EKG Post CPR: Would you activate?

[Jabbed]

Counter-counter point regarding point 1: (I know you would have activated this case, so this debate is purely academic) Reperfusion arrhythmia implies there is evidence of reperfusion or at least an absence of active ischemia, which I see no evidence of. To imply reperfusion means there is a lack of ST elevations along w/ AIVR (which I am not 100% convinced of given some irregularity in the rhythm) and/or evidence of classic reperfusion T-waves (biphasic or inverted T-waves) along w/ a lack of ST elevation. If you are implying this ECG represents partial reperfusion, then you must also accept that ST elevations are still present which means there is still active transmural ischemia and is a clear indication for cath lab activation. Also, don't rely on reciprocal changes in anterior MIs, you will get burned.

If you have a patient presenting even with a decent history for ACS (not talking SOB or weakness, although I would probably activate even in those cases with this ECG), you need to activate this ECG. ST elevations with terminal QRS distortion in V2 and V3 is essentially pathognomonic for STEMI. When this is present, don't bother repeating ECGs, just activate. We as lowly ER doctors should not be burdening ourselves with the liability of caring for someone with this ECG alone. It's okay to be wrong every once and a while. Our job isn't to have a hit rate of 100% on cath lab activations. That shouldn't excuse being over aggressive with activation with cases that are clearly not ACS, or post arrest cases w/o STEMI, but we shouldn't be afraid to be wrong.

AIVR is a reperfusion arrhythmia. Most medical codes seem to have wonky wide complex rhythms with weird ST-T immediately post-arrest. I generally just chalk this up as reperfusion from global hypoperfusion and watershed injury.

Had a similar ECG the other night in a 40 year old drug overdose that I didn't activate that ended up having a K of 7.7 and pH < 6.7. We spend a lot of time studying EKG patterns, but it's still only one part of the picture.

But yes, I probably would've activated this case. Ultimately, I might have repeated another ECG or two and considered a quick US to look for wall motion abnormalities in order to convince my consultant.

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[dadaddadaBATMAN]

S/p arrest hyperkalemia cases almost never have an ECG that lacks all evidence of hyperkalemia unless it is multifactorial. Lack of terminal R-wave in aVR and V1, lack of right axis deviation, lack of bradycardia, lack of sinusoidal pattern, lack of peaked T-waves, lack of QRS prolongation. If your post arrest patient is lacking all of that, you can rest assured that they probably didn't arrest from severe hyperkalemia.

The ability of physicians to predict hyperkalemia from the ECG - PubMed

The ECG is not a sensitive method of detecting hyperkalemia, even in high-risk patients. The specificity of the ECG is better for hyperkalemia, but empiric treatment of hyperkalemia based on the ECG alone will lead to mistreatment of at least 15% of patients.

pubmed.ncbi.nlm.nih.gov

Can physicians detect hyperkalemia based on the electrocardiogram? - PubMed

An ECG is not a sensitive method of detecting hyperkalemia and should not be relied upon to rule it out. However, the ECG has a high specificity for detecting hyperkalemia and could be used as a rule in test.

pubmed.ncbi.nlm.nih.gov

Here’s a few studies that back up my last review of this that note though specificity of ekg findings can be helpful, sensitivity even in high k levels of ekg alone is garbage.

Can you back up your statement with some literature? That’s a specific population that’s difficult to study, and you’re making some very strong statements. Smells funny to me.

You have no idea what drugs were given from the prompt he gave. If they just gave calcium/bicarbonate (or a crapload of Epi) the ekg may be falsely normalized.

I agree with cath lab activation. I disagree that it is “definitely not” hyperk. That’s a difficult diagnosis to exclude without labs, and you ignore it at your peril.

