Thunder Bay Regional Hospital (TBRH) developed a chest pain strategy (CPS) to support its emergency physicians in making the difficult clinical decisions required to properly evaluate and manage ED “chest pain” patients. This strategy was developed to ensure excellent patient care in a setting of diminished inpatient bed availability and increasing ED congestion. It focuses on rapid risk stratification, using history, electrocardiogram, physical examination and 3 new point-of-care cardiac markers: myoglobin, CK-MB mass, and cardiac troponin I.

Following the introduction of the CPS in 1997, TBRH realized significant ($500 000/yr) institutional resource savings through a 60% decrease in the admission rate of non-myocardial infarction, non-unstable angina chest pain patients, a 30% decrease in ED chest pain evaluation time, and improved ED availability of monitored stretchers. The CPS has allowed TBRH to simultaneously decrease costs and improve patient care.

In this issue, Dr. David Mutrie illustrates both the utility of departmental care protocols and the caution we must take in drawing conclusions from them. The latter point is particularly important if one wishes to apply these conclusions to other institutions.

The Thunder Bay Regional Hospital (TBRH), in Ontario, established simple guidelines for the management of patients with chest pain. Following the implementation of these guidelines, Mutrie reports shorter chest pain assessment times and reduced admission rates for non-myocardial infarction and non-unstable angina patients, without any obvious increase in inappropriate discharge of patients with ischemic disease. Can we therefore conclude that the guidelines were responsible for these improvements and that this set of guidelines would similarly improve performance in other emergency departments? The answer, unfortunately, is No. The fact is, the establishment of any organized approach to a clinical problem tends to improve performance. This is perhaps a sad reflection on “individual” practice patterns, but it is true nonetheless.

A 46-year-old man presented to the ED after the sudden onset of chest pain 45 minutes earlier. He had been straining (installing a fan) when the pain began. He described the pain as a severe pressure that radiated to his left shoulder and arm. No radiation to the neck or back was noted. He denied shortness of breath, nausea, diaphoresis, syncope or palpitations. He had not previously experienced similar symptoms and felt well until the moment the pain began. Past medical history included poorly controlled hypertension for 15 years and a 35 pack-year smoking history.

I love my job. I truly enjoy going to work and being part of the controlled pandemonium. The IVDA in 12 that was given Narcan by EHS and arrived awake enough to grab his full syringe and start injecting again. The sound of swear words wafting through the department and the sights and smells of human waste products exuding through all body orifices. Sometimes it is overwhelming: the noise, the demands, and the sadness of the conditions that people end up in.

The most likely answer in this case is D, but the correct answer is B. Because of diagnostic uncertainty, this man underwent urgent cardiac catheterization. Angiography revealed 80% occlusion of the left main coronary artery resulting from the false lumen created by an ascending aortic dissection. An immediate transesophageal echocardiogram showed mild aortic insufficiency, a left ventricular ejection fraction of 40%, and diffuse anterior hypokinesis. The patient underwent emergency surgery to repair both aortic dissection and the aortic valve, and to perform bypass grafting to the left main coronary artery.