Definite Cause of Chest Pain Sometimes Up in the Air

“It’s not what you don’t know that hurts you — it’s what you do know that ain’t so.” — Will Rogers

The highly informative and nicely written piece by Richard O’Leary, Jr., M.D., “If There Is a Doctor on the Plane...” (August 2006) was marred by a misleading piece of clinical advice. The relief of chest pain by an antacid does not reliably distinguish the esophageal discomfort of “heartburn” from more ominous chest pain of cardiac origin. 

Although Good Samaritan laws and common sense tell us we cannot perform as well at 35,000 feet as we might in the emergency department back home, a rich cardiology literature and many plaintiffs’ actions tell us that 20 percent of patients with unstable angina or myocardial infarction incorrectly self-diagnose their discomfort as reflux or heartburn. Further, 15 percent of patients with myocardial infarction (MI) get some, and 7 percent complete relief of their ischemic pain with antacid administration.

Half of patients with proven MI reported an increase in belching, and we now know that esophageal reflux is more common in patients with ischemic heart disease than in the general population. Further, myocardial ischemia is often precipitated by reflux.

Don’t ever count on an antacid to tell you why your patient has chest pain — at any altitude!

Thomas J. Poulton, M.D.
Evansville, Indiana

Ethical Dilemma of Blanket Unconsented Pregnancy Tests

I was distressed to read the July 2006 “Practice Management” column “Preoperative Pregnancy Testing: Mandatory or Elective?” concerning preanesthesia pregnancy testing. In interpreting some of the legal issues, scant attention was given to the ethical/privacy/minor patient concerns, which were discussed in detail by a 2003 Joint Task Force on Pregnancy Testing (members of the practice parameter group on preanesthesia testing and the Committee on Ethics who were jointly appointed by the ASA president).

In February 2002, the “Practice Advisory for Preanesthesia Evaluation” was published in Anesthesiology. In October 2003, the ASA House of Delegates approved an amendment to the parameter specifically addressing pregnancy testing. The issue was whether pregnancy testing should be “offered to” women patients or should be required and done without their consent.

The ethical and privacy concerns are serious because testing women for pregnancy is usually not medically indicated for anesthesiologists because there are no modern anesthetic drugs that independently (apart from the surgery itself) affect either the pregnancy or the developing embryo. It would be very similar to testing an entire class of patients, like those who are indigent, for another socially important condition such as HIV without their consent. Early pregnancy and HIV sero-positivity are very socially, but usually not surgically, important issues. Yet the results of these tests could negatively affect a patient in many nonmedical aspects of their lives.

Let me emphasize that testing for pregnancy for ACTUAL MEDICAL INDICATIONS, at THE PATIENT’S REQUEST, or OFFERING patients the test in case THE PATIENT would want to postpone elective surgery is an entirely different issue. For instance it is medically indicated for a gynecologist to test for pregnancy before performing a hysterectomy because it directly affects the surgical technique and risks for an early pregnancy. A gynecologist should probably refuse to perform a hysterectomy without such an indicated test.

Other than hysterectomy or other abdominal surgery, there is probably no comparable situation where an anesthesiologist should refuse to care for a pregnant patient, or should drastically alter anesthetic plans, because we currently use no drugs that are proved to directly harm an early human pregnancy or human embryo. When not medically indicated, testing, billing for and recording on medical records the results of a “mandatory” unconsented pregnancy test is an issue that affects only women patients. Even the Joint Commission on Accreditation of Healthcare Organizations has ethical objections to subjecting an entire class of patients to testing for the benefit or protection from liability of the health care providers or the philosophy of, for example, a Catholic health care institution. If an institution or an anesthesia department wants to require women patients to have pregnancy tests, then they should inform their patients in advance that they will be tested for pregnancy, that they could be denied their surgery if the test is positive, and that the results of the test will be on their medical records and available to insurance companies and/or employers.

In short, the ASA Committee on Ethics, the ASA Joint Task Force on Pregnancy Testing and the revised Preanesthesia Evaluation practice advisory all agree that unconsented pregnancy testing is unethical in most situations involving competent patients. The revised practice parameter advises that pregnancy testing should be “offered” to women patients. If medically indicated, it should be specifically consented to, and the patient should indicate who, other than herself, she would want to know her results (spouse, common law partner, parents, her insurance companies, her employer?).

The ethical issues for preprocedure pregnancy testing can be addressed by at least informing your patients that they will be tested; and even more ethical and respectful would be a policy of informing and obtaining consent for the test.

Susan K. Palmer, M.D., Chair
ASA Committee on Ethics

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