Selling the Story II

Here is the first scenario: A middle-aged gentleman with hypertension, diabetes, and a history of two coronary stents placed 2 years ago has had little physical activity since he injured his back last week. As he starts to increase his activity, he gets substernal chest pain, worse as he pants, radiating to his back, associated with shortness of breath and diaphoresis. An EKG en route shows ST depression in lead III and V3 and sub-millimeter depression in several other leads. The initial troponin is positive.

Here is the second scenario: A middle-aged gentleman with some chronic medical illnesses who has been bedbound due to a back injury develops acute onset shortness of breath and pleuritic chest pain. He is quite tachypneic and hypoxic. EKG is nonspecific, and a mild troponin leak is likely due to right heart strain.

Of course, these two patients are the same, but the stories are spun to suggest an MI in the first case and a PE in the second case. How do we approach such a situation? Two posts ago, I argued that clinical information cannot and should not be given impartially. The person telling the story ought to interpret it and make sense of that data. But of course, this puts the onus on the listener to find flaws in the logic or see incongruities in the story.

This is an actual instance that happened when I was on the coronary care unit. Possibly because we were on a cardiology rotation surrounded by patients who had heart attacks, we interpreted the data as the first scenario when it turned out to be the second. In the end, it was the attending who caught us, allowed us to backtrack, and redirected our clinical efforts. This is why clinical medicine is so hard; it is not cut-and-dry, and you have to go down one path in order to test the waters. There's no use in remaining stagnant in ambiguity. But when things simply don't seem right, it's always important to question your assumptions.