Wednesday, December 06, 2006

The power to reassure

While covering the ICU (intensive care unit) earlier this year, I received my first call on the pacemaker hotline. This hotline service is offered by one of the hospitals at which I rotate to patients who have pacemakers, so that when they have emergency issues they can call in and transmit electrical tracings for interpretation. I’m not sure who staffs the line during the daytime, but at night and on weekends, it falls to the ICU resident to field the calls and give advice.

Let me just pause for a moment and note that the whole concept of a pacemaker hotline, as great as it sounds, is probably somewhat flawed. Pacemakers, it so happens, are rather complex machines; they are the gadgets of electrophysiologists, physicians so specialized that they have completed not one but two fellowships after their internal medicine residency. In contrast, I have not even completed half of my residency, which to me suggests that I have about as much business interpreting a pacemaker tracing as I do trying to repair a malfunctioning jet engine before takeoff.

Despite these reservations, I nonetheless was the on-call ICU resident, and the nurses were telling me that a little old lady was on the other end of the pacemaker hotline, expectantly awaiting my advice.

“Hi, this is Dr. C,” I said.
“Hello, doctor.”
“How can I help?”
“Well, doctor, I have been having stomach pains most of the afternoon. I think it might be related to something I ate for lunch, but I thought I would see if it could be my pacemaker.”
“Hmm, are you having any chest pain?”
“Palpitations or shortness of breath?”
“No, doctor.”
“On a scale of 1 to 10, how bad is the pain?”
“About 4 to 6.”
“ And it started after lunch?”
“Yes, it started about an hour after lunch, and has been going on for a couple of hours.”

I looked at the tracing that had been placed in my hands. It looked ok to me, but then again, what did I know? The tracing only showed one lead, as opposed to the twelve-lead EKGs or two-lead telemetry strips with which I was familiar, and it didn’t specify which lead it was. The heart rate was normal, though, and the pacemaker seemed to be pacing appropriately. I stared at the thing for a minute or two, and I must have appeared to be somewhat confounded, because one of the more experienced ICU nurses came over to me, and winking knowingly, said, “Just send her to the ER.”
“Is that what the residents usually do?” I asked.
She nodded. “Yeah.”
“But I think she just has a stomachache.”
She shrugged helplessly.

“Miss, your pacemaker tracing looks fine. I’m not sure why you’re having abdominal pain, but I don’t think it’s related to your pacemaker,” I said. “If the stomach pain is bothering you, I suggest that you go to the ER to be evaluated.”
“Ok, doctor, but I think I’ll just wait it out then. I’m sure it will get better in a little bit. Thank you very much.”
“All right, you’re welcome, have a good night.”

I hung up the phone feeling pleased with myself; I had just saved this lady a trip to the ER, which would have been a great inconvenience to her and definitely ruined the rest of her night. I started jotting down a note in the logbook. Suddenly a pang of doubt hit me – was I really sure that she was ok? The cardinal rule of medical hotlines is to always send the patient to the ER, no matter what the complaint. Not only had I broken that rule, I had taken a stand on my own and would be personally responsible for anything that might happen. I thumbed through the other entries in the logbook – one after the other, the entries read, “patient agreed to call 911 for an ambulance,” “patient to leave immediately for ER,” “patient waiting for EMS.” Uh-oh. I looked again at the tracing – wait a minute, this tracing wasn’t completely normal, one of the waves had an abnormal shape. It was probably just her baseline waveform, and not really a reason to be having abdominal pain, but was I really willing to put my neck on the line?

The same ICU nurse, who could sense my doubt, repeated, “Just send her to the ER.”
“What do you think, do I need to call an ambulance for her or should I let her drive herself?” I had no experience in this.
“Maybe somebody can take her. Or she can call an ambulance herself.”

I called her back. “Hi, this is Dr. C again. I was just looking at your tracing further, and I decided that based upon the tracing, I can’t really be certain that nothing is going on with your heart. I have to strongly recommend that you go to the ER to be evaluated. Do you think there is someone who can take you?”
“No, doctor, I’m sure that I’m fine. The nearest emergency room is an hour’s drive away, and there’s nobody to take me.”
“Well, can’t you call an ambulance?”
“No, doctor, really, I’m going to be ok.”
“The problem is, without being able to see you and evaluate you, I can’t be sure that you aren’t having a heart attack.”
“But doctor, I’m not having any chest pain.”
“Yes, well, sometimes a heart attack presents unusually, as abdominal pain, or as a variety of other symptoms. I just can’t really tell from here. I have to strongly recommend that you go the ER for evaluation.”
I held back from playing my ultimate trump card, that is, threatening her that she could die, since I was pretty sure she just had a stomachache.
“I understand doctor, but I’m just going to wait a little bit and see if it doesn’t get better.”

This time I hung up the phone feeling deeply unsatisfied. I had set my imagination in motion, and it was leading me in directions I didn’t want to go. The abnormal electrical wave on the lady’s pacer tracing started glaring at me, mocking me. Did I need to absolutely insist that she go to the ER? There was only one thing to do: I paged the cardiology fellow.

“Hey, this is Wyatt, the ICU resident, I’m sorry to bug you, but I was wondering if you could look at a tracing from the pacemaker hotline. It’s a little old lady having abdominal pain, and I think the tracing looks ok, but I’m not entirely sure how to interpret it.”
I faxed him the tracing. He agreed, the tracing was fine, but he thought she should go to the ER to have her abdominal pain evaluated.

At least now I could let the matter rest. I didn’t need to call her back to insist upon anything – I would just let my “strong recommendation” to go to the ER stand. I felt cuckolded, though; this was not why I had become a doctor. A patient had called for reassurance, one of the greatest things that a physician can offer, but I had only heightened her anxiety. I had said and done things that I didn’t believe simply because of fear of liability. In fact, in the end I had made it my chief objective to ensure that she received absolutely no comfort from talking with me. Defensive medicine, we call it. A result of our hyper-litigious society, it is one of the most destructive forces in medicine today, paralyzing our ability to care for our patients if we let it. In this case, my lady would have been better off not speaking to me at all.

18:40, that was the low point of my call night. Three hours later, after I had resuscitated a coding patient, set him up on a mechanical ventilator, thrown in a subclavian central venous line, and tucked him in for the night, I felt a whole lot better. I was a doctor again.