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?

[Anna Flaxis, BSN, RN]

How about the guy who drives himself in because he "just doesn't feel right", and it turns out he's in V Tach?

[MassED, BSN, RN]

we handle our walk-ins the same way any CP presents, you do the EKG after your VS/triage note. If it's an acute MI, an overhead page for a patient to our critical care room is called and the patient goes there via w/c or stretcher (whichever is quickest)... and depending if the patient is cath lab criteria, they will go there in MINUTES. The only difference between ambulatory and ambulance CP patients is that we know ahead with EMS, they have done their rhythm strip (whether it's accurate or not, if it's called as STEMI, we take it as such until proven otherwise) Of course those pts have IV/ASA/and maybe NTG. But still treated with a critical care room and treated the same. Ambulatory pts have immediate EKG.... Sounds like this guy came in and had a arrythmia shortly after you did the EKG? .... what I **MIGHT** have done was to call overhead for the ED doc or send the pt to a critical care room as I was simulatenously putting in a line/putting them on a stretcher/but most importantly on our Zoll in case of defibrillation needs.

They can give ASA in triage, but NEVER nitro without IV access. If the EKG was suspicious for STEMI, they are immediately activated to the critical care bay side of the ER.

[MassED, BSN, RN]

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.

m

trust your gut. Always. If you're one who understands that, you need to use it. I do and it never ever steers me wrong. You may not know exactly what "it" is that is wrong, but once you identify that, then look into what might be wrong. Trust it.

[Altra, BSN, RN]

You did fine.

No, please don't hit the "code" button, as that is NOT what is occurring.

[Esme12, ASN, BSN, RN]

I would not hit the code button the patient is not coding. Once you have some experience under your belt I am sure your facility will train you for triage. There are policy guidelines at every facility that designate the care of the ED patients. Getting the EKG was key. In the furture I would not leave the patient I would call ino the main room to the charge nurse and request help sat......well done

ESI Emergency Severity Index Handbook

http://www.ahrq.gov/research/esi/esi1.htm

[Lunah, MSN, RN]

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

THIS! So many of our STEMIs come through triage!! Ugh.

Side story: I remember about 10 years ago when I was a paramedic student, I saw a particularly tragic case. A man and woman in their late 60's were on the way to the ER; he was driving and she was having chest pain. While driving, the wife went unconscious and her husband tried to do chest compressions on her while driving, unclipping her seatbelt in the process. He then wrecked the car. The wife arrived alive, but had a horrible head injury with no brain activity from the car accident ... I will never forget how absolutely shattered that man looked, sitting next to her bed in the ED, holding her hand and sobbing.

[MassED, BSN, RN]

You did fine.

No, please don't hit the "code" button, as that is NOT what is occurring.

using a "code" button, if you have one in an ED, is useful to get attention when you need it quickly. Whether or not it's a code, it may be one shortly... better to have peeps on hand when it does and to prepare accordingly.

[Aymese]

LunahRN,

I too have witnessed a similar tragedy. A couple years ago, a 50 yo F patient with crushing CP was being driven by her husband to the city's "heart hospital" 25 miles away. She arrested in the car and he pulled off and performed CPR on her. A couple of people stopped to help until EMS arrived. She had a return of spontaneous circulation and we opened a 100% occluded RCA. By the time we were done, I noticed she had begun posturing. ICU started her on hyothermia protocol right away but she never recovered from her brain anoxia and passed away leaving behind 2 teenage girls and a husband.

Within a month of this patient, I was coincidentally offered a great opportunity to help start up the PCI program at the community hospital in this woman's hometown. I always remember her story and told it to many people involved in the project so people could fully understand how important our goal was. I truly feel that she would be alive today if this service had been offered at the time.