ER doc misread EKG? (long vent)

UM Review RN, ASN, RN · Aug 24, 2005

Your inexperience speaks for itself,

Has nothing to do with experience, it has to do with following the AHA standards. I have enough experience to know that 51% of MIs do not show EKG changes at all. Troponin markers are by far the most reliable of the three cardiac markers, and because this patient did not just have an EKG change but also an elevated troponin, I think we can safely assume that the patient's positive MI status was missed in a couple of different ways by this ER doc.

When an ER doc sees an elevated trop, he should not be thinking, "Hm, Pt is SOB so must have CHF" (for which the BNP is the diagnostic, not the trop. Although the OP mentions that Pt was dx'd with CHF, it is not mentioned whether this was proven by BNP and/or CXR). He should be thinking, "What in the good green earth is killing this patient's heart cells?" and at least asking for a cardiac consult.

I have, as I said before, no desire to argue about this with you, Doug. I only know the standard that our hospital follows is the American Heart Association standard for diagnosing and treating AMI, and this little case study would not have happened at our hospital.

SEOBowhntr · Aug 24, 2005

Angie,

This is about ACUTE MI's, not microinfarcts. I agree that small elevations in Troponin are indicative of a "Cardiac" event, however, Troponin's are less acute than CK's. A small bump in Troponin doesn't always indicate an acute MI, the patient in this scenario was having an ACUTE MI, not a NSTEMI. The term NSTEMI is a new thing that helps Dr.'s make money, more so than a true MI. Microinfarcts can often be the result of many things other than CAD, such as cocaine abuse, hypotension, hypoxia, etc.

Also, I have seen many patients who had Acute EKG's without any elevation in their labs whatsoever, so the labs are only a part of it. A full assessment of the patient is essential to get the "big picture."

And don't put too much on the AHA, they are a money driven organization in many ways. Cordarone use and recommendations are an excellent example of where their ways part with practice and practicality.

The Troponin and BNP are both overrated lab tests!!! I've seen many patients have 90% + blockages having acute MI's go to the cath lab with an initial Trop. level of

Doug

SEOBowhntr · Aug 24, 2005

I only know the standard that our hospital follows is the American Heart Association standard for diagnosing and treating AMI, and this little case study would not have happened at our hospital.

And little do you know, that ER doctors in every hospital I've worked in have made mistakes just like this one!!! They happen every day, and unfortunately, until someone starts competencying doctors like nurses are competencied, they will continue to happen, even in your hospital.

UM Review RN, ASN, RN · Aug 24, 2005

And don't put too much on the AHA, they are a money driven organization in many ways.

You know, this statement sounds almost arrogant when you consider that nearly every hospital in the nation is using (or will be using) AHA standards.

It seems like we both agree that this case warranted further investigation by a cardiologist, whatever way our rationales differed in getting to that point.

Regardless of which test you use, the most likely explanation for an elevated troponin in this case was an AMI, do you not agree?

hrtprncss · Aug 24, 2005

why must there be bickering, we all come from different school of thoughts, we are all here to learn from each other to make us more well informed clinicians, for the benefit of the patient. im here to appreciate everyone else's knowledge and input in various clinical situations and settings. it makes us a better critical nurse.....a nurse with an open mind becomes more well versed with more complicated situations and are better equipped to handle emergent situations...when something is happening with ur patient, ur easiest resource is a fellow nurse, learn from each other...when a patient is crashing in front of our eyes we don't bicker, we formulate a plan and intervene, most of the times that's what's needed because the fellows or the md's are busy intubating and it's up to the nurse itself to initiate interventions to save the patient without having to wait for someone to bark orders at you.

UM Review RN, ASN, RN · Aug 24, 2005

And little do you know, that ER doctors in every hospital I've worked in have made mistakes just like this one!!! They happen every day, and unfortunately, until someone starts competencying doctors like nurses are competencied, they will continue to happen, even in your hospital.

I disagree. We have a very specific set of standing cardiac orders from the time the patient hits the ER.

Sounds like you have a little bit of a chip on your shoulder about the docs. Our docs are VERY competent. All of 'em. They might not be the most pleasant docs at 0330, but they're competent.

UM Review RN, ASN, RN · Aug 24, 2005

why must there be bickering, we all come from different school of thoughts, we are all here to learn from each other to make us more well informed clinicians, for the benefit of the patient. im here to appreciate everyone else's knowledge and input in various clinical situations and settings. it makes us a better critical nurse.....a nurse with an open mind becomes more well versed with more complicated situations and are better equipped to handle emergent situations...when something is happening with ur patient, ur easiest resource is a fellow nurse, learn from each other...when a patient is crashing in front of our eyes we don't bicker, we formulate a plan and intervene, most of the times that's what's needed because the fellows or the md's are busy intubating and it's up to the nurse itself to initiate interventions to save the patient without having to wait for someone to bark orders at you.

Thank you. I'm sorry if you see these responses as "bickering." I don't. I have answered in the interest of giving reliable information that is germaine to the discussion of this case.

Threads often veer a tad off-course in the doing, however, and on this board, everyone is very respectful of different opinions, no need to worry about "bickering" at this point.

UM Review RN, ASN, RN · Aug 24, 2005

The Troponin and BNP are both overrated lab tests!!! I've seen many patients have 90% + blockages having acute MI's go to the cath lab with an initial Trop. level of

In reading this, particularly pertaining to this case, I'm thinking that you're splitting hairs unnecessarily. But so be it.

MOST of the guidelines DO transfer over into practice, else they wouldn't have become clinical standards in the first place. No test is perfect; that is why doctors diagnose.

But as a good friend of mine is wont to say: "If it looks like a duck, walks like a duck, and quacks like a duck, it's probably a duck."

It's been great sharing this discussion with you, Doug, but now I must really get some sleep. :)