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January 2005
Rural family medicine, part II: the lady vanishes
I was on call Thursday night
when Sally, a well-dressed 56-year-old woman, came into
the emergency department complaining of chest pain.
The pain started at one shoulder and radiated toward
the other shoulder, then wrapped around her back. "It's
actually more of a burning sensation rather than pressure," she told me as the LifePak spat out a rhythm strip.
It didn't look like the textbook waveforms, but there
was nothing obviously wrong that jumped out at me.
ISOLATION
TANK
It was my last week of rural family medicine and I was
looking forward to heading back home after several weeks
stationed in a town of 2,000 people. The medicine itself
was intensive. And since there wasn't much else to do
in town, I spent most of my free time reading up on
cases I saw that day or just waiting in emergency for
people to come in. My preceptor gave me plenty of responsibility
and instruction. If it wasn't for the isolation, it
would have been the perfect rotation.
Sally's pain was puzzling, though.
She had actually come in earlier that morning with the
same complaint. One of the other physicians assessed
her and diagnosed her with reflux. Her EKG was normal
and her cardiac enzymes were negative, but she'd been
asked to come back in for a repeat blood test. "None
of my family has had any heart problems, but I do have
a hiatus hernia," she said. "Can reflux cause this type
of pain?"
Drawing from my distant knowledge
of anatomy, I explained to her the concept of referred
pain. She nodded. I asked her why she hadn't come back
for the repeat blood test, explaining that sometimes
after a heart attack, cardiac enzymes are not elevated
until a few hours after. "Actually, when I got home
from the hospital, I threw up and then went to lay down.
Then the pain got worse and now I am here again."
I called my preceptor at home and
relayed the story. My impression was that she was having
more reflux and that she should see her doctor in the
morning. He agreed. I offered Sally the choice of staying
in hospital overnight, but she decided to go home. As
she slowly walked out of the hospital, I reminded her
to get her bloodwork done the next day.
CURIOUSER
AND CURIOUSER
The end of my four week rural rotation came suddenly
as I found myself turning in my hospital keys and pager.
Before I left for the drive home, one of the nurses
rushed up to me. "Do you remember the patient from last
night with the chest pain?" she asked. "She had an acute
MI!" She showed me the recent EKG that showed unmistakable
ST elevations. Tombstones, they're called. Sally had
come back in the morning for her blood test. The positive
troponin didn't come back until the afternoon at which
time there was a frantic effort to locate her. When
she returned to the hospital, she was immediately airlifted
into the city.
I drove out of town wondering what
had happened with Sally. It was clearly a misdiagnosis
on my part, but was it bad medicine — or even malpractice?
Would it have made any difference if she'd had her bloodwork
done that day? What if we were in a tertiary centre
or for that matter if my preceptor had seen her personally?
What if I was a little better at reading EKGs, or if
I had ordered a 12-lead? What if I called the lab techs
back into the hospital to do a troponin? "In family
medicine, especially rural, there are times when you
never know for sure, and you have to be able to live
with that," my preceptor once told me.
Back in the city at the University
Hospital, I made some enquiries about Sally, thinking
I'd visit and follow up. They told me they had no record
of her coming in.
Next month: Introspection and
internal medicine
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