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

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This thread reminds me of the time an ED resident admitted a chest pain patient to me. When I evaluated the patient, she had left shoulder pain which was chronic, never anything with her chest.
 
Birdstrike said:
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.
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No worries, bud. We all do that from time to time. I do appreciate you admitting your mistake which I don’t think is really necessary but refreshing to see on a semi-anonymous Internet forum.
 
Zebra Hunter said:
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.
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That was the odd part. In both cases, it was a story of intermittent, recent exertional chest pain.

kjamess said:
They blew it off, but still were concerned enough to cath them the next day
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That.
 
New one for me yesterday... scrotal compartment syndrome. Yes, it actually exists. In my 10 years I had never even heard of such. This guy had an incarcerated inguinal hernia (fat containing; didn't even have incarcerated bowel). It caused so much inflammation and edema that it created a scrotal compartment syndrome. His ultrasound (ordered by the screening APP) had decreased flow to both testicles. Urology said they see it occasionally.
 
southerndoc said:
New one for me yesterday... scrotal compartment syndrome. Yes, it actually exists. In my 10 years I had never even heard of such. This guy had an incarcerated inguinal hernia (fat containing; didn't even have incarcerated bowel). It caused so much inflammation and edema that it created a scrotal compartment syndrome. His ultrasound (ordered by the screening APP) had decreased flow to both testicles. Urology said they see it occasionally.
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That sounds absolutely horrible. Had no idea that existed and to be honest I kind of wish I still didn’t....
 
southerndoc said:
New one for me yesterday... scrotal compartment syndrome. Yes, it actually exists. In my 10 years I had never even heard of such. This guy had an incarcerated inguinal hernia (fat containing; didn't even have incarcerated bowel). It caused so much inflammation and edema that it created a scrotal compartment syndrome. His ultrasound (ordered by the screening APP) had decreased flow to both testicles. Urology said they see it occasionally.
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That's nuts.
 
nlax30 said:
As a Cards subspecialist I’m enjoying these cardio stories. Anyone get pushback from an EP (Electrophysiology EP) in the ED?
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During residency I was told by EP that the hypotensive bradycardic patient that I floated a pacer in was just having a "prolonged vagal episode." Wasn't really pushback per se, but I did think it was a less than stellar explanation for his ultimately 2 day long episode of bradycardia requiring transvenous pacing.
 
All renal specialists- omg you can't use anything other than N/S for this ESRD patient.
 
nlax30 said:
As a Cards subspecialist I’m enjoying these cardio stories. Anyone get pushback from an EP (Electrophysiology EP) in the ED?
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I don't think we interact with EPs often enough to have too many conflicts. Also most of the time they are not the ones that are going to be the primary admitting team either way, so that minimizes potential for conflict further.

Occasionally you get silly pushback on patients with a pacemaker coming in with syncope that need to be interrogated, but that's usually relatively easy to overcome. The funny part about that is how it's sometimes the same people who would be fighting your admissions tooth and nail not so long ago, now don't want to be bothered to come down and do a pacer interrogation even when it might spare the patient an admission. But I think that's just baseline inertia, rather than true obstructionism.
 
Renal cyst rupture as a consequence of sexual intercourse.
 
NITRAS said:
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.
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Congrats for your reasonable and ethical approach. I also try to help ED colleagues in hematuria and small renal colics.

If the patient has groos hematuria or heavy colic I often take it to the ward, at least I suggest admission to the patient. It saves significant headache from the ED doctor and is also more comfortable to me.
 
I had a patient sent from clinic by GI attending for acute on chronic pancreatitis. His panc was burnt out - developed DM, etc. his lipase was minimally elevated. The GI fellow told my NP it couldn’t be pancreatitis. That’s fun.
 
I'm a little bit more sympathetic to that GI doc's view. There's not much you can go on for acute on chronic pancreatitis, to make a definitive diagnosis. These cases are almost always a pain in the @ss most of the time, with a lot of drug seekers using a history of legit pathology to fake their complaints. You won't see much on the ct, or lipase levels, to guide you to a diagnosis.
 
bravotwozero said:
I'm a little bit more sympathetic to that GI doc's view. There's not much you can go on for acute on chronic pancreatitis, to make a definitive diagnosis. These cases are almost always a pain in the @ss most of the time, with a lot of drug seekers using a history of legit pathology to fake their complaints. You won't see much on the ct, or lipase levels, to guide you to a diagnosis.
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Exactly. You won’t see much - hard to prove or disprove. So saying “it’s not pancreatitis” without seeing the patient after his attending sent him to the ER with acute on chronic pancreatitis is entirely inappropriate.
 
