Agree on the two areas the expert overstepped, he really seems to be unable to help himself and is laying it on really thick.
97/40 in a patient in pain would catch my eye. It should be rechecked and discussed in the MDM. It might be as simple as "BP is low normal, lower than I would expect w her discomfort but she takes beta-blockers and the BP today is similar to the BPs recorded on her last two visits."
ACS is possible, but PE and dissection would also be high on my differential.
I've always thought of thoracic back pain as a trap. The differential diagnosis is broad, and reflexively concluding MSK cause is risky, as this case clearly shows. I can "reproduce" trapezius muscle tenderness, just as I can reproduce costochondral joint tenderness, but that doesn't mean I'm diagnosing costochondritis in everyone I see with chest pain. Not even close.
IMO, discharging a pt in 6-10 minutes is just plain bad practice. the NP clearly didn't adequately assess the patient. I'm not saying that no diagnostics were needed, but the whole chart is cringeworthy. I've reviewed plenty of these in M&M-poor documentation and shoddy care in the setting of a patient with soft vitals, high pain scale, and a complaint that suggests the need for more than a cursory evaluation.
Let's also point out that template charting and EMRs make this so much worse. you can make a chart look like you did a thorough assessment when in reality the opposite happened.
Despite the fact that this patient' back pain presentation could not be related with ACS or AMI as the first option, there is one Dx that should be r/o taking in consideration her hx of long standing hyperlipidemia and cigarette smoking which is dissecting aortic aneurysm including the presence of hypotension. If this Dx would be taking in consideration, then the workout would included ECG Echo CT chest cardiac enzymes, etc increasing possibility of catching the real Dx.
I am agreed with the statement about detailed physical exam like the reviewer was claiming is an overstep and probably will not add any light to the Dx.
Out of an abundance of caution… and realizing that MI in women is not necessarily textbook.. I can see myself ordering Cardiac enzymes.. labs.. placing her in telemetry , EKG .. addressing the hypotension and pain… at the least.. just because I’m a novice NP and afraid of missing something like this. In my opinion what I would have done.. I’m thinking is BASIC. Rule out worst case scenario first.
3. A BP of 97/40 requires context in the sense that it is taken by a non-invasive blood pressure cuff using oscillatory readings. These readings are most effectively reading the MAP and then use an algorithm to estimate systolic and diastolic pressure. I find that we often get caught up with a SBP <90 cutoff and then disregard the MAP, when the MAP is the measured value and the SBP/DBP are calculated values. Obviously this is different with arterial line and other invasive BP measurements.
These values can be further distorted depending on the limb/location of the cuff measurement.
For instance, assume the BP cuff had calculated a pressure of 85/46. The MAP is still 59 (measured) while it changed the calculations of SBP and DBP. Hence why some more vital signs sure would be nice!
In my mind the only thing that truly stands out is pain of 10/10. If the patient was in the room eating pop corn and complained 10/10 pain - it is very easy to overlook that. 10/10 pain should imply tears or screaming or very visible discomfort. I'm betting that wasn't the case. Once you account for this, the BP becomes somewhat less concerning (especially if you have prior BPs for comparison). Just my $.02
97/40 is low for a 52 year old. Worth a re-check at the least.
I'd worry most about aortic dissection as a differential - sudden onset 10/10 back pain. Have a feeling that a similar case would probably end up with a CT angio here (if CXR, bloods, ECG etc were non-diagnostic).
Over 50 with chest pain and women often do not have CLASSIC signs of MI but I would be very concerned for MI/AAA with this patient at a minimum would have gotten chest xr, routine labs including Trop and EKG. Likely would admit for further chest pain assessment.
I think it would have been possible to miss angina if sudscapular mid spine pain was the only presenting symptom. I also feel that the MD who reviewed the chart post hoc, appeared biased in the case making references to VERY detailed assessments an finally, I certainly agree on the bias inherent in the fast track in the ED. I would not consider this bp reading as very low and can be a normal finding and therefore consideration of associated symptoms are needed.
