ER doc misread EKG? (long vent)

sjt9721, BSN, RN · Aug 11, 2005

ERNURSE4MS makes a good point, but from the report you received, it sounds like the ED nurse agreed that the EKG showed sinus rhythm (ouch!). Even if the doc & I disagree, my nurse-to-nurse report includes my interpretations and assessments, not just the physician's! In this situation I would most certainly have raised a stink in the ED regarding inappropriate admission location, lack of consult, etc.

The posters have identified many breakdowns in this particular case. Certainly this incident should trigger some education for the ED medical & nursing staff. ACS guidelines, EKG interpretation, etc, etc...

This situation also reminds those receiving patients to review the chart upon patient's arrival to their unit. Looking over the lab results, EKG, care notes, & such when the arrives can be beneficial and creates a more complete picture than merely a report by phone/fax.

Keep up the good work in advocating for your patients!

student4ever · Aug 11, 2005

Haven't seen an ER doc misread an EKG before that I have known about, but last week the ER MD on nights called a cardiologist out of bed, into the hospital for "a really funky looking EKG" which the cardiologist promptly said, "it's 'funky looking' b/c whoever did the EKG mixed up the leads. Call me when you have a real problematic EKG." And the scary thing is, it was a NURSE who did the EKG - not even a tech... :angryfire

JAHJF · Aug 12, 2005

ERNURSE4MS I totally get you point (have been in situations myself where doc didn't seem to want to do what is needed and you don't have orders so what do you do) but I don't feel that this was this case in this situation or w/this specific nurse. I never intended to sound down on ER nurses (I deal w/many wonderful ER nurses on a regular basis); I just hope someone learns something from this and things are looked at more closely at my hospital's ER.

Thank you all for your replies. :)

Sadly this pt was made a DNR, taken off the vent and passed away tuesday in ICU (about 2 weeks later).

dutchgirl · Aug 17, 2005

Hurray for you calling the cardiologist! Thank goodness the pat got to the cath lab, and hopefully in time... I can't help but wonder - don't you have 12 lead machines that give their own interpretation??? It would at least say "abnormal ekg"

grammyr · Aug 18, 2005

Have had a doc misread an EKG and one that did nothing when the patient presented with CP. The nurses raised such a stink and even bet him a steak dinner, that he went ahead and shipped the patient to a Cardiologist. (She had 3 stents placed). The second patient came back a few hours later even more symptomatic and was having an anterior MI. We shipped her straight to the cath lab also.

We have not had any protacols until now and we are in the process of writing some protacols for this and some other things. If anybody out there has any suggestions on this please let me know.

JAHJF · Aug 18, 2005

Hurray for you calling the cardiologist! Thank goodness the pat got to the cath lab, and hopefully in time... I can't help but wonder - don't you have 12 lead machines that give their own interpretation??? It would at least say "abnormal ekg"

If you read my above post this patient passed away.

But, we do have machines that make wheir own interpretation (most often it isn't 100% correct, but what machine is) and it did call this EKG an undiagnosible/abnormal EKG (or something along those lines).

SEOBowhntr · Aug 24, 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.

er nurse,

you are kidding, right???? this is part of the problem in nursing!!! whether we are factually "right or wrong," the doctor is always right. now i am a large imposing man, but i have many times told many doctors which way is up because they didn't know, and they listened. we as nurses need to always know who we can call to depend on to get the job done when a doctor isn't doing his job correctly. i would encourage each of you, to know who you can call director, medical director, etc to ensure that the right thing is done for the patient.

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

???? angie,

not necessarily. that (+) troponin may be related to chf, renal failure, uncontrolled htn that stressed the heart, etc. i think you also need to know that your trop will be the last of your cardiac panel to rise!!!! a more definitive and acute lab for cardiac issues is the ck-mb. that being said, ekg changes can id an mi long before labs will.

jahjf,

good job in getting the patient taken care of!!!!! unfortunately, you had to do this, because had the er md and rn had half a brain, you'd have never been involved in this patient's care, and the patient's prognosis would likely be better with more timely and appropriate treatment.

this is an issue where we as nurses, if we truly think we are right, must really be patient advocates at the highest level.