TimesNewRoman said:
Exactly. You won’t see much - hard to prove or disprove. So saying “it’s not pancreatitis” without seeing the patient after his attending sent him to the ER with acute on chronic pancreatitis is entirely inappropriate.
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Ever seen anyone die from a burned out "acute on chronic" pancreatitis with normal enzymes?
 
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I would never admit "chronic pancreatitis" unless there were abnormal vitals, they couldn't tolerate PO or had some other PROVABLE problem going on, like an abnormal sodium or something. There is nothing we can do for these people in the hospital, and most of them are drug seekers trying to game the system
 
GeneralVeers said:
Chest wall tenderness, negative EKG, negative troponin x 1, and HEART score < 4 means discharge.
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I generally agree with this. It is pretty much the mainstay of my practice, the only modification I make is that the time of pain onset/duration matters.

I only "believe" a negative trop if it is AT LEAST 3 hours from time of pain onset. Of course we are talking about "low risk" chest pain the first place. But if a pt is otherwise low risk, (HEART score <4), EKG negative, but chest pain started 1 hour prior to arrival; I will repeat the trop (delta trop) in 2 hours while observing the pt on tele in the ER such that the last troponin is at least 3 hours from onset of pain.

Yes I recognize there is considerable debate about the timing of trops and the most conservative comentaters would say that in a high risk patient that only a trop 8-10 hours after onset of pain can truly be interpreted as negative to suggest AGAINST NSTEMI; however, if the patient is really high risk that is why we (I) admit them at that point to get serial trops q6h for like the next 24 hours.
 
RoyBasch said:
I generally agree with this. It is pretty much the mainstay of my practice, the only modification I make is that the time of pain onset/duration matters.

I only "believe" a negative trop if it is AT LEAST 3 hours from time of pain onset. Of course we are talking about "low risk" chest pain the first place. But if a pt is otherwise low risk, (HEART score <4), EKG negative, but chest pain started 1 hour prior to arrival; I will repeat the trop (delta trop) in 2 hours while observing the pt on tele in the ER such that the last troponin is at least 3 hours from onset of pain.

Yes I recognize there is considerable debate about the timing of trops and the most conservative comentaters would say that in a high risk patient that only a trop 8-10 hours after onset of pain can truly be interpreted as negative to suggest AGAINST NSTEMI; however, if the patient is really high risk that is why we (I) admit them at that point to get serial trops q6h for like the next 24 hours.
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I usually discharge all low-risk patients if I can HEART score them out. I use 1 troponin. If they are high risk, I simply admit them. I almost never use serial troponins anymore, as I'm not sure there is much diagnostic utility in low-risk patients.
 
GeneralVeers said:
I usually discharge all low-risk patients if I can HEART score them out. I use 1 troponin. If they are high risk, I simply admit them. I almost never use serial troponins anymore, as I'm not sure there is much diagnostic utility in low-risk patients.
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I'm interested in hearing how this plays out with the HEART scores. I agree the 2nd troponin never seems to be useful in low risk chest pain.

But pretty much every old person with chest pain is at least a 4. What do you do with the 4-6 range? Do you not get repeat troponins on them? Admit them all after 1 troponin? Send them home?

When you have someone who is truly high risk 7 or more, do your hospitalists ever push back without the repeat troponin? I could see mine telling me to call them back after the repeat is back if I tried this.
 
GeneralVeers said:
I would never admit "chronic pancreatitis" unless there were abnormal vitals, they couldn't tolerate PO or had some other PROVABLE problem going on, like an abnormal sodium or something. There is nothing we can do for these people in the hospital, and most of them are drug seekers trying to game the system
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This guy wasn’t your typical panc - very legit. Inpatient rehab now dried out. Compliant. Had a complex history. Having bad pain and not tolerating PO. Seen by GI attending who wanted him admitted and get an MRCP. Lipase was up, but not 3x normal.
 
