ER doc misread EKG? (long vent)

hollyster · Jul 31, 2005

There are a few studies done that show a majority of MDs misread initial EKGs and miss changes from previous EKGs. If you do not study and read EKGs on a daily basis you are going to miss subtle changes(how a MD could miss CHB is bewildering.)

We were pushing for tele and 12 lead refreshers every year for CCU staff but the facility did not feel that was necessary.

Editorial Team / Admin · Jul 31, 2005

has anyone had an er doc misread an ekg?
78f pt came to er from nh where she was staying for rehab (she was a&ox3, totally with it) c/o cp and sob (troponin 1.36). during report rn told me they gave fluid bolus (b/c she looked dehydrated), lasix, and k+ po, she was stable in sr, c/o sob, bnp 670 so diagnosed w/chf, md says no ekg changes (taken at 2100) from ekg last month when in for abcess surgery.
0045 pt gets to floor trying to sit up out of bed c/o "can't breath", o2 sat 93% on 2l (hx copd). monitor room calls out concerned about rhythm.
pt's in complete heart block???????? admitting md on floor and agrees that pt is in chb (after about 30min of convencing on our parts, don't know why he couldn't see it) will transfer to icu and consult cardiology now! i look at er ekg and it is also chb and i have to explain to the cardiologist that i'm waking up at 2am (took that long to get consult) that he could have been called at 2100 when er ekg showed chb.
she also didn't get an asa or any kind of anticoag. (and we have standing orders).
he took pt to cath lab for 2hrs, placed 2 stents, and transvenous pacer. pt also had to be put on vent. 2 days later (last time i worked) she was still in unit on vent being paced? i just can't help feeling that some of this could have been avoided.
talked to er rn and he said it wasn't his problem b/c you don't argue w/doc's and doc called it sr (so he didn't even look for himself)??
isn't it our responsibility to advocate for pt (i argued w/the im doc and he realized i was right and apologized).
sorry so long, just had to vent.

sure, that has happened before. so sorry it had to happen to you. did anyone look at the ecg after the er physician called it sr?? you are correct, you must advocate for the patient. glad you persisted.

the er nurse has the wrong idea about er patient care...should be less intimidated and more aggresive in the patient advocacy department. that was a total cop out on the part of that nurse in er. the er physician needs a refresher course in ecg interpretation.

siri, crnp, clnc, rlnc

tridil2000, MSN, RN · Jul 31, 2005

sure, that has happened before. so sorry it had to happen to you. did anyone look at the ecg after the er physician called it sr?? you are correct, you must advocate for the patient. glad you persisted.
the er nurse has the wrong idea about er patient care...should be less intimidated and more aggresive in the patient advocacy department. that was a total cop out on the part of that nurse in er. the er physician needs a refresher course in ecg interpretation.
siri, crnp, clnc, rlnc

good for you for standing firm and calling the:yelclap: :yelclap: :yelclap: cardiologist at 2 am!!!!

i am very proud of you!!! we need more rns like you!!!

what a load of crap from the er rn though!!! i might have written up an incident report on the whole thing myself!

trish rn bsn cen ccrn

beesnest · Jul 31, 2005

The troponin was elevated....presumably normal renal function....means we need to examine the EKG closely.

I had a woman with an elevated troponin, the doc insisted it was a lab error because she didn't "look like she's having an MI". So she went to the floor, bradyed down to the 30's, got a repeat EKG (with changes, that he admitted to himself) and he still didn't think she had that look until 4h later when a second, higher troponin came back.

De-Nile; it ain't just a river in Egypt.

UM Review RN, ASN, RN · Jul 31, 2005

Has anyone had an ER doc misread an EKG?
78F pt came to ER from NH where she was staying for rehab (she was A&Ox3, totally with it) c/o CP and SOB (troponin 1.36). During report RN told me they gave fluid bolus (b/c she looked dehydrated), lasix, and K+ PO, she was stable in SR, c/o SOB, BNP 670 so diagnosed w/CHF, MD says no EKG changes (taken at 2100) from EKG last month when in for abcess surgery.
0045 pt gets to floor trying to sit up out of bed c/o "can't breath", O2 sat 93% on 2L (HX COPD). Monitor room calls out concerned about rhythm.
Pt's in complete heart block???????? Admitting MD on floor and agrees that pt is in CHB (after about 30min of convencing on our parts, don't know why he couldn't see it) will transfer to ICU and consult cardiology NOW! I look at ER EKG and it is also CHB and I have to explain to the cardiologist that I'm waking up at 2am (took that long to get consult) that he could have been called at 2100 when ER EKG showed CHB.
She also didn't get an ASA or any kind of anticoag. (and we have standing orders).
He took pt to cath lab for 2hrs, placed 2 stents, and transvenous pacer. Pt also had to be put on vent. 2 days later (last time I worked) she was still in unit on vent being paced? I just can't help feeling that some of this could have been avoided.
Talked to ER RN and he said it wasn't his problem b/c you don't argue w/doc's and doc called it SR (so he didn't even look for himself)??
Isn't it our responsibility to advocate for pt (I argued w/the IM doc and he realized I was right and apologized).
Sorry so long, just had to vent.

