A 52 year old male who works as a business executive happens to have a slow day at his office and ventures out to the gym for about an hour. He works on the treadmill for some time and heads back to work to finish his project at the office computer. After he begins to type his report, he feels a sharp and heavy sensation in his chest. He stretches his arms and thinks he must have pulled a muscle at the gym and continues to focus on his report. The pain seems to be stubborn and he takes a Tylenol to try to kill it. It does not go away even after twenty minutes and he calls his wife. She gets all worked up and tells him to call his doctor’s office. He was reluctant but she tells him, “Your Company pays a hefty premium for our health for insurance. You should not be suffering with pain and not calling your doctor. Just call your doctor and do what needs to be done. Honey, nothing is more important than your health.”
He calls the doctor’s office but gets surprised when the nurse tells him, “Well, Sir, if you are having a chest pain, you should not wait and get down to the emergency department right away. Would you like me to call an ambulance for you? “Ambulance? I am not dying, I probably just pulled a muscle” he thinks but replies politely, “No, thank you, I can get there myself.”
As he drives down to the hospital, he feels a bit awkward. He didn’t think he would end up driving to the hospital anytime soon. After all, he is as healthy as he can be. He exercises regularly, has a healthy body weight, and has kept a perfect cholesterol profile that almost made his doctor proud. Slowly that feeling turns into anxiety and fear as he is changed into hospital gowns, hooked up to an EKG monitor and poked several times to draw multiple vials of blood. He begins to think something must be terribly wrong with him.
On the other hand, as the on-call admitting doctor, I had the complete opposite feeling when the ER doctor presented his story to me. He was just another one of what we call “a low risk rule out admission.” What that really means is that we do not believe that the chest pain is likely to be from a heart attack but we would admit him to the hospital anyway to make sure it isn’t. Whether they admit it or not, the fear of inadvertently missing a heart attack is always in the minds of most doctor practicing hospital medicine in this country and they believe that this fear somehow dictates the way they practice medicine. Well, I was no exception to that. I reassure the patient as much as I could without giving away everything I was thinking. “Well, so far everything seems normal and this pain could just be from a pulled muscle but there is still a small chance that it could be a heart attack and we need to run a few more tests to be sure. We will admit you to the hospital overnight for observation and release you in the morning if everything turns out fine.”
At first, he gets a little confused,” If everything is fine, why is the doctor still concerned?” Later, he thinks it is better to be safe than sorry and goes along with the doctor’s plan and wants to make absolutely sure that he did not have a heart attack.
I go back to my business and admit a few more patients to the hospital. I was really shocked as the lab calls with a test result a few hours later. It was a heart attack after all.
According to the CDC Database, for every 143 diagnosis of ill-defined chest pain, there are about there are 21 patients that are diagnosed with heart attacks in the ER. That is a ratio of almost 7:1.
Most patients diagnosed with heart attacks are very different from this particular patient. Most doctors are trained to recognize the features and characteristics of patients with chest pain that are likely to have a heart attack. Some are so obvious that the diagnosis is made within minutes of their arrival. Many carry a reasonable chance of heart attack and warrant the admission. But, most doctors almost feel guilty when admitting patients like this one. Some in the academic teaching hospitals may teach their students not to admit a patient like that. But most of us in the private hospitals still admit patients like him and occasionally save lives by doing so. But, on the flip side, many patients who did not have heart attacks endure the pain and anxiety of being in the hospital. Some also argue that this is exactly what is driving up our healthcare costs unnecessarily. So, is saving one life worth the cost to others? The jury is still out there but I happen to think that it certainly is.