"the choices we make dictate the lives that we lead, to thine ownself be true." - shakespeare/macbeth

in our jobs, this saying goes a long way, but also extends into our patients, and we must be true not only to ourselves, but also to our patients, ensuring an optimal outcome!!!!!

doug

hrtprncss · Aug 24, 2005

i agree with the previous post, we as nurses especially unit nurses are the last line of defense of the patient, it happens, mistake happens, ekg's are misread in the er, but as an icu rn, it's their responsibility to be more proactive and double and triple check things, it's all for the patient's benefits.

UM Review RN, ASN, RN · Aug 24, 2005

???? Angie,
Not necessarily.

We take it as an MI until or unless anything else can be ruled out. In the case in question, there were no other causes for the trops to be up. I've seen a CKMB rise for many more reasons than a troponin would, which is why troponin is the diagnostic for MI, especially with NSTEMI.

SEOBowhntr · Aug 24, 2005

We take it as an MI until or unless anything else can be ruled out. In the case in question, there were no other causes for the trops to be up. I've seen a CKMB rise for many more reasons than a troponin would, which is why troponin is the diagnostic for MI, especially with NSTEMI.

Your inexperience speaks for itself, "never seen a troponin in the hundreds." Troponin is a late indicator of an MI, CK-MB will indicate a cardiac even much sooner. However with that being said, please read this posting on Troponins, it is educational, and I will be posting it in my unit when I get a chance to print it.

http://www.sydpath.stvincents.com.au/tests/Troponin.htm#ACUTE%20MYOCARDIAL%20INFARCTION

"For clear-cut presentations of acute myocardial infarction (AMI) the use of a troponin as a diagnostic tool has no advantage over the usual combination of CK and CK-MB. "

This statement says it all. This issue has little to do with the Troponin level and everything to do with the EKG reading. As said previously, CK and CK-MB's are more acute labs for indicating an acute MI.

Doug

UM Review RN, ASN, RN · Aug 24, 2005

I don't wish to argue with you, but in the interest of accuracy, I must. Please read this from the American Heart Association:

http://www.americanheart.org/presenter.jhtml?identifier=4477

An excerpt (bold-faced and underlined by me):

Troponins specific to heart muscle have been found, allowing the development of blood tests (assays) that can detect minor heart muscle injury ("microinfarction") not detected by CK-MB. Normally the level of cTnT and cTnI in the blood is very low. It increases substantially within several hours (on average four to six hours) of muscle damage. It peaks at 10 to 24 hours and can be detected for up to 10 to 14 days.

AHA Recommendation

Several studies have identified a measurable relationship between cardiac troponin levels and outcome after an episode of chest discomfort. They suggest that these tests may be particularly useful to evaluate levels of risk. In other words. results of a troponin test could help identify people at higher risk for serious heart problems or death. It remains to be proven whether more cost-effective methods of treatment and, eventually, a better outcome will result from routine troponin testing.

UM Review RN, ASN, RN · Aug 24, 2005

In case that's not enough, here's another from the American Heart Association website. There is no mention whatsoever of either CK or CKMB, only troponin:

Journal Report

05/24/2005

Evidence-based guidelines can help treat mild heart attacks, angina

American Heart Association scientific statement:

http://www.americanheart.org/presenter.jhtml?identifier=3031083

The statement offers guidance on which tests are most critical to perform in the emergency department immediately. For example, all patients should be given a rapid ECG within the first 10 minutes in the emergency department to measure the heart's electrical activity. They should also have blood tests for troponin, a biomarker for heart cell death, Gibler said.

These tests determine if the patient is at low, intermediate or high risk for death, myocardial infarction and other cardiac complications.

If troponin levels are normal, patients are considered low risk, and early conservative treatment is recommended. This includes beta-blockers to reduce oxygen demand by the heart as well as aspirin while still in the emergency department. If troponin levels are elevated, patients are classified 'high risk' and should be treated with an early invasive treatment regimen, which adds coronary angiography, revascularization, clopidogrel (an anti-platelet agent) as well as a GP IIb/IIIa inhibitor, eptifibatide, tirofiban or abciximab depending on the type of revascularization. Patients at intermediate risk can be directed to either treatment group.