A game of risk called “Chest Pain” took place in emergency departments in the 1990s. The rules of the game were that we would see patients with chest pain, and after obtaining a history, performing a physical exam, and getting an ECG, we would guess if they had coronary artery disease.
Then we would “sell” our “guess” to a consultant who proceeded to argue with us. Admitted patients would undergo days of enzyme testing. If they were ruled out during their admission, the consultant would be further convinced of our inherent stupidity and laziness, and this would be used as ammunition in future conversations. If we sent the patient home and he subsequently had a myocardial infarction (and perhaps died), we were considered to be stupid and lazy, but we were also chastised by administration and sued by plaintiff's attorneys. In the end, we were usually left to carry the coffin alone. Let me tell you, this was not a fun game to play.
Over many years, we managed to change the rules of the “Chest Pain” game to mitigate some of the risk. Technology, of course, helped with better blood tests for myocardial injury and improved cardiac imaging, but it was politics that made the biggest difference. We got tired of being thrown under the bus, and our national leaders and hospital ED directors pushed for systematic management algorithms for this patient complaint. This led to less guessing, more formal involvement with cardiology, and the establishment of quality indicators. The advent of STEMI alerts and the chest pain unit are byproducts of this process.
More recently, a similar process occurred with ischemic stroke. In the old days, we would see patients with a stroke, and we would call neurosurgery if blood were present when the head CT eventually came back. If no blood was seen, we said, “Oh, well,” and called internal medicine. It wasn't very complicated, but the outcomes were pretty awful. Then things began to change.
Hung Out to Dry
Many years ago, I met Arthur Pancioli, MD, from the University of Cincinnati. He was one of several visionaries using tPA for ischemic stroke in the ED. He proceeded to tell me about all the editorials being published regarding the danger of doing this. These commentaries described the incredible risk to emergency physicians if something went wrong, and they more or less said thrombolytics for stroke was crazy. But Dr. Pancioli was adamant this was an important therapeutic breakthrough, and he was right. Nearly everyone working in larger EDs today have seen patients with amazing recoveries from ischemic stroke after thrombolytics.
But all those years ago, we were just plain scared. If the patient bled, we would be hung out to dry. We would carry the coffin alone, and no one was interested in putting himself at risk for brain bleeds. A hospital systems-based response to stroke, however, was eventually developed that involved emergency physicians, nursing, radiology, neurology, and critical care. The risk to the emergency physician was diminished, and this paved the way for the miraculous outcomes in ED stroke patients that were unheard of not too long ago.
Processes similar to these two examples are typical of how difficult diagnostic and disease management issues are solved today in progressive emergency departments. Instead of fighting the same battles again and again with consultants and patients, efforts are now made to identify best practices and develop a protocol on which all relevant parties can agree. This is particularly important when these patients present at inconvenient times (like the middle of the night), when consultants are understandably reluctant to see them.
Many challenging ED pathologies can still be more appropriately managed with this strategy. Just last month at our residency program's Morbidity and Mortality Conference, a case was presented of massive pulmonary embolus that resulted in a poor outcome. Of course, the patient showed up in the ED at 4 a.m., and although the diagnosis was made efficiently, the choice of therapy was anything but clear.
As with most M&M conferences, fingers were pointed. What is the best treatment? Is it heparin and thrombolytics for everyone? Or should certain patients be treated by interventional radiology with catheter-directed medications? Being aware of the best proven therapy is important, but it is often the case that the best ED management may not be this option. Rather, it is what the hospital can provide consistently on which all interested parties agree.
This is imperative to your future work in the ED because having a protocol-driven plan for lethal pathologies will avoid you carrying the burden of bad outcomes by yourself. Having a good plan in place before these patients cross your path can prevent your patient's demise and keep you from holding the bag called “blame” all by yourself.
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