Medical Mystery: Weighing a trip to the ER

As soon as I saw my father's number pop up on my cellphone, I was worried - he never calls me during busy office hours.

My mother was in the emergency room with chest pain. As a cardiologist, I had all of the possible causes for her distress flashing through my mind.

She went to the doctor for a routine office visit the day before a long-scheduled trip to Florida. She told him that for several days, she had been having intermittent chest discomfort that lasted for hours at a time. It seemed, she told him, to come on when she ate.

Her regular doctor was not available, so she saw one of his associates, who immediately sent her to the ER. After several hours of observation, she was told that her EKG had some abnormalities, and that a specialized blood test that looks for troponin, a protein released into the blood when there is heart damage, was "borderline" positive. The ER doctor suggested that she stay overnight for further evaluation, and having a stress test the next day. He told her not to eat anything, as she might need a cardiac catheterization. He wished to place her in a "chest pain protocol."

My mother called to get my opinion. Certain that the discomfort was coming from her stomach and not her heart, she was ready to leave the hospital right that minute, and go to Florida the next day. I agreed with her; the discomfort did sound more likely to be related to a gastrointestinal problem. But heart pain can be confusing, and often masquerades behind less-than-usual symptoms. I suggested she stay at the hospital to be sure her heart was not the problem.

Frequent blood tests, blood pressure checks, not being able to eat, the hustle and bustle of a busy emergency room, and an anxious husband only increased her desire to leave the hospital right away. She wanted out of there. Was staying the right move? Should she enroll in the chest pain protocol?

My mother was entered into a chest pain protocol while still in the ER. Protocols - standardized care measures - are used for a number of common medical positions to be certain that important steps are not missed.

Although useful, they can become overly automatic, resulting in slavish attention to procedure over careful thought. My mother wasn't allowed to eat for more than 24 hours, and was put on new medicines, even though she was already taking similar ones at home. There were multiple errors in communication. Most important, she felt helpless, and thought no one was listening to her concerns.

Her stress test was normal, and she was sent home from the hospital less than 24 hours after she got there. At the time of discharge, she asked the doctor what was causing her pain. The doc said, "I don't know. I am pretty sure it is not coming from your heart, but it might be coming from a polyp on your gallbladder that we detected. I suggest you see a gastroenterologist."

I've been on the "doctor" side of situations like this thousands of times over my 27 years in practice. Protocols have value, but it is easy to forget that the patient and family members going through it are scared, often anxious, and need to be treated with compassion.

Care can still be individualized within guidelines, which are not written in stone. In this case, when my mother complained of feeling faint after having had no food or drink in more than 24 hours, just allowing her to drink some water would have gone a long way. Coordinating medications from home with hospital medications, and better communication between doctors and nurses, also would have smoothed the experience.

For my mother, staying in the hospital was still the right move. Heart attacks can present in many unusual ways. If the EKG should change or follow-up blood tests suggest a heart attack, an emergency cardiac catheterization needs to be done quickly to restore normal blood flow to the heart. Only about 1 in 10 people who go to an ER with chest discomfort actually turns out to have an acute heart problem; reflux, gallbladder problems, and musculoskeletal pain are all common sources of this pain.

Recent advancements in screening have decreased the number of people who need to be admitted, but sometimes staying overnight in the hospital is crucial. I have counseled this numerous times over the years, and will continue to do so, for both my patients and my family. Unfortunately, my mother continues to have the same discomfort, and the actual source of her discomfort will remain a medical mystery for now.

On arrival to Florida, after the forced delay of several days, she found that the first available appointment for a gastroenterologist was in January.

David Becker, M.D., is a board-certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, and has been in practice for 27 years.