A knock on the exam room door interrupting a patient visit is usually one of two things, a call from another physician or a patient with chest pain. It wasn’t a doctor. It was about a longstanding patient in his 60’s who was having chest pain. I took the call expecting to speak with the patient but instead found myself talking to his wife, (he was playing the part of the stereotypical male and had refused to call me) she was calling from home worried about him. He was driving back from work with pressure in his chest and in a cold sweat. The symptoms were so concerning that I was puzzled they were even calling me. “Tell him to pull over and dial 911,” was my firm advice.
A few minutes later another knock came. This time the patient was on the phone. He told me that the pain had resolved and he was feeling better. As the pain was gone and he was only minutes away I told him he could come to the office for an evaluation.
When he arrived I inquired further about the nature of his pain. “It isn't really pain,”he said, “it is a pressure, like I have to burp. When I burp I feel better.” He went on to tell me that he had experienced pain like this in the past and that he had been previously diagnosed with acid reflux. He was confident that it was not heart related. He was still pain free and he denied any exertional component to his pain so I thought he might be right. I ordered an electrocardiogram anyway.
I went in to see the next patient while the nurse hooked him up to the ECG machine. A few minutes later I had the report in my hands. There were some mild changes in the lateral leads, minor enough to be possibly normal but significant enough they could be associated with decreased blood flow to the heart. He was comfortable and still certain it was indigestion so I decided to compare the ECG to one done previously.
He reported having an ECG done prior to a previous surgery so I logged into the hospital system to search for the report. I couldn't log in! I found myself locked out of the system due to a password problem. I had the staff call the hospital support desk while I went back to the other patient. I had decided that if the ECG findings were different from the previous one I would need to send him to the emergency room. If the findings were not new I would treat him for indigestion and send him to the cardiologist.
Twenty minutes later I still couldn’t log into the hospital system and did not know what to do. I decided to search for his paper chart in the garage attached to my office to see if there was an ECG from several years earlier. I found the chart and opened it to the ECG section. There I found a very faded ECG. It was perfectly normal. The changes on his ECG were new. I realized it might be his heart after all.
I went back into the office to share the news with him. When I walked into the room he told me the pain was returning. I quickly gave him a dose of nitroglycerin and an aspirin and had my nurse call 911. Within minutes the medics were on the seen and loading him on to a gurney for the trip to the emergency room.
The next day I received the report from the hospital. The major artery to the left side of his heart had been 95% blocked. The cardiologist had performed an angiogram and placed a stent. Remarkably, he was already on his way home. As I read the report I was struck with how close he had come to having a heart attack. His insistence that it was indigestion could have easily resulted in a missed diagnosis.
His story reminded me of some fundamental medical truths-
- Denial is a dangerous thing.
- All chest pain is serious until proven otherwise
- Never trust a computer when you need it.
- Men, especially married men, are often stupid. (just ask their wives)
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