Still waiting for a single case of death by "burned out pancreas pancreatitis."
 
OneTwoThreeFour said:
It's hard when every patient comes in with a baseline HEART of 3.
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I had a patient with a HEART score of 2 (1 point for age in a 50-something year old, 1 point for troponin 0.04, normal at my institution is 0.01-0.03) with slightly elev. creatinine, very GI sounding story, normal EKG, I waited and did a 2nd trop a few hours later, still 0.04, d/c home. I check on my record of patients routinely a few days later. Guy came back with a change in his quality and story in the middle of the night, still normal EKG, and trop jumped to 0.22 and admitted w/ cath showing a suspect lesion 90%.
I kinda give up at this point when HEART score fails, lol. Can't say I would've done anything differently though.
 
KGflyboy said:
But pretty much every old person with chest pain is at least a 4. What do you do with the 4-6 range? Do you not get repeat troponins on them? Admit them all after 1 troponin? Send them home?

When you have someone who is truly high risk 7 or more, do your hospitalists ever push back without the repeat troponin? I could see mine telling me to call them back after the repeat is back if I tried this.
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ADMIT.
NO.
That said average age at my institution is ~80yo, and cardiologists are on the conservative side (probably because w/ this age range they see enough things go wrong w/ normal trop's and EKG's.
 
Rendar5 said:
I had a patient with a HEART score of 2 (1 point for age in a 50-something year old, 1 point for troponin 0.04, normal at my institution is 0.01-0.03) with slightly elev. creatinine, very GI sounding story, normal EKG, I waited and did a 2nd trop a few hours later, still 0.04, d/c home. I check on my record of patients routinely a few days later. Guy came back with a change in his quality and story in the middle of the night, still normal EKG, and trop jumped to 0.22 and admitted w/ cath showing a suspect lesion 90%.
I kinda give up at this point when HEART score fails, lol. Can't say I would've done anything differently though.
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Well, a HEART score of 0-3 has a MACE rate of 0.9-1.7%, so some people WILL fall through into that category unfortunately. But, yeah, sucks to see someone bounce back like that.
 
I realize I'm not the first person to say this, but I feel that the fact that someone is still "low risk" for MACE even with a troponin >3x normal limit and a moderately suspicious story underscores the fact that HEART is a guide, not a rule.

I quote HEART in notes on discharges where it's basically "I thought about ischemic heart disease in this case but don't feel that was likely the case, also low-risk HEART, ...". That's where it's a little more useful on a practical basis. Yes, it helps risk stratify in some cases. If I'm concerned about a person who also happens to have a HEART of 3, I'm still going to want to obs them overnight. Can't help but feel that my clinical concern even with a HEART of 3 makes that "0.9% - 1.7%" risk of MACE indeterminately higher. Even if not, far safer to prevent that 1 in 100 poor outcome.

GeneralVeers said:
I usually discharge all low-risk patients if I can HEART score them out. I use 1 troponin. If they are high risk, I simply admit them. I almost never use serial troponins anymore, as I'm not sure there is much diagnostic utility in low-risk patients.
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Totally agree with this. Even without hs-TnT, I've never liked serial troponins in the ED, very few exceptions aside (e.g., symptoms started three hours ago, nonischemic stress test last month, maybe / maybe not decent story with low-moderate risk, unchanged EKG, good follow-up and can't really justify admitting, etc -- a good HEART application, even).
 
Rendar5 said:
I had a patient with a HEART score of 2 (1 point for age in a 50-something year old, 1 point for troponin 0.04, normal at my institution is 0.01-0.03) with slightly elev. creatinine, very GI sounding story, normal EKG, I waited and did a 2nd trop a few hours later, still 0.04, d/c home. I check on my record of patients routinely a few days later. Guy came back with a change in his quality and story in the middle of the night, still normal EKG, and trop jumped to 0.22 and admitted w/ cath showing a suspect lesion 90%.
I kinda give up at this point when HEART score fails, lol. Can't say I would've done anything differently though.
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Unfortunate that he bounced back but doesn’t mean his initial symptoms were cardiac. Could’ve been coincidence and initial symptoms noncardiac. Even if you admitted him the same thing may have happened when he was sent home the next day after being “ruled out” so nothing you could’ve done in my opinion.
 
