Vacations Can Wait

Contributed by readers. Edited by Sheldon Jacobson, MD

A 45-year-old man called his primary physician complaining of severe chest pain and emphasizing that he was scheduled to depart for a Caribbean vacation the following day. Though already overbooked for the day, the physician agreed to see him. On arrival in the office, this thin, ruddy-complected man appeared in moderate distress and seemed out of breath from his walk from the parking garage. He described an oppressive pain, "as if someone is sitting on my chest," that worsened with both exertion and breathing.

The patient had a nonproductive cough but denied fever, chills, and hemoptysis. He also denied any history of cardiopulmonary disease. He had stopped smoking cigarettes 10 years previously and did not use medications or recreational drugs.

Initial vital signs were as follows: pulse, 108 and regular; blood pressure, 138/92 mm Hg; respiratory rate, 22, and temperature, 99.7° F. Other than a regular tachycardia, chest findings were normal, as was the patient's ECG, which had not changed since a prior tracing in 1989. A chest film obtained in the office was interpreted by the primary physician as showing a segmental right lower lobe infiltrate. The patient was diagnosed with bronchopneumonia, prescribed levofloxacin, and told to follow up with a physician at the resort.

Several days later, the films were overread by a radiologist who noted a 60% to 70% right pneumothorax with a leftward shift of the mediastinum. No right lower lobe infiltrate was seen. When the patient was located and informed of the change in his diagnosis, he related that he had grown weaker and more dyspneic. He was airlifted to a teaching hospital in Florida, where a chest tube decompression was accomplished without incident. He did well and, at first, merely expressed regret that the delay in the diagnosis had caused him a prolonged period of discomfort. Subsequently, however, he wrote a note to his physician saying that he had lost confidence in both the group practice and the physician who had treated him and that he would be going elsewhere for his health care in the future.

DISCUSSION

A number of errors were committed in this case, beginning with the initial decision to see the patient in an extremely busy primary care office that probably was not prepared to deal with a cardiopulmonary emergency. Patients with acute undifferentiated chest pain have to be assessed in proximity to a resuscitation area in case it should become necessary to perform invasive or life support measures. In my view, this patient should have been directed to call 911, and the physician should have notified the emergency department of the patient's pending arrival. He could either have arranged to meet the patient there or had the emergency physician perform the initial evaluation.

The premature closure of the diagnostic process by the physician was very risky and inconsistent with the presenting signs and symptom. During that office visit, the differential diagnosis of pulmonary embolism was still, in my view, quite plausible. In addition, the patient presented with atypical chest pain and the possibility of an ischemic coronary syndrome should have been actively pursued. A normal or unchanged resting ECG reduces the likelihood of active myocardial ischemia, but does not rule it out. One always has to consider coronary artery spasm or true posterior myocardial infarction, among a host of other ischemic pathophysiologic phenomena associated with minimal or no ECG abnormalities at rest. This patient's marked shortness of breath and severe substernal chest pain are not consistent with a segmental or subsegmental area of lung consolidation.

The initial interpretation of the chest film by the primary physician missed entirely an almost complete pneumothorax with a suggestion of development of tension. This was compounded by the lack of a quality-assurance provision for timely overreading of the film.

One cannot help wondering whether this patient's insistence on carrying out his travel plans pressured his evaluation and subliminally led to a premature and erroneous diagnosis by his overburdened primary physician. It is not uncommon that the pressure of taking a long-awaited vacation or attending some special event precipitates an acute incident in a patient with an advanced but previously latent disease process. Such patients come to us lobbying for a clean bill of health. Under these circumstances, it is extremely difficult for us to disregard this extraneous pressure and evaluate these patients solely on the clinical data. Failing to do this, however, places both the patient and the physician at risk.