 

[Zebra Hunter]

The ability of physicians to predict hyperkalemia from the ECG - PubMed

The ECG is not a sensitive method of detecting hyperkalemia, even in high-risk patients. The specificity of the ECG is better for hyperkalemia, but empiric treatment of hyperkalemia based on the ECG alone will lead to mistreatment of at least 15% of patients.

pubmed.ncbi.nlm.nih.gov

Can physicians detect hyperkalemia based on the electrocardiogram? - PubMed

An ECG is not a sensitive method of detecting hyperkalemia and should not be relied upon to rule it out. However, the ECG has a high specificity for detecting hyperkalemia and could be used as a rule in test.

pubmed.ncbi.nlm.nih.gov

Here’s a few studies that back up my last review of this that note though specificity of ekg findings can be helpful, sensitivity even in high k levels of ekg alone is garbage.

Can you back up your statement with some literature? That’s a specific population that’s difficult to study, and you’re making some very strong statements. Smells funny to me.

You have no idea what drugs were given from the prompt he gave. If they just gave calcium/bicarbonate (or a crapload of Epi) the ekg may be falsely normalized.

I agree with cath lab activation. I disagree that it is “definitely not” hyperk. That’s a difficult diagnosis to exclude without labs, and you ignore it at your peril.

Yes, ECGs are terribly unreliable for predicting hyperkalemia; however, when hyperkalemia is causing acute issues, like say cardiac arrest, the lack of ECG findings consistent w/ hyperkalemia is essentially enough to rule it out as the cause of cardiac arrest, because its common sense. A single amp of bicarb, a single dose of calcium chloride, and 5 rounds of epi is not going to lead to resolution of sodium channel blockade that hyperkalemia causes. Find me a single case report demonstrating cardiac arrest 2/2 hyperkalemia w/o any tell tale signs of hyperkalemia. I'm sure I'll get plenty of anecdotes, but most of the time, these cases are pretty obvious hyperkalemia if that was truly the cause of cardiac arrest, most people just aren't great at picking up signs of hyperkalemia on ECG.

 

[dadaddadaBATMAN]

Yes, ECGs are terribly unreliable for predicting hyperkalemia; however, when hyperkalemia is causing acute issues, like say cardiac arrest, the lack of ECG findings consistent w/ hyperkalemia is essentially enough to rule it out as the cause of cardiac arrest, because its common sense. A single amp of bicarb, a single dose of calcium chloride, and 5 rounds of epi is not going to lead to resolution of sodium channel blockade that hyperkalemia causes. Find me a single case report demonstrating cardiac arrest 2/2 hyperkalemia w/o any tell tale signs of hyperkalemia. I'm sure I'll get plenty of anecdotes, but most of the time, these cases are pretty obvious hyperkalemia if that was truly the cause of cardiac arrest, most people just aren't great at picking up signs of hyperkalemia on ECG.

I’m not going to go diving through literature because I can think of three cases in my residency and two in my short time as an attending where I saw visible changes from grossly abnormal to relatively “normal” ekg in periarrest (sine wave) and s/p arrest patients. 2g calcium and an amp of bicarbonate will normalize an ekg for 30 minutes or so. It doesn’t last, but it does normalize.

Thanks for the discussion. Always interesting to hear other people’s perspective.

 

[emergentmd]

I was a little peeved when the cardiology RN who often comes to the STEMI activations looked at the EKG and said "this isn't a STEMI. This is j-point elevation." I was most pissed about that.
I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression."

I just looked at the EKG more closely and I will unequivocally say that this is NOT. I repeat NOT. J Point elevation.

I don't care if 10 cardiologist tell me I am wrong, but this is NOT J point elevation.

This Nurse I can understand is full of crap, know very little about cardiology and I will give a pass.

For the Cardiologist to tell me that this is J point elevation, he is full of Crap and need to back to do his residency.

I repeat. This is NOT J point elevation. Nothing about the History OR EKG points to J point elevation.

Show this to 10 Cards and none will tell you this is J point elevation.

 

[Birdstrike]

The Rising Corpse

A patient comes in after clutching his chest, collapsing, being found in V-fib and defibrillated. The post-defib EKG is normal. He goes in to V-fib 6 more times and I successfully defibrillate him back to sinus each time, while arguing with the absolutely, catastrophically, awful cardiologist over the phone, who is trying to tell me there is no correlation between that presentation and coronary disease that might need intervention. Between each episode of V-fib, he rises up off the bed, grunting and screaming, fighting for life like a corpse digging himself out of the grave. A repeat EKG takes an appearance similar to the OPs EKG. I fax the EKG to a different cardiologist who takes the patient to the cath lab, and finds a 95% LA occlusion.
Two days later, the patient leaves the hospital neuro intact.

