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A cardiac arrest made me realise the importance of doctors' sixth sense

Anonymous

I recently, at the age of 49, survived an out of hospital cardiac arrest. It helped that I am a GP and was on a ward round in a local care home. The nurse sitting next to me started CPR immediately and I was defibrillated within a few minutes by a team of paramedics. Usually only 5% survive such an event. Often survivors suffer cognitive deficit, which hopefully for me is minimal.

I did not really have any major risk factors except a strong family history: four generations of heart disease presenting at a young age. My mother and uncle are still alive after their heart attacks at ages 46 and 36 respectively. The emergency angiography showed my coronaries were 100%, 95% and 90% blocked. I now have three stents, hopefully doing a grand job.

Because of my family history and some atypical sensations at age 48, I thought it would be a good idea to get screened for heart disease. So within the year before my event I had an exercise tolerance test. This was equivocal to the cardiologist, so he recommended I have a thallium scan. This showed no evidence of significant risk for ischaemic heart disease. I was seen in an outpatient clinic four months later by the registrar, who counselled me on lifestyle modification and then she discharged me from the clinic.It was an odd consultation. I did not think she knew I was a doctor. I left the room feeling unhappy with how our encounter went but I know this can happen.

I was unaware that the sensitivity of thallium scanning locally is 93%, a false negative rate of 7%. I wonder if this had been discussed with me whether I would have requested further tests. It has left me thinking about patients I knew with negative investigations and subsequent drastic events – often advanced cancer. I have had difficult consultations when they have asked why nothing was found before.

From the cardiologist’s point of view it has really made me see how difficult their jobs are, especially when NICE guidelines are based on risk scores. For lower risk cases minimally invasive tests are recommended. Because an angiogram comes with a risk of complications, they are only performed for higher risk cases. The atypical pain meant I had a thallium scan. If it was family history only I would have had a CT angiogram.

This leaves me wondering about the use of our sixth senses and the importance of medical acumen. This has to be balanced against the risk of over investigating a population and the harm that can cause. I usually avoid going to see a doctor but in this case it was my strong family history that made me seek help. If I were offered further invasive tests and I knew the risks involved would I have declined it? I found that even as a doctor, I reverted to the patient role and relied on specialist advice.

Three months post event I went to see my first consultant to try and understand what had happened. Being human, I was stern and sort of angry. It must have been hard for him to sit and listen to me. Although nothing could be changed, I hope he realised that I thought communication could be changed for future throughout the process and that it might protect him more.

The lessons I have drawn from this are: the use of a good consultation, that screening tests have pitfalls and patients may need to be more aware. In the future for my patients’ sake I will endeavour to be better informed on the sensitivity or specificity of each test. Finally, I have learned when to use your acumen and sixth sense.

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Readers' comments (5)

  • Look up Bayes' Theorem, it looks at conditional probability.
    Your false negative result of 7% , if converted to Bayes' may have given you a clearer, understandable probability of you having a heart attack, but 50% of statisticians disregard Bayes.
    I agree with with you mentioning sixth sense. I have heard many stories from fellow GP's about cases where they have gone against specialist advice about negative investigations and ordered further tests, it is a grey border. It has happened to me on several occasions , gut feeling, "there is something wrong here!" Cannot put my finger on it, order this, and yes, diagnosis, but then often another -ve test. What a lot of so called experts cannot grasp that humans are individual and cannot be pigeon holed. The NICE guidlines advocated a CXR for any person over age 35 yrs with cough of 3/52. Another problem is that guidelines gradually become accepted and interpreted as rules, especially lawyers, whom we want to avoid.
    I am so glad that you were "fortunate" to have your cardiac event where you did. Supposing you were on your own on a lovely country walk, which somewhat worries me, as I do a lot of bird watching, and have several risk factors.
    Good luck to you. JON.

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  • a consultant ENT I knew always trusted his sixth sense, even if all the scans came back negative he would always open them up for a look around, and he was always right, there would always be a cancer insitu. Same with nurses, a patients vitals may be good, they may seem ok, however you would always put the resus trolley next to them as you had a funny feeling. it is the art of being a Dr and a nurse that we are able to sense things however unscientific and its the one sense that we are losing as we are relying to much on results.

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  • I agree with Jacqueline, sadly the art of a diagnostic sixth sense is being eroded by the spectre of litigation.

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  • What I find worrying is that with such severe and live threatening disease you had a " uncertain " stress test

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  • A GP stating please check me out, I have chest pains and a lot of my relatives died of heart disease.Is it odd to only get a thalium scan? when a CT angiogram was also available, my private patients seem to only get CT angiograms. Must be odd to be told all is normal and then nearly die from the original problem

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