Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
Dec - 19
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Feb - 8
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A near miss
8 Dec2009
Some time ago, I was making post call rounds. The team presented a patient admitted from the oncology service. He was in his 50s and had new chest pain. He described the chest pain as substernal pressure with radiation down both arms. He received relief from stretching against the wall. The pains lasted around an hour.
The team reported a negative nuclear medicine stress test 2 months ago.
When I talked with the patient, his story seemed 50% perfect and 50% strange. I asked if the patient had ever tried nitroglycerin, and he had not.
His ECG was unremarkable. His troponins were normal.
The housestaff were skeptical (as I would likely have been at that stage of my career). They focused on the atypical parts of his story.
I suggested that we try ntg for any pain episodes and obtain a stat ECG.
The story did not make sense, so I looked up the stress test. Behold it was not a stress test, but rather a MUGA scan. My team unfortunately did not know the difference.
We rarely use MUGA scans these days. The scans are primarily used to follow a class of chemotherapeutic drugs that damage the heart – adriamycin being the drug he was taking. They can show old damage, but are mostly used to estimate ejection fraction.
The team had misinterpreted the scan results. Because no stress is involved, this test does not substitute for any form of stress test.
Overnight he had chest pain relieved by nitroglycerin, with no ECG changes. His MIBI was remarkably abnormal, and his cardiac catheterization showed 80% left main disease.
Fortunately, this story turned into a teachable moment. We had a near miss the sobered us all. By proceeding with the evaluation the patient did get the appropriate management.
This story reminds me that patients do not always give perfect stories. As I get older I focus on the parts that fit with the most dangerous diagnosis so that I do not miss something really important.
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- Costs – why they are too high
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- 17 days at the VA – Day #7
- Will biking hurt my bones?
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2 Responses to A near miss
Margaret Polaneczky, MD
December 8th, 2009 at 8:43 am
Nice save.
I've learned over the years to get the op notes for any major operation my patient claims to have had on her uterus or ovaries, and the results of their most recent bone density or mammogram that they tell me was "normal". Such reviews have turned up diagnoses such as osteoporosis, cervical cancer, breast cancer and more that my patients failed to tell me about in their history.
Graham
December 8th, 2009 at 8:58 am
And even if the stress test is normal, the sensitivity is at best mid-80s. Still missing a lot!