OK, what I see here is an inappropriate admission to your unit when the Pt. actually should've gone from the ER to the ICU.

I'd have done an incident report citing delay in appropriate treatment as a result. Also note that the P&P calls for a stat ASA which was not given, etc. in your report.

To be perfectly honest, IMHO, ya all got lucky this time, and the ER needs to get their stuff together quick.

Very scary.

UM Review RN, ASN, RN · Jul 31, 2005

Just curious: with a trop of 1.36, ER MD didn't want to consult cardiology?!

JAHJF · Jul 31, 2005

I've only been an RN for a year and I've worked Step-down this whole time, THANK YOU all for your encouraging words.

She was admitted to the hospitalist (the on call MD was an internal med doc) and he took about 30min to see the CHB (he kept looking at the R-R and we kept saying LOOK AT THE P's!!!!) so I see how a doc could miss it but an ER doc (I was shocked to say the least). I think they all thought it was anxiety/CHF/COPD? and were just going to watch her (b/c they didn't think she had EKG changes, so she came to me) and consult cardio in the morning.

And no ASA?, we're supposed to be an accredited CP center (I don't care if you do think it's anxiety/GI etc, give them the ASA).

The cardiologist wasn't mad at me and he apologized for sounding upset (he's very nice all the time) but he did ask "so your saying the ER doc missed this?"

What exactly are you supposed to say to that?

(I have a feeling that he's going to make a stink about the whole incident.)

Sounded like a cope out on the ER RNs part to me too, what was he thinking saying it wasn't his problem (I would have felt like crap! and he should too); but I have trouble with even getting a good report out of him sometimes. I think nurses who don't care should move on.

I don't think we got lucky, but maybe the pt did, that is if she ever comes off the vent (last I heard it didn't look good for her, but I'll let ya'll know if I hear anything else).

UM Review RN, ASN, RN · Jul 31, 2005

I've only been an RN for a year and I've worked Step-down this whole time,And no ASA? [...] we're supposed to be an accredited CP center (I don't care if you do think it's anxiety/GI etc, give them the ASA).

OK, you need to know that a troponin of >0.2 means that the patient was positive for an MI. That should've been dx'd right in the ER.

I don't give a hoot what other issues the patient may've had, that the patient didn't get an aspirin from the ambulance to your unit is nothing less than negligent. So yeah, I hope the Cardiologist does raise a stink. Somebody needs to. :angryfire

blueheaven · Jul 31, 2005

I have seen ER docs do the same thing!!! Good that the patient had you for a nurse!!! I was called report from the ER one time by an ER nurse that said "He is having some big beats in groups" Of course when the patient hits the floor I had lidocaine in hand, he was having VT and hypotensive! I have had pts come to the telemetry floor with obvious EKG changes from ER...diagnosed w/ ACS.

JAHJF · Aug 1, 2005

She is still in the unit, doing poorly :crying2: from what I hear, son is coming in from California.

ERNURSE4MS · Aug 11, 2005

okay it does sound like the er doc missed the mark, but i have to stand up for the er nurse. i have been in this situation, where it was obvious the pt was having an mi but the er doc refused to believe this and even after being shown an elevated trop and ekg changes still didn't call it mi. i reported this in writing to nm, but felt like a fool calling report and having the nurse on the other end give me the 3rd degree. i cannot treat a pt without orders from a doctor. if the doc won't listen all we can do is cover ourselves. i thank the lord that my incident report was the final straw for this doc and he got the boot from our facility. i don't know the circumstances with the er nurse you dealt with but just wanted you to get a look from the other side.it is always sad when we know a pt is not getting the best care even though we tried.