This is a challenging case, and underscores the need for health care systems to have leeway for nursing staff, and providers to properly assess patients.
The trap that is set when a patient is assigned to FastTrack often makes it very challenging for providers to voice their concerns and have an appropriate workup done.
Ultimately, of course, it is the mid level, or physicians call as to what workup will be done. Unfortunately they are under serious time constraints, and constant scrutiny by bean counters to see patients quickly,... I believe this is the biggest factor for lack of appropriate work ups, and missed diagnoses.
Even if an appropriate history and physical exam was done (unlikely in this case), the provider may not have considered ACS as a cause for the patients symptoms, and as an ED provider of more that 20 years, I am still fooled from time to time. That being said, the hypotension should not have been ignored.
I think that keeping vigilant, and ignoring the pressures put on you to hurry up, and see patients more quickly is the best way to avoid potential pitfalls such as this.
If she presented to a primary care office, she likely would have been seen in a 15 minute visit and possibly (probably?) diagnosed similarly and in the same 6-10 minute time frame. I am not saying this right, but it is accurate.
What caught my attention for this article was how it was framed by Doximity in my feed. It was titled “the case that proves the dangers of fast track.” It seems this could’ve just as easily happened in a regular ED triage and evaluation process. I definitely don’t think it proves anything about Fast track systems - calls into question the depth of reasoning by the individual NP. However, I do think that fast track or intake area dispositions made rapidly should be limited to a predefined set of low risk conditions and done by the highest trained provider in the emergency department respectively. for example, in our system, (a freestanding, regional level, one pediatric trauma center) our intake process uses pediatric emergency physicians. While most of us don’t enjoy the shift, we’ve all acknowledged that the subtleties in presentation and the known imprecision of ESI triage allows some patients with serious conditions to slip through being billed as level four or five complaints. The experience, training, and disposition to consider life and limb threatening conditions is part of the emergency physician’s training and differs from the general pediatrician’s and advance, practice providers who work at our emergency department. While these providers could easily care for the vast majority of patients who come through our rapid assessment intake process, patients coming through this process deserve, an assessment by somebody trying to identify subtle nuances of presentation. The disposition from our intake area can be 1) discharged home, 2) super track (a pre-specified set of low risk, easily managed, presenting complaints) or main ED for a full evaluation. This helps to avoid some of the premature closure based on the simple designation of super track mentioned by another commentor. of note, I am the medical Director for the diagnostic safety program at our hospital and have an ongoing project with five years of data. Our analysis have not demonstrated that being seen in our intake area increases the risk of diagnostic areas leading to subsequent hospital admissions. And it’s important to get the right provider in front of the right patient and for all providers in the emergency department from nurse practitioners and PAs to the board-certified emergency physicians…to recognize situations that are beyond their scope of practice and represent significantly higher risk, obtain the appropriate testing, and or consultation for life or limb threatening conditions.
The timing of assessment and discharge may be skewed because the documentation may have all been done at discharge, as frequently happens. I do agree that the expert oversteps in the areas you mentioned. I would consider 97/40 a low bp and I hopefully would have questioned the patient further. I also wonder at the pain worsening with movement, as that would point away from cardiac issues.
So first of all - I acknowledge it’s easy to look at everything after the fact with 20/20 vision. Full disclosure - I’m an NP.
I absolutely do not do the exam the expert witness for the plaintiff describes - nor have I ever seen that done in any ER I have worked in for the past 20+ years. Ever. With many, many physicians. I’m astounded someone suggested this would be the standard of care.
The hypotension with severe pain would have been concerning for me. I also have heightened suspicion of cardiovascular issues with thoracic pain (particularly midline), including aortic dissection. Not to mention women present differently for ischemia and infarction. I hear what y’all are saying but for someone with acute 10/10 pain, a blood pressure of 97/40 would make me concerned. I suppose this is because I’ve seen it with a gent who drove himself to the er while his aorta was dissecting - he had excruciating pain and a very soft blood pressure. He unfortunately did not survive.