15 years later, I still remember the patient's name.

 

[WilcoWorld]

Most interventionalists are concerned about reporting their mortality numbers. If they take someone to cath, they have an anoxic brain injury, and the family later withdraws care, then it's a reported mortality even if no intervention was done. At least that's my understanding. I'm not an interventionalist so I'm not entirely up on the nuances of their mortality data.

That's not the case if you enroll in hospice before the patient dies.

To the original question: I'd activate cath lab every time unless the family is in the ED asking to let the patient die in peace.

 

[WilcoWorld]

I just looked at the EKG more closely and I will unequivocally say that this is NOT. I repeat NOT. J Point elevation.

I don't care if 10 cardiologist tell me I am wrong, but this is NOT J point elevation.

This Nurse I can understand is full of crap, know very little about cardiology and I will give a pass.

For the Cardiologist to tell me that this is J point elevation, he is full of Crap and need to back to do his residency.

I repeat. This is NOT J point elevation. Nothing about the History OR EKG points to J point elevation.

Show this to 10 Cards and none will tell you this is J point elevation.

Agreed, and I DO see reciprocal ST depressions. It's an anterolateral STEMI & I see inferior and septal ST depressions.

 

[emergentmd]

The Rising Corpse

A patient comes in after clutching his chest, collapsing, being found in V-fib and defibrillated. The post-defib EKG is normal. He goes in to V-fib 6 more times and I successfully defibrillate him back to sinus each time, while arguing with the absolutely, catastrophically, awful cardiologist over the phone, who is trying to tell me there is no correlation between that presentation and coronary disease that might need intervention. Between each episode of V-fib, he rises up off the bed, grunting and screaming, fighting for life like a corpse digging himself out of the grave. A repeat EKG takes an appearance similar to the OPs EKG. I fax the EKG to a different cardiologist who takes the patient to the cath lab, and finds a 95% LA occlusion.
Two days later, the patient leaves the hospital neuro intact.

15 years later, I still remember the patient's name.

But you were wrong. It was clearly Jpoint Elevation.

 

[emergentmd]

But you were wrong. It was clearly Jpoint Elevation.

In all seriousness, this case should have went to MEC. What a derelict of duty.

 

[dadaddadaBATMAN]

The Rising Corpse

A patient comes in after clutching his chest, collapsing, being found in V-fib and defibrillated. The post-defib EKG is normal. He goes in to V-fib 6 more times and I successfully defibrillate him back to sinus each time, while arguing with the absolutely, catastrophically, awful cardiologist over the phone, who is trying to tell me there is no correlation between that presentation and coronary disease that might need intervention. Between each episode of V-fib, he rises up off the bed, grunting and screaming, fighting for life like a corpse digging himself out of the grave. A repeat EKG takes an appearance similar to the OPs EKG. I fax the EKG to a different cardiologist who takes the patient to the cath lab, and finds a 95% LA occlusion.
Two days later, the patient leaves the hospital neuro intact.

15 years later, I still remember the patient's name.

As a general rule I avoid getting the attention of admin, quality, etc as I find going to war tends to burn both sides pretty bad.

This is a case I would report to any Qa committee I could and would even consider reporting to a state board. That’s so far beyond the pale it might cross into the “obligated to report” level of malpractice in my state. In my state as in many others not reporting things that are clearly below standard of care can potentially put your license at risk as well if it later gets discovered.

 

[Birdstrike]

As a general rule I avoid getting the attention of admin, quality, etc as I find going to war tends to burn both sides pretty bad.

This is a case I would report to any Qa committee I could and would even consider reporting to a state board. That’s so far beyond the pale it might cross into the “obligated to report” level of malpractice in my state. In my state as in many others not reporting things that are clearly below standard of care can potentially put your license at risk as well if it later gets discovered.

The level of f**kery that I've witnessed, would shock you. Some of it's so bad, I won't even post about it.

