I am a new nurse with one year of experience working on a med/surg floor in a small 50 bed acute care hospital. Recently I recieved a 56 yr old male with the diagnosis of chest pain and left pleural effusion. This patient was four weeks post CABG x3. In the ER his troponins were .02, EKG showed acute NSTEMI MI (which the ER doc attributed to his hx CABG and past MI). The ER gave him 2MG Morphine IVP for his chest pain and 1 inch NitroBid paste. He then became nauseated and they gave IV Zofran. The hospitalist for my unit recieved report from the ER doctor and ok'd the transfer to my floor without ever assessing the patient herself or even writing any orders for the patient. He was brought up with what we call "transitional orders" which are written by the ER doc and included: oxygen, telemetry, admit to med/surg for observation, and to contact hospitalist for any further orders. Upon the patient's arrival to my floor I found him to be short of breath with minimal exertion, very diminished lung sounds to L side, chest pain which was radiating down his back and both arms, general weakness. I felt very uncomfortable caring for this patient with his recent cardiac history and ongoing chest pain on my uniy, even more so since the hospitalist never saw the patient and didn't write any orders because she said she thought he was a "typical rule out chest pain". I called the hospitalist with my concerns and the patient's current assessment. She at first asked if we could transfer the patient to our ICU. However our ICU was full at the time, and besides the point could not care for this man if he was indeed having an MI. So instead she ordered IV morphine, zofran, and repeat troponins. She did not come to assess the patient at this time despite my concerns. I gave the morphine and stayed with the patient for the next 45 min completeing the admission process. After 45 min, the patient still had no change with his chest pain and I checked the troponin level which we had recently ordered. The Troponin level was now .40 two hours after the Troponin of .02 that was taken in the ER; I immediately called the hospitalist and told her she was going to have to come see this patient because with his rising troponin and unrelieved pain I did not feel that we could adequately care for him at this facility. Fifteen minutes later she came down and decided to start a nitro and heparin drip and transfer the patient to a bigger facility that was able to intervene if appropriate. The nitro drip could not be started on my floor due to hospital policy, so the patient ended up back in the ER so the drips could be started while he awaited transfer. My questions to try to have some understanding are: Is it normal for an EKG to show an Acute MI post CABG? I know they show infarcts of an undetermined age, but acute?? Also was this patient even acceptable to be transferred to my floor in the first plave given his history? And why would the hospitalist think that this patient wasn't worth assessing? What is your take on this situation, what else should I have done, was I overthinking the situation? Is it normal for troponins to elevate after CABG?
Jul 10, '12
I just wanted to say kudos to you for being persistent and advocating for this pt! Sounds like he needed more and you were able to get the ball rolling! Ivanna
Jul 11, '12
Awesome job advocating for this patient! To answer some of your questions:Yes it is possible for these patients to have abnormal ECGs like you described and not be infarcting. You said that it was non STEMI, but the machine read acute. Usually this is due to pathologic Q waves or R wave progression-can be acute or old. You can almost never rely on the machine's interpretation. Without see the actual ECG I could not definitively say. Yes! This patient should have been seen upon arrival to the floor! Minimally within the first 1/2 hour.The patient's cardiologist should have been consulted from the ED and transferred to a more acute setting. Beyond an MI this patient could also have had a PE or tamponade. Unless he was a good actor or I'm missing something he should have been in ICU over night.
Jul 16, '12
He was increasing his troponins and having CP.Either his st segment was elevated or not.
Either way, hes earned a trip to the cath lab...
Aug 13, '12
Why wasn't cardiology informed...and his surgeon? This guy was way out of the scope for a hospitalist. If his troponins were increasing, and his chest pain was not subsiding he needed to get a repeat EKG and probably to the cath lab. You did a fantastic job advocating for this patient! I hope he did well.
Aug 13, '12
very very very great job. I really appreciate your work.
you act like a Nurse.
according to the latest guideline from AHA, all patient with chest pain must be assess less than 10 minute at arrival to ER and EKG must be read by clinician to early diagnosis of MI.
in this case, your hospitalist have shortage to care about pt.
for diagnosis of acute MI two condition must be availible:
1. diagonal St elevation with sharpen T wave
2. STE in two neighbor lead
did this condition existed in your patient EKG????
if yes, your patient had an acute MI. If no, there is somthing else like a unstable angina because troponine level invrease in U/A.
overal, you done the best.
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