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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Just a routine er visit!
- Richard C. Berglund (25 May 2003)
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Think, out of the box: The lesson learnt.
- Malvinder S. Parmar (25 May 2003)
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Unrealistic
- Declan P Fox (27 May 2003)
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Unrealistic?
- Andrew G Robinson (29 May 2003)
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Patient's awareness
- David C. Walker (29 May 2003)
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Experience of a similar case
- David P Mitchell (30 May 2003)
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The importance of musculoskeletal symptoms
- Sophia Y Khan, Richard G. Hull (4 June 2003)
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Richard C. Berglund, Boneventure Medical Group Hoffman Estates, IL 60195
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The case presented illustrates how a relatively routine ER visit can become magnified out of proportion to the apparent initial presenting data. What is most concerning is the timespan required to manage this patient - I presume the patient was not managed solely by one physician and one shift of ER staff. Accordingly the comunication skills between various staff needed to ensure a care plan for this patient cannot be made only upon admission and with initial presenting data, but rather need to be maintained in flux throughout the patients diagnostic and treatment period. Thank you for an interesting and stimulating case presentation. Competing interests: None declared |
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Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
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Although acute coronary syndrome is the most important diagnosis to consider and rule out in a patient presenting with chest pain in the emergency department but it is important to consider other diagnoses, that are equally important, as illustrated by this interactive case. I congratulate Tessa Richards, Ed Peile and BMJ on this initiative and bringing physicians (general practitioners and specialists), the patient and other health care workers around the world, together through this forum. I believe that in addition to having a lively discussion the important goal of this exercise should be to deal with the various issues, uncertainties and questions raised by the participants and the case. Hindsight is always perfect (20/20) but commentators (the consultant) should try to answer the questions or controversies raised during the discussion. The purpose is not to undermine the authors or their approach to the patient as it would be variable and depends on the resources available at the hospital when the patient presents to their emergency department. However, it is important to look back and identify the problems in the management and learn and teach from these mistakes or misjudgments. Unfortunately, five commentaries were published in relation to the case and none dealt with the questions raised by the reader’s during the discussion. I hope the editors and commentators would keep this in mind and would try to answer the questions raised during discussion in future interactive case presentations. In brief, the present case taught or re-enforced the following points: 1. The clinical history is the most important and gives clue in majority of cases about the patient’s origin of symptoms, as in this case and pointed out by Alistair Howitt. 2. All chest pains above the belt are not of cardiac origin and highlights – think out of the box. 3. If there is no ST elevation on 12-lead electrocardiogram, even in a patient with acute coronary syndrome, there is no indication of thrombolytic therapy, except if patient has left bundle branch block on electrocardiogram or is experiencing right ventricular infarction (that would require right-sided leads and could be missed on 12-lead electrocardiogram). 4. Emergency transthoracic echocardiogram is useful only in a select group of patients presenting with acute chest pain (when you're suspecting cardiac temponade, papillary muscle dysfunction or rupture etc). Thrombolytic therapy based on echocardiographic findings of acute ischemia in the absence of ST elevation is not supported in the literature. 5. Always think of a test that would answer the clinical question(s) in the emergency department. The commentator(s) (especially the cardiology commentator) should have mentioned or at least discussed which would have been the best test in this situation. In this case, after chest x-ray, a helical (spiral) CT scan was the single most important test that in fact provided answers to most of the questions. A transthoracic echocardiogram in the emergency department was futile and did not help in narrowing the differential diagnosis and likely resulted in unnecessary expense and waste of time. Competing interests: None declared |
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Declan P Fox, Family Physician/ED cover N Ireland, Scotland, Canada
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Fascinating case, made me think. Reminiscent of the NEJM cases which I read eagerly in my younger days. But! How many hospitals in the NHS could match the performance of this one, in speed and skill of responses to this case and in investigations done? How many people diagnosed with aortic dissection outside a cardiac surgery unit would make it to such a unit within four hours? And finally, I know units where troponin stat is regarded as a rather weird request. Declan Fox MRCGP
Competing interests: None declared |
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Andrew G Robinson, resident Vancouver