 

[emergentmd]

Yeah, the more I go outside of major cities or dumpy ER/Hospitals, I find the quality of care definitely goes down.

Worked in a hard to staff ER so they hired a FM doc who didn't know how to put in Central lines or intubate. Don't think they let her work by herself and one time had to call in the medical director to put a central line in.

Worked in a tertiary receiving hospital, also hard to staff, and had an unstable GI bleed that had to go to the ICU. The only person I talked to was the NP/PA managing the ICU. didn't seem to concerned that pt was hypotensive/hgb under 6 with frank melena. Hope the guy did well but doubt the doc even knew about the pt.

 

[RustedFox]

The level of f**kery that I've witnessed, would shock you. Some of it's so bad, I won't even post about it.

Post about it. Please.

 

[RustedFox]

Worked in a tertiary receiving hospital, also hard to staff, and had an unstable GI bleed that had to go to the ICU. The only person I talked to was the NP/PA managing the ICU. didn't seem to concerned that pt was hypotensive/hgb under 6 with frank melena. Hope the guy did well but doubt the doc even knew about the pt.

Calling GeneralVeers...

 

[bravotwozero]

The level of f**kery that I've witnessed, would shock you. Some of it's so bad, I won't even post about it.

Something tells me you’ve been on a hospital peer review committee.

 

[Birdstrike]

Something tells me you’ve been on a hospital peer review committee.

Actually I have not. That's the amazing thing.

 

[timpview]

Cardiology perspective here..

1. yes I would activate too

2. it is 90%+ about the mortality reporting..

Brain-dead post arrest patient that gets intervened on is now a mortality on my record.. basically the same as if I took an elective 59 year old to the lab and killed him by perforating his artery. Each patient death is recorded. At my institution I have to discuss each death at least at 2 different “quality” meetings. My name goes next to the patients for every person who has no clue what’s going on to think that I killed another patient. If admin wants to fire me they have a collection of patient deaths. It also changes pci mortality numbers for the group effecting star ratings and reimbursement… which mostly means threats from admin to get our act together. Yes, there are some tricks of changing to hospice that helps alleviate some of that (though in the real world isn’t as easy as it sounds) and sometimes the critical illness component influences your death with some star systems but in general you will have to answer for something you have zero control over… that’s not even considering the impact in states with public reporting of mortality numbers (though I’m not a 100% sure if those states select out such cases)

4. if no intervention, then it’s not a death recorded on your hands but likely will require justification of why you put a brain dead patient through a “needless and costly” procedure in at least 1-2 admin meetings. It’s like people thinking placing a radial sheath is similar to sawing through the sternum of a corpse but nonetheless I get questioned for such cases all the time.. also used against u at any point for “being too aggressive” especially given recent changes in post arrest pci outside of STEMIs..

Lastly, there is the issue that the natural reflex at 2 am is to justify NOT having to come in.. it just sucks having too. And it’s hard to explain to others but something that obviously is our problem and a part of the job we stupidly chose. But it’s still a real thing… and the push in the literature NOT to activate all post arrest patients is now what is used to justify that natural reflex in your sleep deprived, just woken up from REM sleep mind. But that’s our problem to fight through but it does influence how you act.

 

[turkeyjerky]

Cardiology perspective here..

1. yes I would activate too

2. it is 90%+ about the mortality reporting..

Brain-dead post arrest patient that gets intervened on is now a mortality on my record.. basically the same as if I took an elective 59 year old to the lab and killed him by perforating his artery. Each patient death is recorded. At my institution I have to discuss each death at least at 2 different “quality” meetings. My name goes next to the patients for every person who has no clue what’s going on to think that I killed another patient. If admin wants to fire me they have a collection of patient deaths. It also changes pci mortality numbers for the group effecting star ratings and reimbursement… which mostly means threats from admin to get our act together. Yes, there are some tricks of changing to hospice that helps alleviate some of that (though in the real world isn’t as easy as it sounds) and sometimes the critical illness component influences your death with some star systems but in general you will have to answer for something you have zero control over… that’s not even considering the impact in states with public reporting of mortality numbers (though I’m not a 100% sure if those states select out such cases)

4. if no intervention, then it’s not a death recorded on your hands but likely will require justification of why you put a brain dead patient through a “needless and costly” procedure in at least 1-2 admin meetings. It’s like people thinking placing a radial sheath is similar to sawing through the sternum of a corpse but nonetheless I get questioned for such cases all the time.. also used against u at any point for “being too aggressive” especially given recent changes in post arrest pci outside of STEMIs..

