Monday, July 26, 2010

Ounces of Caution, Pounds of Cure

When my car needs repairs for problems I can't identify, the strategy of starting off with the cheapest interventions makes sense. Why spend the money on the most costly intervention and risk unnecessary expenditures?

This approach to solving problems makes good sense, until you start talking about the car being your own body. Case in point, if you have a problem with your brain or heart whose origin you can't identify, do you want the doctor to throw the take-2-aspirins-and-call-me-in-the-morning strategy at the problem or the ER-stat-to-make-sure-it's-not-a-stroke-or-heart-attack strategy?

With the car problem, the main consideration reduces to the issue of cost-benefit. If the cheapest solution works, great, you haven't emptied your bank account to tackle it and the benefit is that your car continues to function. If your car is the most precious possession you own you may not choose to take the chance that the simple and cheap solution could end up doing long-term damage because it didn't address the underlying issues.

That's the kind of consideration that comes into play when your car is actually you and the problem is an unusual headache or atypical chest pain. No one wants to take the chance that the simple solution could overlook a serious problem. At least that's how modern health care thinks about it. Or so it seems.

Last Wednesday, I was in the instructional technology lab talking to the padawans when I became conscious of a dull pressure on the left side of my breast bone a couple ribs down, right over my heart. "Hm. A pain in my chest. That's strange."

Mentally I compared it to pain I developed 20 years ago when I was a graduate student in medical art. At that time—for the period of several months—whenever I sat slouched and then straightened up, my chest would feel tight in that same place. (Ignore the issue of slouching. I still do it.) If I arched my back, I could get the nitrogen that accumulated to release with a knuckle-cracking pop. But this felt different. I left a voicemail message for my wife and mentioned it to a colleague and the boss in case it should change too rapidly for me to mention later.

Sitting at the reference desk for an hour the discomfort seemed to disappear, but when I started walking around it seemed to return. After another 2 hours I decided to call my wife again and have someone drive me to the hospital. My wife works in benefits administration and urged me to call our primary care provider whom she was certain would have a walk-in EKG machine. As luck would have it, that afternoon was when the office, a teaching clinic, was off for rounds. The answering service operator insisted I go to the hospital. Off I went with my colleague driving.

The emergency room admitted me as soon as I walked in at 3:21 p.m. and hooked me up for an EKG. That and a blood test for enzymes that get released when the heart tissue dies that causes the pain of a heart attack both came back negative. Still, as a precaution, the attending physician admitted me for observation.

The question is if a car is running well and has always been well maintained, is comprehensive service justified? If I am a healthy male with low cholesterol and no history of heart trouble, was this course necessary? When your heart is potentially at risk, no one would recommend taking a chance; so in I went. My wife arrived to settle me into my room and said goodnight so she could get the kids home from our friend's house.

On hindsight, here is the kicker. The attending physician stopped in before the end of the evening. Chest pain that originates from the heart does not change with movement. Mine did. Likewise it cannot be replicated by manual pressure. Mine could. She speculated that my pain was musculoskeletal in origin. I must have strained my chest muscles or breastbone; although I could identify no specific, originating event. She said a stress test the next morning would likely confirm her hunch.

The stress test comprises an MRI scan with thallium dye in your coronary arteries—the arteries surrounding and feeding the heart. It’s done in 2 stages, the first after getting your heart rate elevated using a treadmill, then the second 2 hours later after resting. I did great. No evidence of narrowing of arteries that could have caused chest pain. I even impressed the cardiologist who observed that my heart rate at the same point on the treadmill as other patients was lower than average. That sounds pretty fit for someone who doesn’t do much exercising. Of course, you have to put that into perspective: I’m more fit than the average person being tested in the emergency room. Go ahead, laugh.

When all was said and done and my wife had picked me up to drive me home, I had a prescription for extra-strength Motrin to ease the ache and a full coronary workup at emergency room prices.

My question again: Was all that entirely necessary? With a few minutes of pre-screening by phone, a physician could easily have gauged my symptoms for the likelihood of a heart attack. I had no sweating connected with the pain. There was some dizziness, but not concurrent with the pain (plus this had already been happening for 2 weeks and seemed likely to be latent vertigo from a cruise I’d just returned from). The pain changed based on activity. I could recreate it by pressing on the spot where the pain originated. All of this was determinable through dialogue. In fact, apart from the EKG, the enzymes tests, and the stress test, the attending physician and cardiologist both determined this by talking to me, as obviated by their combined skepticism that my pain was heart-related, and 2 nurses, 1 physician assistant (educated at Arcadia University!), and 2 resident physicians surely also determined this though none of them actually articulated so.

To the comment that EVERYONE offered—it’s better to be safe than sorry—I must reply: That’s what medicine is about—risk assessment. I am low risk for heart attack and the verbalization of my symptoms plainly suggested I was not having one. Considering my risk, I could have gone into the doctor’s office to get a walk-in EKG. Yes, I have a family history of heart trouble (my dad had quadruple bypass surgery—at 81 years-of-age, non-emergency—and both parents have high blood pressure), but that’s information that’s already in my medical history. It would have been a fraction of the emergency room cost to have a preventive stress test done as part of routine screening.

Wiser medical, insurance, economic, political professionals will comment about my observations from a more informed perspective, but this event gave me a noteworthy personal connection to the health care debate.