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Guest post: Door-to-balloon time

September 18, 2014

By Aaron Segal, MD, and Richard Young, MD.

The doctor in this story was Dr. Segal, who was in private practice in Plano, TX at the time of the incident. Dr. Segal now works for United Healthcare. The corresponding author is Dr. Young.

I was four miles from home on a Saturday morning jog when my phone rang. Under the shade of a nearby tree, I listened to the voicemail.  An unsteady female voice informed me that her husband, my patient, had been moved from the emergency room of a local hospital to undergo an emergency heart procedure.

Her voice slowly eased as the conversation unfolded. Her husband had woken up with chest pain and told her that he had to go the ER immediately. They both knew he had experienced chest pain before. I had ordered several tests in the past that reassured me and my patient that there was no life-threatening heart disease, but he had insisted that on this day that he should be evaluated without delay. An abnormal electrocardiogram in the ER prompted the emergency physician to diagnose an anterior wall myocardial infarction. The patient was then consented and prepped for an urgent heart catheterization. When I spoke with his wife, my patient had just arrived in the ICU for recovery. The heart cath was normal. There had been no heart attack.

Normally, I would summarize this information as good news, but this story was odd. My patient was not a 75-year-old man with a long history of diabetes and hypertension. He was 27.

However, he was not a typical 27-year-old man. A history of many years of steroids prescribed – actually overprescribed, in my opinion — for asthma as a child left him with osteoporosis and a history of several fractures. He had a tension pneumothorax once, so he could understandably be very sensitive to chest discomfort. He told me a previous doctor diagnosed him with mitral valve prolapse, but this was never clinically significant in my care of him. Most importantly though, was the early-repolarization on his EKG that we’ve known about for years, and which I actually recalled that Saturday morning without looking at his chart.

Some might have labelled him as a hypochondriac. For me, that description was too harsh. However, I felt there was an underlying anxiety disorder in someone who had more organic medical history than a 27-year-old should have.

As my care of him progressed after our first clinic encounter and many organic causes of his chest symptoms had been ruled out, we began entertaining mental health contributors to his constellation of symptoms. He didn’t want to see counselors because he wasn’t “crazy”. Trials of anti-anxiety and anti-depressant medications helped a little, though his reports of their effectiveness were never consistent, and he would often stop taking the medications after a month or two. My description of an SSRI as a pill for “stress” seemed to improve his adherence and overall well-being, at least a little.

 

The Cardiologist

I called the cardiologist at the hospital as soon as I got home, and he filled in the gaps in the story that the patient’s wife could not. But the cardiologist’s explanation did not make much more sense.

On the day of the heart cath, the ER doctor looked at the EKG and immediately activated the cardiac cath team because he believed the patient was having an acute anterior MI. The majority of the cath team arrived at the hospital in 10-15 minutes, but the cardiologist was at another hospital about 30 minutes away. When he arrived as the last member of the team, the patient was on the cath table, consented for the procedure, and the team was dressed in sterile gowns and gloves. The cardiologist looked at the EKG and diagnosed the ST segment changes as being consistent with benign early repolarization. The point-of-care cardiac enzymes were normal. He proceeded to do the cath anyway.

I asked him, “Why did you do the cath if his EKG showed benign early repolarization and his enzymes were normal?”

He hesitated just a little and said, “I know, but the team was there ready to go. The ER doctor ordered the heart cath, so I just went ahead and did it. Besides, if I didn’t do the cath it would make our door-to-balloon-time quality score go down. I never refuse to do a heart cath that the ER physician ordered.”

At this point, I started to feel slightly nauseated and a little tremulous. I wasn’t at all convinced about his claim of the impact of this case on the metric of door-to-balloon-time, but I saw no point in furthering this conversation. I also wondered if a contributing factor was a belief by the cardiologist that he was owed something for driving 30 minutes to answer a stat page ordering him to immediately come to the hospital. Clearly, the cardiologist knew this test was a waste. As with so many other declarations of the “standard of care,” this approach was the culmination of a complex interaction of local and national factors with no evidence to support it.

I felt that I had discovered a new rationale for an unnecessary test – validation of an on-call cardiologist and support team who would otherwise be inconvenienced in the face of a possibly inflexible and inappropriately interpreted hospital performance measure.

I saw the patient a few days later in my clinic. He reported that he had recovered from the heart cath without much difficulty, though his leg was still sore. As we reflected on the episode, I felt obligated to explain forces not commonly spoken in normal conversations: hospital metrics, door to balloon time, and intra-professional etiquette. I didn’t want to hammer on the points, but he seemed to understand that the cath really wasn’t necessary. However, he is a genuinely nice man, and it is not his nature to file a complaint or cause trouble. What was done was done and that was the end of it.

I left this encounter feeling like I had still earned my patient’s trust for the next time he feels unwell. He might actually call me instead of just racing off to the ER. I even got him to agree to carry a small copy of his “abnormal” EKG in his wallet.

I felt fairly powerless about the whole affair. I believe that unnecessary tests are a real problem and this was as unnecessary as they come. But to do anything about it meant hassling the hospital, the cardiologist, and the cath team. And I knew my patient would not be a willing part of this. There was no 1-800 W-A-S-T-E-D -T-E-S-T hotline for me to call, an AMA website to log onto, nor a Quality Metrics Gone Wild television show on which to air an expose’. I have no doubt that if a similar situation happens this week, nothing will change. Another patient will receive an unnecessary heart cath, be exposed to the unnecessary risks of the procedure, and the healthcare industry will abscond from the rest of our economy many more tens of thousands of dollars of pure waste.

I have to pick my battles, and it is impossible for one primary care physician to change the standard of care in a hospital-emergency-specialist tandem where larger financial and cultural forces dictate so much of what really happens to patients.

I controlled what I could control. I interrogated the cardiologist, educated my patient, and changed my referral patterns. Otherwise, I had to close this chapter of my professional life and walk away.

 

Conflict of interest: Dr. Young discloses that he was paid a stipend to participate in the CMS Innovation Advisor Program in 2012. Dr. Segal discloses that he now works in a medical care review capacity for United Healthcare.