Lastly, there is the issue that the natural reflex at 2 am is to justify NOT having to come in.. it just sucks having too. And it’s hard to explain to others but something that obviously is our problem and a part of the job we stupidly chose. But it’s still a real thing… and the push in the literature NOT to activate all post arrest patients is now what is used to justify that natural reflex in your sleep deprived, just woken up from REM sleep mind. But that’s our problem to fight through but it does influence how you act.

Honest question, but how in the hell are these cases not excluded from the QA stuff?

I guess I'm answering my own question here, but it would seem relatively simple and logical to do so. It's also not exactly a new issue, it's been ongoing for at least 7-8 years...

 

[dadaddadaBATMAN]

Cardiology perspective here..

1. yes I would activate too

2. it is 90%+ about the mortality reporting..

Brain-dead post arrest patient that gets intervened on is now a mortality on my record.. basically the same as if I took an elective 59 year old to the lab and killed him by perforating his artery. Each patient death is recorded. At my institution I have to discuss each death at least at 2 different “quality” meetings. My name goes next to the patients for every person who has no clue what’s going on to think that I killed another patient. If admin wants to fire me they have a collection of patient deaths. It also changes pci mortality numbers for the group effecting star ratings and reimbursement… which mostly means threats from admin to get our act together. Yes, there are some tricks of changing to hospice that helps alleviate some of that (though in the real world isn’t as easy as it sounds) and sometimes the critical illness component influences your death with some star systems but in general you will have to answer for something you have zero control over… that’s not even considering the impact in states with public reporting of mortality numbers (though I’m not a 100% sure if those states select out such cases)

4. if no intervention, then it’s not a death recorded on your hands but likely will require justification of why you put a brain dead patient through a “needless and costly” procedure in at least 1-2 admin meetings. It’s like people thinking placing a radial sheath is similar to sawing through the sternum of a corpse but nonetheless I get questioned for such cases all the time.. also used against u at any point for “being too aggressive” especially given recent changes in post arrest pci outside of STEMIs..

Lastly, there is the issue that the natural reflex at 2 am is to justify NOT having to come in.. it just sucks having too. And it’s hard to explain to others but something that obviously is our problem and a part of the job we stupidly chose. But it’s still a real thing… and the push in the literature NOT to activate all post arrest patients is now what is used to justify that natural reflex in your sleep deprived, just woken up from REM sleep mind. But that’s our problem to fight through but it does influence how you act.

Ironically these are essentially a rephrasing of the reasons why I would activate from the other side.

If you don’t activate, there may be “quality concerns” after the patient dies as they inevitably would three days later the when it is confirmed they are a potato.

But they should be a potato with thoroughly investigated coronaries.

The admin wheel grinds on us all, we just try to move away as much as possible

 

[WilcoWorld]

if no intervention, then it’s not a death recorded on your hands but likely will require justification of why you put a brain dead patient through a “needless and costly” procedure in at least 1-2 admin meetings. It’s like people thinking placing a radial sheath is similar to sawing through the sternum of a corpse but nonetheless I get questioned for such cases all the time.. also used against u at any point for “being too aggressive” especially given recent changes in post arrest pci outside of STEMIs..

Thanks for jumping in. I appreciate your perspective. I'd be far more likely to accept that rationale at 2am than the aforementioned BS about J-point elevation, so thanks for being honest

 

[RustedFox]

Cardiology perspective here..

1. yes I would activate too

2. it is 90%+ about the mortality reporting..