I’ve been taught over time by those practicing for a long time before me that you must be able to explain an abnormal VS prior to discharge. If this was a runner who was thin, 90s/40s might have been her baseline (and as such, documented against). While we have known standards for hypotension and hypertension, so much is dependent upon the patient, their history, clinical presentation and exam.
While I realize there are perhaps “opioid aware” folks who will report 10/10 pain often, it’s worth diving deeper.
This case really hits me regarding caution with diagnostic momentum.
Something I always wonder about is what else was happening in the department when something gets missed? I realize that isn’t helpful for the patient’s outcome, but I can highlight systems issues vs perhaps poor judgment. I have so many more questions about the patient as well, her HPI, ROS, and PEx.
As far as the steroid question goes, I do not know if that would have increased her risk for MI or not. What I do know is I have not seen this routinely done for back pain for quite awhile - and this case was in 2017. I’m curious if y’all are commonly using steroids for back pain in current practice.
Great opinion comments! It's true that the pulmonary diagnoses also be included in the differential when evaluating symptoms of thoracic back pain. As a patient with a pulmonary embolism I experienced initial severe thoracic back pain/spasms, along with shortness of breath that was worse lying down, mostly relieved with sitting up. Of course the Tspine xrays and Tspine MRI done initially were not helpful. Thanks for your case. - Retired physician
This is not a statement into the debate about mid-levels/NP's in current healthcare; however - I think that many different 'practitioners' are able to diagnose simple health complaints such as a UTI or a URTI - the important distinction is in identifying those patients who may present with superficially simple syndrome (overly generous in this case) but is actually suffering from a serious and preventable illness. The difference is in medical education, experience and clinical reasoning. I cannot imagine how upset I would be if this case was my parent; when looking at how clearly mismanaged and under investigated this case was - I do not think for one second we are benefiting from hindsight here; all patients who have chest or thoracic back pain, especially if elderly or have risk factors for cardiac/vessel disease need exclusion of more serious underlying pathology before the jump is made to MSK/functional disease. I do not see how anything less is at all defensible in a modern healthcare system.
Agree on the two areas the expert overstepped, he really seems to be unable to help himself and is laying it on really thick.
97/40 in a patient in pain would catch my eye. It should be rechecked and discussed in the MDM. It might be as simple as "BP is low normal, lower than I would expect w her discomfort but she takes beta-blockers and the BP today is similar to the BPs recorded on her last two visits."
ACS is possible, but PE and dissection would also be high on my differential.
I've always thought of thoracic back pain as a trap. The differential diagnosis is broad, and reflexively concluding MSK cause is risky, as this case clearly shows. I can "reproduce" trapezius muscle tenderness, just as I can reproduce costochondral joint tenderness, but that doesn't mean I'm diagnosing costochondritis in everyone I see with chest pain. Not even close.
IMO, discharging a pt in 6-10 minutes is just plain bad practice. the NP clearly didn't adequately assess the patient. I'm not saying that no diagnostics were needed, but the whole chart is cringeworthy. I've reviewed plenty of these in M&M-poor documentation and shoddy care in the setting of a patient with soft vitals, high pain scale, and a complaint that suggests the need for more than a cursory evaluation.
Let's also point out that template charting and EMRs make this so much worse. you can make a chart look like you did a thorough assessment when in reality the opposite happened.
Despite the fact that this patient' back pain presentation could not be related with ACS or AMI as the first option, there is one Dx that should be r/o taking in consideration her hx of long standing hyperlipidemia and cigarette smoking which is dissecting aortic aneurysm including the presence of hypotension. If this Dx would be taking in consideration, then the workout would included ECG Echo CT chest cardiac enzymes, etc increasing possibility of catching the real Dx.
I am agreed with the statement about detailed physical exam like the reviewer was claiming is an overstep and probably will not add any light to the Dx.
Out of an abundance of caution… and realizing that MI in women is not necessarily textbook.. I can see myself ordering Cardiac enzymes.. labs.. placing her in telemetry , EKG .. addressing the hypotension and pain… at the least.. just because I’m a novice NP and afraid of missing something like this. In my opinion what I would have done.. I’m thinking is BASIC. Rule out worst case scenario first.
