More to be learnt from the discussion than the diagnosis

Two thirds of the 120 rapid responses to this case report came from outside Europe, with fairly even representation of North America, South America, the Middle East, and India and Pakistan.¹ Family doctors were in the minority, as physicians with backgrounds in internal medicine, cardiology, and emergency medicine debated the likelihood of different critical illnesses. It was good to see lively contributions from junior doctors and medical students too.

The responses suggested three distinct focuses of learning (box).

Focuses of learning from interactive case report

• A forum for exchanging specialist views around a difficult decision in critical care

• Sharing communication issues from different perspectives, enriched by a valuable patient contribution

• Reflection (along the lines of a critical event review) around the role of primary care in prevention of cardiovascular disease

The value of the debate on the cause of Peter Hartl's chest pain came less from those who cast their votes for coronary syndromes or dissection of the thoracic aorta (the lead differential diagnosis) than from those who exposed reasoned approaches for others to consider. The debate around thrombolysis was a good example.

Although Al-Qysi's software algorithm would have predicted that the risk of acute myocardial infarction was sufficient to justify treatment, Marinovic and Bell pointed out the dangers of thrombolysis in view of the likelihood of dissecting aneurysm. Marinovic reasoned that raised d-dimer and fibrinogen concentrations indicated a probable bleeding process or collection of blood somewhere in the mediastinum rather than pulmonary embolism. Parmar suggested deferring anticoagulation but reducing preload until dissection had been ruled out by computed tomography. Likewise, Ramdany advocated repeating electrocardiography in 30 minutes to reassess for ST pattern evolution that would warrant thrombolysis.

There was also a lot of discussion around investigation, after Glaser checked the evidence that transthoracic echocardiography could neither rule in nor rule out acute myocardial ischaemia. Helical computed tomography was advocated by some, including Robinson, who reminded us that as the results of early investigations accumulate and the patient's condition progresses, the pretest probability of conditions like pulmonary embolism may change. Ellrodt explained that he would choose computed tomography over transoesophageal ultrasonography, which cannot detect pulmonary embolism, but Herkner reminds us that the chosen contrast and time exposure for computed tomography differs depending on which of these two diagnoses is the most important reason for the investigation. He points out that often the choice of investigation is pragmatic “because critically ill patients do not only appear in the late morning when all resources are waiting to be employed.”

This discussion exemplifies the difference between education and training. “Training teaches us to solve puzzles not to solve problems. Education teaches us to solve problems, the nature of which may not be known at the time when the education is taking place, and the solutions to which cannot be seen or even imagined by the teachers.” ²