of a hundred times, the hospitalist comes down, sees the patient, goes through a detailed evaluation, the bravado collapses, and they admit the patient because they know you can't rule people out at the bedside.

My point is that you cannot rule out ACS in the ED. Not that you should discharge everyone with reproducible chest pain. Not any particular history, lab test, sign or symptom can rule it out. Heck, even a stress test can't with 100% certainty. You can't admit everyone.

I never have a problem with chest pain admission. They are simple, easy, and I can understand the position ED docs are in.

I'm sorry for diverting the thread.

 

[GeneralVeers]

Chest wall tenderness, negative EKG, negative troponin x 1, and HEART score < 4 means discharge.

 

[Birdstrike]

Chest wall tenderness, negative EKG, negative troponin x 1, and HEART score < 4 means discharge.

#Gangsta