Brain-dead post arrest patient that gets intervened on is now a mortality on my record.. basically the same as if I took an elective 59 year old to the lab and killed him by perforating his artery. Each patient death is recorded. At my institution I have to discuss each death at least at 2 different “quality” meetings. My name goes next to the patients for every person who has no clue what’s going on to think that I killed another patient. If admin wants to fire me they have a collection of patient deaths. It also changes pci mortality numbers for the group effecting star ratings and reimbursement… which mostly means threats from admin to get our act together. Yes, there are some tricks of changing to hospice that helps alleviate some of that (though in the real world isn’t as easy as it sounds) and sometimes the critical illness component influences your death with some star systems but in general you will have to answer for something you have zero control over… that’s not even considering the impact in states with public reporting of mortality numbers (though I’m not a 100% sure if those states select out such cases)

4. if no intervention, then it’s not a death recorded on your hands but likely will require justification of why you put a brain dead patient through a “needless and costly” procedure in at least 1-2 admin meetings. It’s like people thinking placing a radial sheath is similar to sawing through the sternum of a corpse but nonetheless I get questioned for such cases all the time.. also used against u at any point for “being too aggressive” especially given recent changes in post arrest pci outside of STEMIs..

Lastly, there is the issue that the natural reflex at 2 am is to justify NOT having to come in.. it just sucks having too. And it’s hard to explain to others but something that obviously is our problem and a part of the job we stupidly chose. But it’s still a real thing… and the push in the literature NOT to activate all post arrest patients is now what is used to justify that natural reflex in your sleep deprived, just woken up from REM sleep mind. But that’s our problem to fight through but it does influence how you act.

Great post. Thank you.

It highlights just how "statistics" are used to mask the truth about what really happened.

You mean a patient with terrific coronary artery disease who collects diseases like they were pokemon either died or has terminal brain injury while you took them to cath lab? Egads, man! That's not SUPPOSED to HAPPEN! Who did something WRONG?!

Truth: amazingly sick people die. They die all over; including cath labs and ICUs. Its not a reflection of our "quality".

 

[AlmostAnMD]

Speaking of statistics:

ECG Timing After Return of Spontaneous Circulation and Angiography in Cardiac Arrest

This cohort study evaluates the association between the time from the return of spontaneous circulation to electrocardiogram (ECG) acquisition and the diagnostic accuracy of ECG for ST-segment elevation myocardial infarction in patients who experience out-of-hospital cardiac arrest.

jamanetwork.com

I'm not really a "literature" guy but this does generally back my own practice and theory. They said get ekg (or REPEAT) in 8 minutes after ROSC to eliminate false positives.

 

[dadaddadaBATMAN]

Thanks for jumping in. I appreciate your perspective. I'd be far more likely to accept that rationale at 2am than the aforementioned BS about J-point elevation, so thanks for being honest

Would have to be pretty careful on that recorded line

 

[dadaddadaBATMAN]

Speaking of statistics:

ECG Timing After Return of Spontaneous Circulation and Angiography in Cardiac Arrest

This cohort study evaluates the association between the time from the return of spontaneous circulation to electrocardiogram (ECG) acquisition and the diagnostic accuracy of ECG for ST-segment elevation myocardial infarction in patients who experience out-of-hospital cardiac arrest.

jamanetwork.com

I'm not really a "literature" guy but this does generally back my own practice and theory. They said get ekg (or REPEAT) in 8 minutes after ROSC to eliminate false positives.

If I ask for an ekg it’s at least ten minutes till I get it so I’d say this is my practice too.

 

[emergentmd]

Its no diff than the CRAP that ER docs have to go through. Like a healthy guy who came in to the ER with a viral infection but happen to have tachycardia/fever (yeah they do actually go together) who didn't get a SEPTIC full shotgun workup then comes back 2 dys later with pneumonia/sepsis?

Its sad how medicine has been taken away from us and now wrapped around admin's fingers wanting to capture every last cent from CMS.

I have great sympathy for all specialist when I call them at 2am. It usually starts with, "sorry to bug you at this time". No one wants to come in at 2am unless absolutely necessary. If someone without a Clear STEMI came in at 2am who you know is likely brain dead, I would be cursing my life too.

Just like the 2am call to the floor to intubate/chest compression on the 60 year old dialysis/septic pts who is on max pressors. I could not imagine being called from home to run a code when I know my night/next day has been completely obliterated for someone who likely will never leave the hospital.

