“I just moved here from Portland two weeks ago,” said Ms. Shelly in a weak voice. When I walked into the room, I immediately noticed her blood pressure was 224/108. The patient was mostly sleeping, but when I started speaking with her, it was apparent to me something was wrong. “Do you have a history of any heart problems?” I asked Ms. Shelly. “I had aorta surgery two times…” she murmured before falling back asleep. Aortic dissection. My upper-level resident walked in towards the end of me seeing Ms. Shelly but did not look at all concerned. “I want to get STAT CT chest. We need to rule out a dissection. She told me twice that she’d had aorta repair surgery in the past,” I told my upper level. “Let’s hold off on any STAT imaging. She is not endorsing any chest pain, and EKG and CXR are normal. Get her list of home meds from her daughter, and start her on some scheduled BP meds. Call cardiology. Order PRN meds, hydralazine and labetalol. Put parameters on those. I need to go see the next patient.” Before I could say anything else, my upper level left the room. Against what my upper level told me, I ordered a STAT CT chest and typed in the comments box, “BP 224/108, confused, concern for dissection, PE, reports hx of aorta surgery.” We’ve been told never to order STAT imaging unless you have a very high clinical suspicion of something dire that’s happening to your patient. heart attack. Pulmonary embolism. Aortic dissection. If you order STAT imaging and it wasn’t indicated, this could take away from another patient who needed an imaging study done. You will get dinged for it hard. About 25 minutes later, in the doctor’s lounge, I presented Ms. Shelly to my attending with my upper level and co-intern present. Her nurse called my upper level. “CT shows type A aortic dissection; please come to the patient’s room ASAP!” My upper level ran out of the room as my attending called cardiothoracic surgery. The surgeon saw Ms. Shelly, and she went into surgery. The last I heard was that she was recovering in the ICU. The next day, my attending told me it was a good call to order the STAT CT chest. “I was just following my gut.” I didn’t disclose the disagreement I had with my upper level. Too often in medicine, there is this hierarchy of decision-making. At times, I can understand why it exists. As a PGY-1 (first-year resident), you do not know much. You only have limited clinical experience and knowledge from the books. In the same breath, you did learn about the conditions that can kill a patient. heart attack. Pulmonary embolism. Aortic dissection. We also learned to do no harm to a patient and to always act in your patient’s best interests. I acted in Ms. Shelly’s best interest, which saved her life. And I am a first-year resident. No matter what stage in your medical career, you are a doctor. “MD” means making decisions. If your patient is in a possible emergency, do everything you can if you have a high degree of confidence. If you question anything about the patient’s case, get help ASAP. Would I have done things differently? I would have called my attending after speaking with my upper level. I wouldn’t have changed anything else. If I had waited and no one ordered the CT chest, Ms. Shelly would have died. Source
