Chest Pain in Pregnancy

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Michael H. -

While I recognize that the ultimate goal of this segment was to provide some insight into the decision making process around chest pain/PE workup in pregnancy, I found the process of this segment to be utterly distasteful. While you were rightly correct to be concerned regarding PE in this patient, the patient (and her mother) clearly expressed a treatment preference that did not involve imaging. Moreover, they could actually articulate their reasoning as to why not, and nowhere was it mentioned in the segment that the patient lacked the capacity for decision making (it sound as admirable efforts were made to facilitate communication and clearly outline options). Although distressing, patients make choices that are against our recommendations, and in fact against their best interests, all the time. It is not our job (as was done here) to recruit other people into browbeating someone into making the decision WE think is best, but rather to provide information to the patient and allow them to reach the decision that best accords with their wishes and values, even if we disagree. To suggest it was appropriate to cajole this patient into receiving a scan they clearly didn't want flys in the face of the basic tenants of patient autonomy and decision making.

Jess Mason -

Thanks for your comment. It can be a tough call when to submit to what seems to be a bad decision and not try to convince the patient otherwise. In this case I believed we were best serving both of our patients (the 16-year-old and her soon-to-be-born child) by encouraging her to get the imaging. A life threatening PE would have been an utter tragedy to miss and that would have serious implications in many ways. I can’t imagine standing before her family delivering tragic news, as well as hospital ethics, physician review committees, and possibly a jury. I think when you really feel you’re acting in the patient’s best interest it is our obligation to explain that and do our best to encourage a decision that aligns with safety. In non life-threatening cases, of course the approach is different, and I have much more tolerance for allowing a minor to have autonomy in decisions with which I don’t agree. It was also an added challenge that this was a minor and that made the stakes feel higher. It’s always important to hear other opinions though and I appreciate that you listened and offered your thoughts.

Bridget M. -

I am replying here, rather than starting a new comment thread, as I agree with the sentiments of Michael H.

An informed decision discussion involves presenting a patient with accurate information, and then respecting their decision. The word 'convince' was used multiple times in this segment, and as above I found it to be very distasteful. The patients right to autonomy was not at all respected, it seemed like a very paternalistic approach to practising medicine.

Rather than defending your care of this patient, I hope you use these comments as an opportunity to reflect on bias that maybe influencing the care you provide to patients.
- When your values are in conflict with a patients values, how do you reconcile that gap ?
- How do we reconcile that gap while providing both culturally safe and 'medically' safe care?
- What alternatives were available to you that would have satisfied your valves of providing 'safe' care to the patient, and her values?

These are some of the reasons why I love Emergency Medicine, and what I think make Emergency Medicine an art rather than a science. Providing care for the patient in a way that matches my value system (Evidence Based Medicine) with a patients values.

Jay H. -

Just curious about this patient’s dimer being 1000. No mention was made of the adjusted normal for pregnancy which would mean this is a normal 3rd trimester value. I am retired so not keeping up on current literature as I was when practicing, so is the adjusted value no longer considered valid?

Jess Mason -

That's a great point. Using the YEARS criteria the dimer cutoff is 1000. We've got a calculator for YEARS here:

Timothy R. W. -

This comment ties in with the patients desire to not have radiation exposure as discussed above. It also ties in with the comment I made 1 year ago on the first of these EMRAP discussion relating to CP in pregnancy. It is topic I pointed out then based on an important paper published in Annals of Emergency medicine 22 years ago (Pulmonary Embolism: Making sense of the diagnostic evaluation, Ann Emerg Med. 2001 May;37(5):504-14).

The topic being we need to focus more on long term outcome and less on making the perfect diagnosis of venous thromboembolism in patients with transient risk factors and good cardiopulmonary function. This is especially the case in a pregnant patient with good cardiopulmonary reserves who can tolerate a small PE and does not want/need radiation nor actually treatment (risks might outweigh the benefits). In a stable pregnant woman with no DVT seen on US of her legs and no right heart strain seen on Echo - the probability of her having a large PE is miniscule and the probability of her throwing a large PE later is miniscule (if you don't believe that read the above reference which includes 100+ supporting research articles showing we don't need to be certain and as this was pre CTA we almost never were certain of a negative workup). To go on and subject her to more diagnostic testing which exposes her and the fetus to radiation that she does not want (right or wrong) for an answer you do not need (she will be fine if you follow the outcome standard and stop the workup, she might not be fine if you anticoagulate her) is simply bad medicine and displays a lack of truly understanding this "disease." She will deliver in a few weeks, her risk factor (pregnancy) will be gone soon after, she does not have a DVT so won't suffer a bad outcome even if she has a small PE (which does not need treatment once her risk factor resolves). At most you might bring her back for repeated lower extremity ultrasounds. I think this issue of outcome standard vs gold standard has been TOTALLY lost since the advent of CTA. Now it is too easy to get CTA and be done, but it is not needed in a lot of patients and in this case especially a more nuanced approach should be considered.

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