Learning Our Lessons, Chapter 1: Listen To Your Gut

Last fall, my patient Kelly came to the office with shortness of breath. She’s an athletic black woman with a history of asthma; she’s also a nurse at our hospital. It was fall and her allergies had been acting up. She had already called asking for a refill of her Flonase and her Albuterol inhaler. “But it’s not working, I’m just so short of breath!” she said.

I’d treated her for asthma exacerbations before, but this time her wheezing was not pronounced. She was blowing her nose, and she had a few scattered wheezes. Her oxygen level was 97%, her vital signs were normal, and she looked well enough, but she couldn’t finish a full sentence without needing to stop and take in another breath.

“I guess the allergies are really bad this year, huh? My asthma’s doing new and strange things!” She was convinced that she was having a bizarre asthma attack.

Could this be a PE? I thought. PE, or Pulmonary embolism, is when a clot forms in the deep veins of the leg (a deep venous thrombosis, or DVT) and travels up to the lungs and blocks blood flow, preventing oxygen from getting to the body (a PE). This is deadly serious and needs to be acted upon quickly. It’s also not uncommon- it’s considered one of the most common 3 causes of cardiovascular death in the U.S. (the top two being heart attacks and strokes) (1). There are an estimated 650,000 to 900,000 cases of PE in the U.S every year (2). So, not rare; and, very dangerous.

I asked her about common risk factors and symptoms: “Kelly, have you had any recent plane trips? Any leg pains or cramping?” No, she hadn’t. She didn’t smoke, she hadn’t had surgery. No one in her family had had clots. But she was on the Pill, which can raise the risk of clots.

I walked her up and down the hall on the oxygen monitor. It stayed at 97%. We did a 12-lead EKG. It was normal.

I told her what I was worried about. “You seem too short of breath for the degree of wheezing you have,” I said. “This could be something more serious, like a PE.”

She disagreed. “Oh, I don’t think so,” she said. “I really don’t want to have to go to the ER for this. Can we try treating for asthma?”

This moment is where they would have frozen the film had we been starring in an after-school special for med students. This is where the wise narrator comes in and says, “If you’re AT ALL, EVER considering a life-threatening diagnosis for a patient, you need to rule that out FIRST before considering more benign diagnoses. Now let’s see what Dr. G does.”

Kelly is a nurse, and I respected her wishes, even though I had a nagging sense of screwing up. We discussed this and came up with a plan. We would escalate treatment for asthma. But, she would have a set of labs before leaving the office, including a D-dimer, which is a sometimes-good test for a clot. It’s good in that if it’s negative, there is no clot. If it’s positive, it can mean a million things, one of which is a clot. She agreed and off she went.

I saw my afternoon of patients and then, at lunch, looked up her results.

The D-Dimer was 2500. That is really, really positive. I dropped my almond butter-and-jelly wrap and called Kelly’s cellphone.

“Kelly, the D-dimer is positive, you’ve got to come in to the ER,” I said. I was shaking but trying to sound calm, thinking CRAP CRAP CRAP I should have sent her to the ER in the first place.

Kelly was unperturbed. She was obviously also eating lunch, and replied, between munches, “But I think the Advair is helping, I feel better. I really don’t want to have to spend hours in the ER.”

Here is another point where the imaginary after-school special would be paused. The narrator would say, “Here, Dr. G has another opportunity to act on her clinical instincts. Let’s see what she does.”

I again bowed to Kelly’s clinical judgment. We again compromised. I ordered a CT scan of the chest as an outpatient, but insisted that she go and have that done same-day. I was very anxious about getting it done that day, and spent a lot of time coordinating that. Lunch was a three-minute affair. Other paperwork and calls went out the window. I also had to forego my lunchtime call to home, to check on my mom and Babyboy. That was painful. Even though the conversation usually consists of talking about his poop, if he ate, what he ate, if he napped, and for how long, it’s my chance to hear his little squeals and burbles, and honestly, get grounded. But, back to work.

One-o’clock came and I tried to keep my mind on my full afternoon of patients. I hoped that Kelly would get the CT scan done. By late afternoon I checked, and it hadn’t been done! I called her cell. I was furious with myself. CRAP CRAP CRAP I should have sent her to the ER in the first place, I thought, again.

Kelly answered. She didn’t sound calm anymore. She was scared, breathless. “I’m here, I’m in the ER, I got really short of breath all of a sudden… I thought, Oh my god, this IS a PE, and I called 911 on myself,” she explained. I could hear the blipping and beeping of the ER in the background.

I went and saw her. She was stable, but her oxygen levels were much lower. She had a CT scan done right away that showed several blood clots to the lungs.

The after-school special narrator steps in: “Both Kelly and Dr. G were very lucky that the PE was not fatal. Dr. G learned a valuable lesson from this case. Let’s go over the lesson again, kids: If you’re AT ALL, EVER considering a life-threatening diagnosis for a patient, you need to rule that out FIRST before considering more benign diagnoses.”

I try to learn from my mistakes. I’d say that from this experience, I have a much lower threshold for sending patients to the ER if I even for one millisecond consider the possibility that what they have may be at all life-threatening. And, I try very hard not to be swayed by the patient’s attitude. My feeling is, if I’m concerned, I need to act on that concern.

Of course, this approach could also be considered “trigger-happy”, and what has contributed to a consistently overflowing ER, as well as increased healthcare costs in this country. Future post: When the ER Docs Think You’re Overreacting, and You Are.

1. Glynn RK et al. NEJM 2009; 360: 1851-61

2. Pulmonary Embolism. http://emedicine.medscape.com/article/759765-overview

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