nlax30 said:
Unfortunate that he bounced back but doesn’t mean his initial symptoms were cardiac. Could’ve been coincidence and initial symptoms noncardiac. Even if you admitted him the same thing may have happened when he was sent home the next day after being “ruled out” so nothing you could’ve done in my opinion.
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Agreed. In the last month, I've had two patients bounceback the very next day with acute CVAs who initially presented with completely unrelated symptoms. One patient presented for chronic leg pain and the other presented from a nursing home, reportedly for chest pain for the last week, but was denying any issues when she arrived. No matter what you do, someone is eventually going to have a bad outcome that you saw. Every single one of our elderly patients are ticking time bombs.

Thankfully, ACEP has finally got our back on this, at least regarding chest pain patients, and stated the following in their new ACS clinical policy statement: "based on limitations in diagnostic technology and the need to avoid the harms associated with false-positive test results, the committee based its recommendations on the assumption that the majority of patients and providers would agree that a missed diagnosis rate of 1% to 2% for 30-day MACE in NSTE ACS is acceptable."

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary S... - PubMed - NCBI
 
Zebra Hunter said:
Agreed. In the last month, I've had two patients bounceback the very next day with acute CVAs who initially presented with completely unrelated symptoms. One patient presented for chronic leg pain and the other presented from a nursing home, reportedly for chest pain for the last week, but was denying any issues when she arrived. No matter what you do, someone is eventually going to have a bad outcome that you saw. Every single one of our elderly patients are ticking time bombs.

Thankfully, ACEP has finally got our back on this, at least regarding chest pain patients, and stated the following in their new ACS clinical policy statement: "based on limitations in diagnostic technology and the need to avoid the harms associated with false-positive test results, the committee based its recommendations on the assumption that the majority of patients and providers would agree that a missed diagnosis rate of 1% to 2% for 30-day MACE in NSTE ACS is acceptable."

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary S... - PubMed - NCBI
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Even on the Cardiology side we deal with similar struggles. I’ve had a few patients have a completely normal myocardial nuclear perfusion study only to come back within a week with ACS. Just have to remember basic physiology and that plaque rupture causing ACS is just as likely to occur in mild non-obstructive lesions that we would not have seen anyway on a stress test whether exercise or nuclear perfusion.
 
Rendar5 said:
I had a patient with a HEART score of 2 (1 point for age in a 50-something year old, 1 point for troponin 0.04, normal at my institution is 0.01-0.03) with slightly elev. creatinine, very GI sounding story, normal EKG, I waited and did a 2nd trop a few hours later, still 0.04, d/c home. I check on my record of patients routinely a few days later. Guy came back with a change in his quality and story in the middle of the night, still normal EKG, and trop jumped to 0.22 and admitted w/ cath showing a suspect lesion 90%.
I kinda give up at this point when HEART score fails, lol. Can't say I would've done anything differently though.
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So what? He had coronary disease, it’s now stented. He’s not going to be a cardiac cripple with a trop of 0.22 unless it was on its way down from 120. You provided standard of care diagnosis and treatment and return precautions, patient came back. Nothing to see here.
 
UKEMdoc said:
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%
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We had something similar with the surgeons. They demanded to see every abdominal pain in the ED after a case of missed appendicitis. It lasted less than a day. It's way easier to pretend you're smarter than the ED docs when you only have to do it retrospectively.
 
Rendar5 said:
I had a patient with a HEART score of 2 (1 point for age in a 50-something year old, 1 point for troponin 0.04, normal at my institution is 0.01-0.03) with slightly elev. creatinine, very GI sounding story, normal EKG, I waited and did a 2nd trop a few hours later, still 0.04, d/c home. I check on my record of patients routinely a few days later. Guy came back with a change in his quality and story in the middle of the night, still normal EKG, and trop jumped to 0.22 and admitted w/ cath showing a suspect lesion 90%.
I kinda give up at this point when HEART score fails, lol. Can't say I would've done anything differently though.
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A positive troponin (your institution's normal limit is ≤ 0.03) is 0.04 and therefore is considered HIGH risk according to the HEART Score. This is corroborated by Dr. Barbara Backus and others as effectively nullifying going down the rule out pathway.

http://rebelem.com/management-and-disposition-of-low-risk-chest-pain/
http://www.emdocs.net/great-powerful-heart-score-weakness/
 
I’ll have to check but the upper limit of 0.03 at my institution may be only to the 97.5th percentile (2 standard deviations) and not the 99th percentile determines by the HEART score pathway (whose assay had 0.04 as upper limit). You are right though that trop’s of 99th percentile or up are still determined to be admissions per the HEART pathway, which I didn’t realize but does make sense.
 
