Playing a Hunch
Amy Crawford-Faucher ~
There's one thing about being a family doctor: After a while, almost every patient you see is a familiar face. This can be a blessing or a curse, but mostly it's a blessing.
This morning I'm in my office, reviewing today's patients with Julia, the medical student rotating in our office.
I'm especially looking forward to my 10:30 appointment. It's the first checkup for a newborn girl named Ella. I've known her parents, Emily and Dave, since before they had their first daughter, Katie, now three. I think of them as one of "my" families.
Emily and Dave, in their late twenties, have been together since college. Emily works full-time in a management position. Everything about her is calm and unflappable. Her dark blue eyes, neat dark-brown hair and pleasant expression radiate quiet competence. She easily weathers the garden-variety worries and crises of career and child-rearing.
Dave stays home with the kids. He's a little stocky, sports a short blond beard and exudes nervous energy. Basically healthy, he has some minor medical issues that worry him, and he often calls in with concerns.
Their newborn, Ella, was delivered a week ago by cesarean section. I'm eager to see how she's doing--and how her parents and sister are handling this shift in the family structure.
While finishing with my previous patient, I send Julia to introduce herself to Emily and Dave. She walks in as my nurse is weighing and measuring Ella.
"It's a big change, having a newborn again," Emily is saying. "Nursing is going all right; I'm not getting much sleep. But basically we're doing well." Casually, she pats her chest. "If it weren't for this pain that started a while ago, I'd be totally fine."
This offhand comment catches my nurse's attention. She asks Julia to come and get me.
Hmm, I reflect. With this new baby, I'd half-expect Dave to report some anxiety-related symptoms...but Emily?
At first glance, Emily seems pretty much as usual. Upon closer examination, she looks subtly different. Her normally unruffled expression is a bit withdrawn and inwardly focused.
We start to talk. The pain isn't in her breasts, but deep in her chest. She's never felt it before; it came on gradually as she got ready this morning. It's a pressure that makes it a little hard to breathe. It maybe got a little worse with walking, but maybe not. She doesn't feel sick to her stomach, and she's not feeling chilled or hot.
I put my stethoscope against her chest and listen. Her heart rate is normal, her lungs are clear, and the rest of her vital signs are normal.
"I'm not sure what this pain is," I say. It's hard to admit this to a patient, but it's the truth. Emily is young and healthy; the odds are that it's nothing.
We discuss the most likely reasons: heartburn, a muscle pull, anxiety.
But my nagging disquiet remains. There are some potentially deadly reasons too: a blood clot in the lung, a heart attack.
And there's the look on Emily's face.
I feel my focus shift entirely from baby to mother.
"I'm sorry, but we'll need to reschedule Ella's check-up," I say. "I need to investigate this chest pain more closely."
Dave gets Ella dressed again. We give Emily oxygen, baby aspirin and an electrocardiogram.
The EKG isn't perfectly normal, but it doesn't show anything really wrong, either. I pause to consider.
I have a young, healthy, but exhausted new mother in my office who wants nothing more than to be reassured about her chest pain so that she can go home, breastfeed her baby and get some sleep. I really want to oblige her. Maybe I'm reading too much into her symptoms. And visiting the ER is expensive, time-consuming and stressful; I'd love to spare her that.
But yet. I know Emily. If she's concerned about this pain, then I'm concerned.
Julia and I step outside to discuss the options. I try to explain my hunch--the inner equation that sums up my clinical experience and my knowledge of a patient's personality, history and family, to produce a clinical impression. For me, this "medical math" has become second nature, especially with patients I know well.
Again, we run through possible causes of Emily's chest pain. Again, I do the medical math, balancing her stoic nature and the potential risk of a bad diagnosis against the potential harm of an unnecessary ER evaluation.
The answer becomes clear. I step back inside to tell Emily why we need to call an ambulance to take her to the nearby hospital.
While waiting for the ambulance, I page the ER doc on duty and explain Emily's situation and my concerns.
"Really." His tone is ironic, world-weary. "Perhaps you or she is anxious? Or overreacting?" He sighs mightily and hangs up. I'm annoyed, but not really surprised.
The ambulance whisks Emily off to the ER--and, I hope, to a clear diagnosis.
An hour later, the same ER doctor calls back.
"Why did you send her to us and not to the main hospital?" he demands angrily. Her blood work showed a heart attack; Emily is now en route to the main hospital for a cardiac catheterization.
I feel a twinge of vindication. I knew something was wrong. Mostly, though, I'm relieved that Emily is getting the care she needs.
Her procedure reveals a coronary-artery dissection, in which an artery's inner layer tears away from the vessel wall. Blood collects in the space created and blocks the artery, causing chest pain, heart damage--and sometimes sudden death.
So now I have a young, previously healthy, but exhausted new mom who's in the intensive-care unit, an equally tired and worried dad who's at home with a toddler and a newborn. And I have a call in to the ICU cardiologist.
Fortunately, this cardiologist is gracious--and glad for my expertise in medicine use during breastfeeding. Together we work out a regimen that gives Emily the necessary drugs while eliminating others so that she can safely continue to breastfeed, which is important to her. I feel grateful that even though I can't be with Emily in the hospital, I can still help with her health and mothering goals.
The dissection was caught in time to prevent any permanent damage, so Emily is sent home after three days--tired but stable, and ready to be reunited with her family.
This story ends well. Emily makes a full recovery. In following years, I see the family regularly for well checks, school physicals, sick visits, contraception counseling, immunizations for a trip overseas--the usual. She continues to work full-time, and Dan gets a job outside the home. They win a basement renovation on a TV decorating show.
Life goes on.
I'm soon to move out of the area, following my husband for his dream job. I know that I need to see Emily and Dave and their girls before I leave.
Our last visit begins like so many others: As I walk in, Katie and Ella are giggling and playing with the blood-pressure cuff; Dave is fidgeting in his chair; Emily is sitting serenely in hers.
After we chat for a bit, the girls hand me a double picture frame. On the left side, I see a color photo of them playing on a swing set; on the right side, a black-and-white cath film showing their mom's heart vessels and the offending dissection.
Dave clears his throat. I fear that he's going to ask one last question about migraines. But he doesn't. Instead, he adds the final element to the medical-math equation.
It goes like this:
"Hey, Doc, thanks again for saving my wife's life."
About the author:
Amy Crawford-Faucher is a family physician and the residency director at Forbes Family Medicine in Pittsburgh. She believes that stories have great power--in medical education, patient education and for advocacy for strong family medicine and primary care. "I was prompted to share this encounter because I fear that Emily's care could have been seriously delayed that day, if she had gone to a practice that either didn't know her well or wasn't equipped to treat patients of all ages."