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?