Dr. Gaurav Sharma

This response to the comments above is based on scientific facts and has been drafted objectively to not only educate every individual regarding the circumstances of such a medical case and assist them in taking a rational and informed decision in such situations. Chest pain in any individual of any duration (few minutes to few days or many weeks) is quite a complex diagnosis (confirmation of underlying cause) especially if the individual is a young female. The underlying causes of chest pain may range from Acute Gastritis to Esophageal Ulcer, Gastric Ulcer, Acute Myocardial infarction, Acute Coronary Syndrome, Aortic Dissection, Pulmonary Embolism, Myocarditis, Musculoskeletal Disorder, Cardiac Arrhythmias, Pulmonary Edema, Pleuritis, etc. The list is quite long. I'm sure that most of the readers would have not even heard of such list of medical diagnosis except one or two mentioned above. As a medical practitioner our job is to consider all possibilities and assess the patient in detail. This is not as easy and straightforward as thought by a person with non-medical background. Even in a super specialty hospital with a team of various medical experts such diagnosis can often be missed or may remain elusive despite thorough investigations. This is because, medical diagnosis depends on various factors, most important is the presentation of the patient and the duration and nature of symptoms. Due to the complex origin and nature of various diseases, and the background history of patient, there can be a significant overlap in symptoms and therefore initial symptoms and diagnostic measure alone can not always predict the final diagnosis. We need to carefully assess the medical condition of the patient, assess the vital parameters, calculate potential immediate or long term risks to life, try to narrow down the possibilities of underlying causes within few minutes without loosing our patience and wisdom, even if the relatives and patient is in panic state, and at the same time re-assure the patient and relatives to calm down, with rationale and scientific opinion. At the same time, we need to start treatment of the patient in such a way that focuses on no harm or least calculated side effects. In this case, the patient with acute chest pain was a young female with history of severe chest pain radiating to left side, left hand, nausea, and vomiting. The patient was restless, very uncomfortable and in severe pain in chest. As a medical protocol we have to assess the patient from all perspectives keeping in mind the possible underlying causes and assess the patient clinically and with appropriate investigations. Therefore, after initial assessment, the common possibilities were informed to the patient and her relative very clearly. It was also explained that the initial assessment has its limitations and therefore necessary investigations and follow-up is essential. As a protocol followed internationally for patients with chest pain, an ECG is an essential tool for aiding diagnosis and if required can be serially repeated to see the developing changes. In all such cases, the potential diagnoses of Acute Myocardial infarction, Acute Coronary Syndrome, Aortic Dissection, Pulmonary Embolism, Myocarditis, Cardiac Arrhythmias, Pulmonary Edema, Pleuritis can be life threatening and a clear medical protocol for assessment and management is must to be followed. Therefore, if an ECG facility is available, it must be done immediately. It is also to be noted that the initial development of such medical conditions may not always be captured in the ECG initially done, and therefore the patient should be followed later by a repeat or serial ECGs, coupled with further detailed clinical assessments and other relevant investigations, as appropriate. The same advise was given to the patient and her relatives and appropriate prescription for suspected gastritis (which is often not life threatening) was given and was administered appropriate medications within the clinic (note that the comments above have clearly ignored the prescription and treatment given in the clinic as injectable medicines). ECG was clearly advised to be done immediately and not to be delayed keeping in mind the gravity of situation. Such standard medical protocols are followed to take appropriate next steps and aid diagnosis. Even if ECG is negative for potential life threatening conditions, it still needs to be repeated with other clinical evaluations and investigations, only when repeated assessments rule out any potential life-threatening medical condition, a patient can be satisfactorily declared 'out of danger zone or medical emergency'. For people at high or moderate risk of Acute Myocardial Infarction (AMI), commonly known as heart attack (as indicated by a validated tool), or Acute Coronary Syndrome (ACS), high-sensitivity troponin test (a blood test) is recommended. Patients and their relatives need to understand that a negative finding on investigations like ECG or troponin does not necessarily indicate that they are not from a serious heart, lung, or other life threading condition. Not only that depending on presentation of a case, an early chest computed tomography (CT scan) can be recommended to rule out other fatal conditions with diagnoses such as Pulmonary Embolism or Aortic Dissection. It is therefore, advised to do appropriate investigations immediately and to be follow-up until a clear diagnosis is clinched and accordingly medical management protocol is followed.
 As a medical practitioner, our role is to try saving the life of patient, with utmost care and patience, and try to search even the most elusive diagnosis, which we know are not ever heard by most patients. It's a challenging task, and very easily could be neglected by few individuals without being empathetic to the kind of effort we do, with presence of mind, quick decision making, and keeping the well being of the patient at the forefront than a personalised subjective decision. We always walk on a double edged sword, if we do investigations and nothing significant comes out in diagnosis, few, though not many, consider it unnecessary, and think that the money was wasted. If anything otherwise happens and a serious diagnosis is discovered later due to avoiding certain investigations or advise, people with same set of mindset may think or say that appropriate care was not taken. 
 Therefore, to handle such possible circumstances, we make sure to give the firm medical opinion, explain pros and cons, and mention the same on a prescription. Rejection or avoidance of any test, investigation, examination, or treatment is certainly a personal choice and is duly considered. However, every minute detail is shared with the patients and relatives, and this is done clearly to avoid any conflict of interpretation at a later time, and safeguard patient's and doctor's interests. If a serious medical case such as this is handled, it is our duty to clearly mention in our notes if the denial for certain medical procedure or advise is given by patient or his/her relatives. And the same step was taken in the above case. However, the patient's relative had the misunderstanding and inappropriate interpretation. At no point in time the treating doctor lost the patience in explaining details or treating patient appropriately. If being the close relative of the patient, a personalised subjective judgement is taken, it is certainly not in the best interest of the patient's life. If the person even has the ability to laugh or being sarcastic in situation, is even more unfortunate. If such advise, notification, irks the patient or relative, it is extremely unfortunate and certainly not an objective assessment of the whole situation but a very personalised statement(s). Criticism is welcome, but always should be done with objective and positive approach and with complete scientific understanding of the situation. In all such cases, it is expected that the patients and their relatives / well wishers should maintain dignified composure and let the treating doctor take necessary steps of medical assessment and procedures.