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Although a previous respondent said that this scenario was unrealistic, and that many hospitals lack these capabilities, the important thing for a doctor working in a smaller hospital is that this patient should be transferred (if possible) to a centre with CT scanning capabilities. And then to a centre with a thoracic surgeon. The mortality from a dissecting thoracic aorta type 1 is 1% per hour, so seconds do count. In future cases it would be interesting to hear from the rural docs at what point do you transfer. To the authors, what was the reason to do a TTE in this patient? Is this standard practice in the UK, or is this a case of 'we have the technology readily available, so lets use it'. Competing interests: None declared |
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David C. Walker, General Practitioner London W14 9RB
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The BMJ is to be congratulated on introducing Interactive Case Reports. I find them immensely interesting and informative. However, of all the commentaries, undeniably valuable as they are, I have found the patient's commentary most interesting. The patient's new-found awareness of no longer being afraid of death indicates the wisdom obtained after a life-threatening experience. I wish him well. Competing interests: None declared |
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David P Mitchell, Lecturer Trinity Collge, Dublin ,Ireland
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This case is very similar to one I saw a number of years ago. A man was brought to the A&E room with central chest pain. He was about 50, a smoker with a history of hypertension. The pain was of sudden onset and limited to the central chest. He was in pain and very sweaty. The ECG showed a a tachcardia and was otherwise normal. Chest X ray was normal. The history at the time simply did not seem 'right' for a myocardial infarct. We admitted him and I re examined him half an hour later. The pain had settled but in the mean time he had developed a cyanotic discolouration of the lower half of the body with a sharp demarkation line at the umbilicus. Our diagnosis was now that of an acute aortic dissection with extension and he was transfered urgently to another hospital where this could be managed. Radiological investigation there revealed an aortic dissection from the aortic arch to the bifurcation. An aotic prosthesis was inserted and the patient survived. He walked into my outpatients three months later with only a slight limp. In our case, echocardiography was not available in our hospital and spiral CT had not yet been invented. While the summary of the case may not give that impression, the history given by the patient simply did not sound like that of an infarct. Lacking the more advanced radiological investigations now available, we were forced to rely on an age old method - re examination the patient - which here was literally life saving. The take home message is that the case summaries may not give you everything a patient will tell you and when advanced radiological methods are not immediately available (late on a Friday evening for example) repeated clincal examination may be of use. Competing interests: None declared |
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Sophia Y Khan, Specialist Registrar in Rheumatology Rheumatology Department, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, Richard G. Hull
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The closing comments of this case report(1) about the patient’s lumbar spondylosis stopping him from returning to work highlights the importance of a proper musculoskeletal examination when assessing patients(2). It also emphasises the significant impact that back pain has in preventing people from working, which inevitably causes a detrimental effect to the economic status of the nation. It has been estimated in a cost-of illness study that in 1998 the overall costs of lower back pain (LBP) in the UK varied between £6.6 billion and £12.3 billion depending on the costing method used(3). Another study performed by Druss et al in the U.S.A. has shown that the annual per capita health and disability costs were comparable for patients with LBP, depression, heart disease and diabetes(4). Back pain therefore should be managed actively both in primary and secondary care using the expertise of allied medical professionals such as physiotherapists and occupational therapists who can advise in modification of the working environment. It is also important to note that most patients with longstanding back pain do not require plain radiographs of the lumbar spine unless there are features in the history to suggest malignancy, infection, inflammatory pain or if there are abnormal neurological findings clinically (5). In summary, we always need to remind ourselves to take a holistic view of a patient’s problems. It is easy to become focused on one element of a patient’s condition especially in the acute setting. Although back pain is not life threatening it can certainly affect quality of life in the long term. Sophia Y Khan Richard G Hull Rheumatology Department, Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY References 1. Sodeck G, Partik B, Domanovits H. Interactive case report: A 42 year old man with acute chest pain: case outcome. BMJ 2003; 326: 1133-6 2. Doherty M, Abawi J, Pattrick M. Audit of medical inpatient examination: a cry from the joint. J R Coll Physicians Lond 1990; 24(2): 115-8 3. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000; 84: 95-103 4. Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major U.S. corporation. Am J of Psychiatry 2000; 157; 1274-8 5. The Ionising Radiation (Medical Exposure) Regulations 2000. Dept of Health. Competing interests: None declared |
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