Rendar5 said:
I’ll have to check but the upper limit of 0.03 at my institution may be only to the 97.5th percentile (2 standard deviations) and not the 99th percentile determines by the HEART score pathway (whose assay had 0.04 as upper limit). You are right though that trop’s of 99th percentile or up are still determined to be admissions per the HEART pathway, which I didn’t realize but does make sense.
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HEART has many gotchas when it comes to each of its sections. I have a PDF presentation that I can send if anyone is interested.
 
kjamess said:
They blew it off, but still were concerned enough to cath them the next day
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The ultimate question with these patients is whether immediate PCI or delayed PCI has any effect on clinically important outcomes of importance, like death, development of permanent CHF, need for pacemaker/defibrillator, stuff like that.

I still think the same way as others here, cardiologists, especially community cardiologists appear to practice cardiological medicine as if they are in the 1980s. Really sad. But most doctors are like that. You know the most within the first few years of residency, but then become complacent and don't really stay Up To Date with evidence.
 
Birdstrike said:
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.
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I never press on anyone's chest with chest pain. Only time I do it is for trauma.

"Doc, a baseball bat hit me in the chest."

Then I will touch the chest.

The PE for chest pain is lousy in the ER. I basically use statistics to determine how I'm going to work up someone. The only real decision I make with the majority of chest pains is whether I'm going to obtain chest imaging to evaluate for PE or dissection.
 
thegenius said:
I never press on anyone's chest with chest pain. Only time I do it is for trauma.

"Doc, a baseball bat hit me in the chest."

Then I will touch the chest.

The PE for chest pain is lousy in the ER. I basically use statistics to determine how I'm going to work up someone. The only real decision I make with the majority of chest pains is whether I'm going to obtain chest imaging to evaluate for PE or dissection.
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Same. Excluding clearly musculoskeletal chest wall pain, I don't care if they tell me it's sore there. Half the time, it's a misunderstanding of "yes, that's where my pain is." The other half of the time, I don't care if your CAD/HTN/HLD/DM/five-stent-having self tells me it hurts to touch but hurt getting the mail today. Coming in either way.
 
Here’s how I always approached patients with complaints of chest pain. They’re all life threatening until I can definitively rule out cardiac disease at the bedside, and, with certainty definitively rule in something non-life threatening. And that’s not very many people.

“I fell and struck my chest on the corner of a table” and the chest c-ray shows a broken rib. That qualifies.

“I have burning pain in my chest” it’s real vague, it sounds kinda refluxy, not really cardiac, but I can’t wrap my head around exactly what it is. This is most patients. Sorry, I don’t care what some academic department’s heart score, that is absolutely NOT as equal definitive as a heart cath, says. That gets ruled out, by someone else, 100% of the time.

“But, but, but, his heart score was...”

Full stop. No one cares. The 41 year old marathon runner you sent home with 2 young kids, a sobbing wife who makes a heart wrenchingly sympathetic witness, whose vague symptoms no one thought could have heart disease, is dead.

A heart cath trumps a decision rule 100% of the time.

And so does an autopsy.

Symptoms of cardiovascular disease are too vague, too atypical too often, minimized by too many patients who are in denial and full of wishful thinking that “nothing’s wrong.”

If you’re sending people home that you’re uncomfortable with because you want a tough-guy rep with the hospitalist of being a “wall,” then you’re doing this all wrong.

If you admit 100% of these, I can’t say that you’re wrong.

#1 killer of Americans?

Heart disease.

#1 diagnosis with the highest liability for Emergency Physicians?

Heart disease.

I’m happy to let someone else take on that risk and liability.
 
