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Missing a Heart Attack in LA: How Much to Prevent One Death?

Posted Aug 26 2008 4:08pm

So there was this horrendous story out of Olive View-UCLA where a young gentleman died after spending three hours waiting in an ER . His presenting complaint was chest pain and he died of a heart attack. He was 33.

Grunt Doc ’s excellent blog asked “ How in the world could this happen ?” I commented that “Missing an MI does not make it wise use of resources to investigate every low-probability case.”

It started a vigorous discussion that highlights important aspects of how doctors and nurses, managers and policy-makers view health care differently.

First let me make it clear that Christopher Jones’ death is a tragedy and in no way can his death be condoned, excused or reconciled. My point is that resources are limited no matter what your product and both policymakers and health care administrators need to make difficult resource allocation decisions. In other words, no matter how you want to sugar-coat it for public consumption, rationing must occur in any industry.

We can build the best possible vehicle and make one available to every adult man and woman in the US, but that does not make it any more feasible to afford allocating of those kinds of resources to a single product of such quality. True, there are differences between a critical health care service and a vehicle, and difference in the consequence of lacking access to one or the other. But the cost of preventing this death is not a single EKG. There is a larger context in which a basic economic principle holds true and governs our lives, our jobs and our livelihoods. That we were not taught such economic truths in medical school or nursing school makes them no less true.

First, there is no way to know if Mr. Jones’ wait in the ER was appropriate or not without knowing what else was going on in that specific ER that specific night. Somewhere, a California policy-maker should be asking if the ER was overloaded and why? If it was because of chronic underfunding of public hospitals, the blame lies with the politicos and the crappy level of public debate that I have been complaining about since I started this blog. Dogmatic responses and misinformation does not help resolve the very real problems providers face in that place where the rubber meets the road. Also, ER overbooking may be due to public ignorance leading to misuse of ER resources by an unrealistic populace.

There should also be an administrator looking at the triage situation in this ER. One commenter on GruntDoc described an ER that did not have a private triage area where EKG’s could be done. This is probably unacceptable in a busy inner-city ER. Perhaps triage decisions were made that an acutely ill 80-year needed to be stabilized before the 33-year old could be seen. The moral implications of this decision go far beyond the purpose of this post, but think about it. It is not an easy, cut-and-dried decision if the resources are not there to take care of everyone all the time.

Second, I must bring up some purely clinical issues. I stand by my comment that an EKG on everyone who walks in the door with chest pain is not necessarily a wise use of resources. I have seen 20-year-old have MI’s, but this is not the classic patient. An EKG may be sufficiently sensitive in a higher probability setting, it may not be sufficient to rule anything out in a 33-year old. Risk factors and not the presence of chest pain determines the probability of heart disease. If the EKG is abnormal, the probability of a false positive is also pretty high. This is not an administrative responsibility, but a medical one; this is basic clinical epidemiology. Anyone who neglects pre- and post-test probabilities is practicing cookbook medicine and not creating value for all those health care dollars being doled out. (Yes, I am being a little sarcastic here…)

So there it is. I suspect that there were resource allocation decisions by both policy-makers and administrators that probably contributed to this death. As tragic as it is, not everyone can be saved, nor should we as a society try to save everyone. Then there appears to be a basic misunderstanding of the role of the EKG in triage contributing to the sense of outrage.

My final thought is that if physicians and nurses were left to make the resource allocation decisions, we would necessarily have an expensive solution. Providing for what our patients need is what we were trained to do, it is what we are best positioned to do, it is what we would give away the farm to do. Balancing my training as a physician and my education in policy and management is the fundamental conflict in my life. Shouldn't we all be a little concerned about the bigger picture, despite our built-in internal bias?

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