 

[timpview]

Ironically these are essentially a rephrasing of the reasons why I would activate from the other side.

If you don’t activate, there may be “quality concerns” after the patient dies as they inevitably would three days later the when it is confirmed they are a potato.

But they should be a potato with thoroughly investigated coronaries.

The admin wheel grinds on us all, we just try to move away as much as possible

Agree. I’m still worried more about that than most of my partners and try and remain “aggressive” in taking these people to the lab.. plus it’s so relatively easy for the potential benefit that I try not to overthink it and do the what would I want if I was moments from death.. even if a 1/100 chance. From the ER side I 100% get it and don’t see why any ER doc would take that risk.

But it’s funny. The reflex reaction from admin and others on our end are to basically celebrate those docs that choose not to do anything. They love people dying on hospice. It seems so much more dignified than dying on a cath lab table. Dead is dead to me so I don’t typically get it… as long aswhat you’re doing doesn’t induce a lot of suffering/pain (major surgery, months in icu, etc) but whatever… and man the cases I’ve seen survive is crazy so you really don’t always know (cpr over an hour, lactates over 20, etc)

 

[CoolDoc1729]

Well I'm happy at least that many of my esteemed ER docs on this forum don't all unilaterally agree. Makes me feel better.

I felt this was a STEMI. And if it's not a STEMI it's an OMI (occlusive myocardial infarction). I know there is no evidence surrounding OMI and ROSC that has never been studied. Anyway I thought it was a STEMI. So I activated. I spoke to the cards interventionalist and he was a little concerned that this guy wasn't going to live anyway...and asked me to get a lactate and an ABG.

I was a little peeved when the cardiology RN who often comes to the STEMI activations looked at the EKG and said "this isn't a STEMI. This is j-point elevation." I was most pissed about that.

Anyway...he was taken to cath within about 30 minutes and he had a 100% occluded mLAD and multivessel disease. I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression." I like this cardiologist and work well with him, so I nodded and left. I don't agree...but that is OK. Anyway I believe the patient was stented. He's been in the hospital for 5-7 days with severe anoxic brain injury and I think they are going to make him comfort care.

So if you hadn’t activated … and the autopsy showed cause of death 100% occluded LAD … 😬

 

[Siggy]

So if you hadn’t activated … and the autopsy showed cause of death 100% occluded LAD … 😬

"Case discussed with Dr. STEMI (on call STEMI cardiologist). EKGs and history reviewed including concern over V-Tach arrest which could represent a type 3 MI. Cardiology recommended _____ because of _____."

What do you say when the on call vascular surgeon refuses to take someone with dead gut to the OR because of futility? What do you say if you activate the cath lab and the cardiologist still refuses to take the patient to the cath lab? I'll give you a hint, it starts with "Case discussed with Dr. Specialist (on call specialty...").

 

[Mount Asclepius]

I don't understand EPs that get into vigorous phone arguments with specialists regarding what they want them to do. I consult the specialist stating my concern once and tell them what I think needs to be done. If they disagree, then I try to accurately and objectively chart the conversation. Sure, I might share some liability on a sinking ship that maybe would be decreased by an intervention that could be beneficial, but I also need to maintain professional relationships and good standing with the other specialists. I don't think arguing, yelling and screaming that someone needs a cath, EGD, IR procedure, etc. is usually overall beneficial. Occasionally I will ask a consultant to come see a patient in the ED if I think their opinion might change with direct visualization. Usually that's not the case though.

 

[RoyBasch]

It usually starts with, "sorry to bug you at this time". No one wants to come in at 2am unless absolutely necessary.

I very much appreciate the input of our specialists, and I also recognize calling someone at suboptimal hours is difficult for them.

That being said, I NEVER start a consultation call with an apology.

I am not sorry.

This is not a social call. If I did not need need to call them, I would not. I am on duty and working. So are they. They are being handsomely compensated (one way or another) in exchange for being available. This is a professional transaction and we are each discharging our respective duties as prescribed. I do not owe them an apology for expecting them to be available precisely as they have contractually agreed.