3. A BP of 97/40 requires context in the sense that it is taken by a non-invasive blood pressure cuff using oscillatory readings. These readings are most effectively reading the MAP and then use an algorithm to estimate systolic and diastolic pressure. I find that we often get caught up with a SBP <90 cutoff and then disregard the MAP, when the MAP is the measured value and the SBP/DBP are calculated values. Obviously this is different with arterial line and other invasive BP measurements.
These values can be further distorted depending on the limb/location of the cuff measurement.
For instance, assume the BP cuff had calculated a pressure of 85/46. The MAP is still 59 (measured) while it changed the calculations of SBP and DBP. Hence why some more vital signs sure would be nice!
In my mind the only thing that truly stands out is pain of 10/10. If the patient was in the room eating pop corn and complained 10/10 pain - it is very easy to overlook that. 10/10 pain should imply tears or screaming or very visible discomfort. I'm betting that wasn't the case. Once you account for this, the BP becomes somewhat less concerning (especially if you have prior BPs for comparison). Just my $.02
97/40 is low for a 52 year old. Worth a re-check at the least.
I'd worry most about aortic dissection as a differential - sudden onset 10/10 back pain. Have a feeling that a similar case would probably end up with a CT angio here (if CXR, bloods, ECG etc were non-diagnostic).
Over 50 with chest pain and women often do not have CLASSIC signs of MI but I would be very concerned for MI/AAA with this patient at a minimum would have gotten chest xr, routine labs including Trop and EKG. Likely would admit for further chest pain assessment.
I think it would have been possible to miss angina if sudscapular mid spine pain was the only presenting symptom. I also feel that the MD who reviewed the chart post hoc, appeared biased in the case making references to VERY detailed assessments an finally, I certainly agree on the bias inherent in the fast track in the ED. I would not consider this bp reading as very low and can be a normal finding and therefore consideration of associated symptoms are needed.
This is a challenging case, and underscores the need for health care systems to have leeway for nursing staff, and providers to properly assess patients.
The trap that is set when a patient is assigned to FastTrack often makes it very challenging for providers to voice their concerns and have an appropriate workup done.
Ultimately, of course, it is the mid level, or physicians call as to what workup will be done. Unfortunately they are under serious time constraints, and constant scrutiny by bean counters to see patients quickly,... I believe this is the biggest factor for lack of appropriate work ups, and missed diagnoses.
Even if an appropriate history and physical exam was done (unlikely in this case), the provider may not have considered ACS as a cause for the patients symptoms, and as an ED provider of more that 20 years, I am still fooled from time to time. That being said, the hypotension should not have been ignored.
I think that keeping vigilant, and ignoring the pressures put on you to hurry up, and see patients more quickly is the best way to avoid potential pitfalls such as this.
Sad story.
If she presented to a primary care office, she likely would have been seen in a 15 minute visit and possibly (probably?) diagnosed similarly and in the same 6-10 minute time frame. I am not saying this right, but it is accurate.
What caught my attention for this article was how it was framed by Doximity in my feed. It was titled “the case that proves the dangers of fast track.” It seems this could’ve just as easily happened in a regular ED triage and evaluation process. I definitely don’t think it proves anything about Fast track systems - calls into question the depth of reasoning by the individual NP. However, I do think that fast track or intake area dispositions made rapidly should be limited to a predefined set of low risk conditions and done by the highest trained provider in the emergency department respectively. for example, in our system, (a freestanding, regional level, one pediatric trauma center) our intake process uses pediatric emergency physicians. While most of us don’t enjoy the shift, we’ve all acknowledged that the subtleties in presentation and the known imprecision of ESI triage allows some patients with serious conditions to slip through being billed as level four or five complaints. The experience, training, and disposition to consider life and limb threatening conditions is part of the emergency physician’s training and differs from the general pediatrician’s and advance, practice providers who work at our emergency department. While these providers could easily care for the vast majority of patients who come through our rapid assessment intake process, patients coming through this process deserve, an assessment by somebody trying to identify subtle nuances of presentation. The disposition from our intake area can be 1) discharged home, 2) super track (a pre-specified set of low risk, easily managed, presenting complaints) or main ED for a full evaluation. This helps to avoid some of the premature closure based on the simple designation of super track mentioned by another commentor. of note, I am the medical Director for the diagnostic safety program at our hospital and have an ongoing project with five years of data. Our analysis have not demonstrated that being seen in our intake area increases the risk of diagnostic areas leading to subsequent hospital admissions. And it’s important to get the right provider in front of the right patient and for all providers in the emergency department from nurse practitioners and PAs to the board-certified emergency physicians…to recognize situations that are beyond their scope of practice and represent significantly higher risk, obtain the appropriate testing, and or consultation for life or limb threatening conditions.