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Interesting the different perspective on this amongst those of us in different fields. I see pts all the time in outpatient clinic who have some sort of c/o chest pain. Have to go through a somewhat similar quick thought process but rarely do those folks get sent to the ED/hospital directly. Even if I think it could be cardiac/angina (obviously depending on the other factors) I’m usually starting on certain meds and arranging for some sort of evaluation (stress, CT, etc). I don’t think the argument of a cath trumps some decision rule is a good one as we shouldn’t be advocating jumping to cath in these pts. Even if it’s cardiac CP, going to cath and getting a stent outside of an actual acute MI doesn’t improve long term outcomes.
 
Birdstrike said:
Here’s how I always approached patients with complaints of chest pain. They’re all life threatening until I can definitively rule out cardiac disease at the bedside, and, with certainty definitively rule in something non-life threatening. And that’s not very many people.

“I fell and struck my chest on the corner of a table” and the chest c-ray shows a broken rib. That qualifies.

“I have burning pain in my chest” it’s real vague, it sounds kinda refluxy, not really cardiac, but I can’t wrap my head around exactly what it is. This is most patients. Sorry, I don’t care what some academic department’s heart score, that is absolutely NOT as equal definitive as a heart cath, says. That gets ruled out, by someone else, 100% of the time.

“But, but, but, his heart score was...”

Full stop. No one cares. The 41 year old marathon runner you sent home with 2 young kids, a sobbing wife who makes a heart wrenchingly sympathetic witness, whose vague symptoms no one thought could have heart disease, is dead.

A heart cath trumps a decision rule 100% of the time.

And so does an autopsy.

Symptoms of cardiovascular disease are too vague, too atypical too often, minimized by too many patients who are in denial and full of wishful thinking that “nothing’s wrong.”

If you’re sending people home that you’re uncomfortable with because you want a tough-guy rep with the hospitalist of being a “wall,” then you’re doing this all wrong.

If you admit 100% of these, I can’t say that you’re wrong.

#1 killer of Americans?

Heart disease.

#1 diagnosis with the highest liability for Emergency Physicians?

Heart disease.

I’m happy to let someone else take on that risk and liability.
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I hear what you are getting at. I tell patients regularly that there is "zero risk tolerance in our society by patients, and by physicians, for missing heart attacks. That's why we do so much testing and we admit so many people, even though the vast majority end up being OK."

If I send someone home with (or had) chest pain it usually under very narrow parameters
- no chest pain in the ED
- serial enzymes are normal / negative / not going up
- serial EKGs are unchanged from prior and not ischemic
- on the youngish side
I especially like it if I have a recent cath report too so I have an understanding of their coronary anatomy.

I tell patients at the beginning that they are going go be in the ED for 4-5 hours.

I'm not quite as conservative as you, I do send some some people who had chest pain. I guess one difference is that I don't spend a lot of time trying to figure out what the diagnosis is. If they have one of the 7-8 diagnoses of chest pain that are emergencies, then I'll treat it. But I think that's a minor difference.

The ultimate problem is, and I'm sure there are EBM scholars here that can elucidate this in better detail than my memory. Even negative stress testing is, at best, like 90-95% sens/spec for symptomatic coronary lesions. So if they are admitted and discharged with negative stress testing, it is still possible they will have a MACE 30 days later.
 
nlax30 said:
Interesting the different perspective on this amongst those of us in different fields. I see pts all the time in outpatient clinic who have some sort of c/o chest pain. Have to go through a somewhat similar quick thought process but rarely do those folks get sent to the ED/hospital directly. Even if I think it could be cardiac/angina (obviously depending on the other factors) I’m usually starting on certain meds and arranging for some sort of evaluation (stress, CT, etc). I don’t think the argument of a cath trumps some decision rule is a good one as we shouldn’t be advocating jumping to cath in these pts. Even if it’s cardiac CP, going to cath and getting a stent outside of an actual acute MI doesn’t improve long term outcomes.
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I would think it's tough to evaluate chest pain as an outpatient? At least where I work, our outpatient docs / RNs / staff tell patients to just go to the ED.

But I know its different at different places. I also work part time at Kaiser, and I almost never get patients sent to me for chest pain by their PMD. Yet it happens all the time at my other job (non-Kaiser).
 
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