As the American medical system transitions towards a healthcare (rather than a sick-care) system focused on delivering quality care (rather than abundant care), we will increasingly have to tailor our clinical decision-making towards precisely achieving a diagnosis, addressing the chief complaint, and providing safe treatments with demonstrable benefit.
Recently, I admitted an elderly woman with multiple cardiovascular risk factors to my hospital. She complained of 14 hours of continuous chest pain since dinner the previous night. No other symptoms were present (including no pleurisy) and interestingly, she had had a recent negative cardiac stress test. Her lungs were clear, and a pacemaker was palpable under the skin of her left chest. Her EKG showed an old left bundle branch pattern with a paced rhythm, and her initial troponin was minimally elevated. Her CK was negative throughout.
Upon a review of her medication, I noted that she took aluminum hydroxide daily for heartburn symptoms, in addition to oral hypoglycemic, and anti-hypertensive medication. After the second troponin went up significantly, in the setting of continual chest pain, we diagnosed a non-ST elevation myocardial infarction, and started anticoagulation and anti-platelet therapy, as well as intravenous nitroglycerin, beta blockade, and an ACE inhibitor. Despite titrating up her nitroglycerin and providing intravenous morphine, her pain persisted. The markers eventually down-trended, but throughout all of this, her pain was unabating. One of my colleagues insisted on providing more beta-blockade, despite the fact that her heart rate was 60 and the rhythm was regular. There were no arrhythmias on telemetry. Eventually the patient developed nausea in response to the intravenous beta-blocker medication.
The consultants on the case - cardiologist, nephrologist, and intensivist - all were soothed by the improved indices: her cardiac markers were down-trending, her blood pressure was controlled, and there was no indication of complications occurring from myocardial infarction. But her pain persisted. In fact, despite everything we had done, the chief complaint was not addressed.
I remembered that her pain began while eating: it was continuous, exacerbated by stress, and refractory to anti-anginal therapies. Recalling that she took aluminum hydroxide for heartburn, I attempted a trial of intravenous ranitidine Within 10 minutes, her symptoms resolved, and she was comfortable. That doesn’t mean that she wasn’t having a myocardial event. In fact later she was found to have a critical lesion in a coronary artery that required angioplasty and stent placement; however, by addressing the chief complaint, we decreased patient discomfort, decreased the stress response, and increased the likelihood that the patient would move forward with a mindset that she could heal.
I’m not saying the anti-reflux medication saved her life, but it is essential clinical practice to address the chief complaint. While it is often difficult to resolve the underlying cause of the chief complaint, sometimes the answer is there in front of you, articulated by the patient in a subtle way.
As the American medical system transitions towards a healthcare (rather than a sick-care) system focused on delivering quality care (rather than abundant care), we will increasingly have to tailor our clinical decision-making towards precisely achieving a diagnosis, addressing the chief complaint, and providing safe treatments with demonstrable benefit. It is not enough to perform CT scans on every patient with lungs to rule out a pulmonary embolus or a stress test on every patient with a heart.
Perhaps it is the defensive medicine (that leaves the chief complaint unresolved while focusing on the usual suspects) that is responsible for the unsustainable and ineffective medical system bankrupting the country. How do we fix it? We pay attention, listen to our patients, and doggedly work to address the issues present in each human being.
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