The timing of assessment and discharge may be skewed because the documentation may have all been done at discharge, as frequently happens. I do agree that the expert oversteps in the areas you mentioned. I would consider 97/40 a low bp and I hopefully would have questioned the patient further. I also wonder at the pain worsening with movement, as that would point away from cardiac issues.
So first of all - I acknowledge it’s easy to look at everything after the fact with 20/20 vision. Full disclosure - I’m an NP.
I absolutely do not do the exam the expert witness for the plaintiff describes - nor have I ever seen that done in any ER I have worked in for the past 20+ years. Ever. With many, many physicians. I’m astounded someone suggested this would be the standard of care.
The hypotension with severe pain would have been concerning for me. I also have heightened suspicion of cardiovascular issues with thoracic pain (particularly midline), including aortic dissection. Not to mention women present differently for ischemia and infarction. I hear what y’all are saying but for someone with acute 10/10 pain, a blood pressure of 97/40 would make me concerned. I suppose this is because I’ve seen it with a gent who drove himself to the er while his aorta was dissecting - he had excruciating pain and a very soft blood pressure. He unfortunately did not survive.
I’ve been taught over time by those practicing for a long time before me that you must be able to explain an abnormal VS prior to discharge. If this was a runner who was thin, 90s/40s might have been her baseline (and as such, documented against). While we have known standards for hypotension and hypertension, so much is dependent upon the patient, their history, clinical presentation and exam.
While I realize there are perhaps “opioid aware” folks who will report 10/10 pain often, it’s worth diving deeper.
This case really hits me regarding caution with diagnostic momentum.
Something I always wonder about is what else was happening in the department when something gets missed? I realize that isn’t helpful for the patient’s outcome, but I can highlight systems issues vs perhaps poor judgment. I have so many more questions about the patient as well, her HPI, ROS, and PEx.
As far as the steroid question goes, I do not know if that would have increased her risk for MI or not. What I do know is I have not seen this routinely done for back pain for quite awhile - and this case was in 2017. I’m curious if y’all are commonly using steroids for back pain in current practice.
Great discussion! Thank you so much!
Great opinion comments! It's true that the pulmonary diagnoses also be included in the differential when evaluating symptoms of thoracic back pain. As a patient with a pulmonary embolism I experienced initial severe thoracic back pain/spasms, along with shortness of breath that was worse lying down, mostly relieved with sitting up. Of course the Tspine xrays and Tspine MRI done initially were not helpful. Thanks for your case. - Retired physician
This is not a statement into the debate about mid-levels/NP's in current healthcare; however - I think that many different 'practitioners' are able to diagnose simple health complaints such as a UTI or a URTI - the important distinction is in identifying those patients who may present with superficially simple syndrome (overly generous in this case) but is actually suffering from a serious and preventable illness. The difference is in medical education, experience and clinical reasoning. I cannot imagine how upset I would be if this case was my parent; when looking at how clearly mismanaged and under investigated this case was - I do not think for one second we are benefiting from hindsight here; all patients who have chest or thoracic back pain, especially if elderly or have risk factors for cardiac/vessel disease need exclusion of more serious underlying pathology before the jump is made to MSK/functional disease. I do not see how anything less is at all defensible in a modern healthcare system.