Thanks rowley, nice synopsis of the debate. Clearly I am on the side of the
ED rule out protocol because that is what we do. The protocol works at
junior level with senior support (i.e. once taught they can get on with it).
We do approximately 800 rule out strategies for cardiac pain per year
(2-3/day) of which 10% show myocardial damage (trop rises).

I am currently doing my MD on the use of PRIME ECG for the evaluation of
chest pain patients in the emergency department. No results as yet, we'll
finish at the end of the year. I have submitted an abstract for the FAEM
meeting later in the year so might get the opportunity to present some of
the work there.

 As I think I said before, Steve Goodacre and I will be running a workshop
on ED chest pain assessment at the faculty meeting where we hope to address
lots of issues. Come along, it will be fun!

Simon


ley Cottingham wrote on 28/6/01 6:15:

>Well, I have given this debate
>a few days to blow itself out
>because it has tapped into a
>very rich stratum of
>viewpoint, some excellent
>medicine and some great
>knockabout slapstick, and I
>think has been very
>productive.
>
>For those who skimmed the
>whole debate, it fell
>essentially into three camps;
>admit, send home and decide
>later. In many respects, the
>response related to the
>seniority of the
>correspondent; more junior
>doctors would have admitted
>and more senior sent home.
>
>As per usual with my little
>clinical tales there is a real
>patient behind it, disguised a
>little. However, the patient
>was seen, diagnosed with a
>first episode of angina and
>referred to the GP who sent
>her up subsequently to the
>chest pain rapid referral
>unit. However, one of the
>cardiologists wrote to
>complain about this and say
>that the patient should have
>been admitted initially. The
>troponin was a red herring,
>incidentally; a low CK and the
>lab not performing the MB
>fraction should have
>reminded everyone that CK
>would have been pointless;
>although it is highly
>cardiospecific it is of course
>quite slow to rise.
>
>As it happens, I think Adrian
>is right that this is a counsel
>of perfection (professor of
>cardiology/medical
>negligence lawyer's mother
>notwithstanding) and
>Simon's excellent comments
>about the risk stratification
>of the patient are absolutely
>spot-on. She is at a low but
>quantifiable risk of acute
>myocardial infarction and
>then of sudden death. The
>issue that we are all
>struggling with is that it
>takes at least 6 hours and
>ideally an exercise test to
>make that decision. The
>same applies if she attends
>her GP with these
>symptoms, and this vignette
>suggests to me that the
>management of these
>patients is changing and
>evolving rapidly, and we are
>not all perhaps sure how
>others are managing such
>patients. It all comes down to
>a root issue in the NHS; what
>degree of risk are we as a
>country prepared to accept
>for a given level of medical
>care? It is the one discussion
>that our politicians, normally
>so loquacious, are noticeably
>silent on, and one on which
>they should give the lead. In
>my opinion, this is the role
>that NICE needs most
>urgently to adopt. In other
>words, it needs to set us
>national audit standards
>which have been agreed are
>acceptable. Thus, if Mr Jones
>goes home and drops off his
>perch, and it turns out that
>fewer than 2% of patients at
>that hospital have done so, it
>is considered bad luck and
>not bad medicine. At
>present, we have an uneasy
>truce; if the family make
>enough fuss, they will get
>money. Whatever good that
>does. If they however shrug
>their shoulders nothing
>happens.
>
>As per usual, I don't quite
>agree with my cardiologists.
>They want all first
>presentations of chest pain
>that could be cardiac to be
>admitted. They want all
>chest pain whether new or
>not to be referred to the
>medical team (I'm not sure
>the medical SHOs feel so
>keen) and of course they
>don't want us to
>thrombolyse anything.
>
>I agree (like Sam Waddy)
>that we need to look at all
>first onset chest pain
>whether coming to
>Emergency Units or
>attending the GP to be
>assessed in a 6 hour system,
>with exercise test and echo.
>Just as we need 8
>Consultants in Emergency
>Medicine per hospital we'd
>need eight cardiologists to
>deliver such a desirable
>service properly.
>
>I don't think that patients
>with known angina who have
>an attack that is classical and
>resolves completely and
>spontaneously or with GTN
>should get any further than
>the Emergency Unit if they
>pitch up. I think patients with
>features suggestive of
>deterioration should also be
>admitted as a substantial
>number of these are at risk
>of sudden cardiac death
>within the next year,
>(sorry, can't find the
>reference) and finally of
>course I believe everything
>barndoor should be
>thrombolysed instantly.
>
>Clinically, the major problem
>we have is a poor correlation
>between symptoms, signs
>(usually non-existent, of
>course) and ECG changes.
>Has anyone tried the new
>Prime waistcoat thing which
>allegedly helps with this
>dilemma
>
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Simon Carley
SpR in Emergency Medicine
Manchester
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