In the middle of a busy morning surgery this week I saw a lovely lady in her eighties. Late the previous evening she had developed chest pain which lasted two hours altogether. The paramedics called in the middle of the night and took an ECG which showed ischaemic changes, but didn't show whether they were new or not. She didn't want to go to hospital, so they told her to see me in the morning. She appeared well for her age, with no signs of cardiovascular upset. But with a history of two hours of chest pain just twelve hours before and an ischaemic ECG, a patient would normally have to go to hospital for observation.
She still didn't want to go. The trouble was that she is now moderately demented. Her husband can cope with her, but she is very forgetful and she gets upset easily. Indeed, she was getting quite restless in the waiting room because of the delay in seeing me. I reckoned that the stress of a hospital admission would do more harm than good, even if she had suffered a small heart attack. Better for her to go home, and for her husband to ring me if she appeared to become unwell. That is what we agreed. She had blood taken for cardiac enzymes before she left, and I arranged for them to come back in a week's time to review her and to discuss management of her worsening dementia. But I had an uneasy feeling as she left. This is what they call “tolerating uncertainty”.
The cardiac enzymes came back as normal next day.