How does your ED handle "walk-in" MIs?

[DayDreamin ER CRNP]

I just got a job in the ED where I precepted but haven't started on the floor yet. While precepting a few months ago, a patient was brought in by the daughter who is/was a CVICU nurse. Pt c/o of some chest pain while doing yard work for the past 3 hours.

The nurse and I were working triage that day and I was attaching the EKG leads, etc and EKG showed acute MI. I went and notified the doc who followed me back to the triage area. When we got there pt had vomited and was now on the floor with the triage nurse.

I replayed that day over and over in my head. I could not stop thinking about what I could have done differently, etc. Should I have hit the "code" button in the room as I was leaving or what?

It did make me question how often does this kind of thing happens and what, if any, protocols could have been in place to help this pt. This is a Level 1 center and very busy and we do have protocols in the treatment rooms but I don't know of any in triage for this situation.

By the way, this pt was taken to the cath lab within 20 minutes of arrival and did have a favorable outcome.

I still just can't help but wonder if it might be beneficial to have aspirin and nitro available in every triage room in locked cabinets.

How does your ED handle this type of situation?

[A&OxNone, MSN, RN]

I work in a Cardiac ER who has a program that is taught all around the country for our process for AMI patients. I will tell you that the first time I hooked somebody up and saw an MI, I did exactly what you did, left the room, got the EKG off the printer, and threw at the doc and told him to come with me.

In triage, it's a little different, esp if somebody was there with him. But next time, if you are in the room alone and you see it, CALMLY (you dont need the pt freaking out) hit the call button, and say,"I need a doctor to look at this EKG as soon as possible and I need somebody to come in here with me with IV stuff (or whatever)", stay with the pt, put them on O2, start working on getting a line, ect.

No biggy. There was nothing you could've done differently. :) The pt is fine and that's what matters. :)

[SpEdtacular, MSN, RN, EMT-P]

The biggest thing for walk in STEMIs is getting the 12 lead EKG within x minutes of arrival and identifying Acute STEMI. That gets the cath lab rolling and reduces door to balloon time (which is the number the EDs are concerned with). Great job!

[ICUenthusiast]

I work in a Cardiac ER who has a program that is taught all around the country for our process for AMI patients. I will tell you that the first time I hooked somebody up and saw an MI, I did exactly what you did, left the room, got the EKG off the printer, and threw at the doc and told him to come with me.

In triage, it's a little different, esp if somebody was there with him. But next time, if you are in the room alone and you see it, CALMLY (you dont need the pt freaking out) hit the call button, and say,"I need a doctor to look at this EKG as soon as possible and I need somebody to come in here with me with IV stuff (or whatever)", stay with the pt, put them on O2, start working on getting a line, ect.

No biggy. There was nothing you could've done differently. :) The pt is fine and that's what matters. :)

^This. Added, if it is a STEMI, a code STEMI is called to the STEMI beeper up in CICU, who sends a nurse down to follow the pt until their cath lab/open heart/treatment is initiated. This also alerts the related teams in cath lab etc. to the incoming emergent patient.. so they can properly get ready for them.

[DayDreamin ER CRNP]

In triage, it's a little different, esp if somebody was there with him. But next time, if you are in the room alone and you see it, CALMLY (you dont need the pt freaking out) hit the call button, and say,"I need a doctor to look at this EKG as soon as possible and I need somebody to come in here with me with IV stuff (or whatever)", stay with the pt, put them on O2, start working on getting a line, ect.

No biggy. There was nothing you could've done differently. :) The pt is fine and that's what matters. :)

Thank you for that. I think I needed some reassurance that I did what I could given the circumstances.

I think what really unnerved me most was that I felt utterly helpless in the triage room and I did think, "What would I have done if I were alone in this triage room." At least on this day, I was with an RN.

I also KNEW something was 'off' with this pt when she was cursing at me and she just did NOT seem the type and she had weird color. I have always been told (in my previous career) that I have really good instincts. I'm just struggling with trusting those now because someone's well-being is in my rookie hands. I don't think there was anything I could have done differently but I did learn a LOT from that episode. The next time it happens I'll be way more prepared and confident.

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[Dazglue, ADN, BSN, MSN, RN]

In our ER, people who complain of chest pain automatically get an EKG as soon as they sign in, in our extra triage room or in the empty code room (one room is always open in case a code comes in) No matter if it is normal or not, a doctor has to look at the EKG and sign off on it. Since the tech is doing the EKG, someone is always with the patient and is never left alone. Now if someone comes in complaining of chest pain, sweating, nausea, vomiting, etc., they go straight back to a room.

[Aymese]

EKG performed within 5 minutes of pt entering waiting room with c/o of CP. When the doc confirms STEMI, they do an overhead "code STEMI" with location. No matter what location in hospital, an ICU and ED nurse, RT, and RN supervisor respond to this code. If it's regular hours, usually a cath lab RN or tech will come also.

Our ED has a code STEMI box which has all the supplies and paperwork needed to quickly prep the pt for cath lab: clippers to prep the groin, radiopaque electrodes, gown, quickcombo defib pads, IV start supplies, and medications (NS, ASA, nitro)Then when the patient is en route to the lab, we take a locked box of ACLS drugs and the portable defibrillator.

Sounds like you did the right thing to expedite the patient to the lab. I bet there was a great door to balloon time! Patients usually wait way too long to come in and can be very sick by the time they present, so I think it's good to have an organized protocol in place to shave off minutes.

[Aymese]

Side note: I also wish people would stop driving themselves or loved one to the ER when they are having chest pain!!

[emtb2rn, BSN, RN, EMT-B]

My er works pretty much the same as described by aymese.

[Anna Flaxis, BSN, RN]

You did just fine.

[Anna Flaxis, BSN, RN]

Side note: I also wish people would stop driving themselves or loved one to the ER when they are having chest pain!!

I second that!

[Mec_Happens]

Side note: I also wish people would stop driving themselves or loved one to the ER when they are having chest pain!!

It's even worse when they drive themselves to an urgent care . I saw this often when I worked in Urgent care.