The majority of my total working hours involves working nights, after business hours, weekends, holidays, etc. I am not sympathetic to physicians who believe they are above working the non-banker hours.

Everybody knows the deal. If you never want to get that call at 1AM on Christmas, you need to work in a no-call specialty like dermatology. If you go into interventional cardiology, obstetrics, neurological surgery, high-density of emergent cases-X specialty, and don't expect/get angry about these emergent calls at off hours, then that was a poor choice made by the specialists when they plotted their career trajectory however many years ago.

Just to be clear by threshold for calling anybody after hours--particularly late after hours--is fairly high. I am also polite and respectful in these communications.

In this case in question I would 100% involve the cardiologist. If they want to de-activate, not cath, delay cath, or whatever, that's on them. I would agree that its not a completely clear cut case. But 100% they have to be involved and render a professional opinion that I would expect they would stand by at a quality meeting on a Wednesday morning at 10:00 AM.

 

[CoolDoc1729]

"Case discussed with Dr. STEMI (on call STEMI cardiologist). EKGs and history reviewed including concern over V-Tach arrest which could represent a type 3 MI. Cardiology recommended _____ because of _____."

What do you say when the on call vascular surgeon refuses to take someone with dead gut to the OR because of futility? What do you say if you activate the cath lab and the cardiologist still refuses to take the patient to the cath lab? I'll give you a hint, it starts with "Case discussed with Dr. Specialist (on call specialty...").

Well

"Case discussed with Dr. STEMI (on call STEMI cardiologist). EKGs and history reviewed including concern over V-Tach arrest which could represent a type 3 MI. Cardiology recommended _____ because of _____."

What do you say when the on call vascular surgeon refuses to take someone with dead gut to the OR because of futility? What do you say if you activate the cath lab and the cardiologist still refuses to take the patient to the cath lab? I'll give you a hint, it starts with "Case discussed with Dr. Specialist (on call specialty...").

To me this is kind of semantics .. 100% I’d want this patient to be evaluated emengently by cardiology .. at least in my dept at night this would not happen without an activation. They can always deactivate.
I thought the question of whether to involve cardiologist emergently was the crux of the question of the OP, and I think s/he did have to even though it’s 99.9% futile in the scenario given.

 

[Siggy]

Well

To me this is kind of semantics .. 100% I’d want this patient to be evaluated emengently by cardiology .. at least in my dept at night this would not happen without an activation. They can always deactivate.
I thought the question of whether to involve cardiologist emergently was the crux of the question of the OP, and I think s/he did have to even though it’s 99.9% futile in the scenario given.

At my hospitals the on call STEMI doc is on the call list. The difference between calling a STEMI alert and calling the STEMI doctor directly is what happens to the rest of the cath lab team. That, to me, is the question. Call STEMI doc directly, or activate the cath lab TEAM. Why wake people up unnecessarily (assuming that the STEMI doc answers their cell phone on the first call)?

 

[dadaddadaBATMAN]

At my hospitals the on call STEMI doc is on the call list. The difference between calling a STEMI alert and calling the STEMI doctor directly is what happens to the rest of the cath lab team. That, to me, is the question. Call STEMI doc directly, or activate the cath lab TEAM. Why wake people up unnecessarily (assuming that the STEMI doc answers their cell phone on the first call)?

1. People sometimes take a damn long time to call back. 30-60 min+ Happens all the time, especially at night
2. Every minute “delayed” by your decision is credited to the Ed, which pisses off admin, and increases liability
3. You have an indication for cath in a high risk case.

I don’t think it’s wrong to call the cards doc directly, but those are all things you have to be aware of when you take that path.

 

[emergentmd]

I very much appreciate the input of our specialists, and I also recognize calling someone at suboptimal hours is difficult for them.

That being said, I NEVER start a consultation call with an apology.

I am not sorry.

Of course I am not sorry but I do feel bad. Just common courtesy IMO just like asking someone how they are doing when you haven't seen them for awhile. Most of the time, we don't care how someone is doing and rather not hear any issues.

I mean, if I had dental pain I am happy to take care of you anytime before midnight but not happy if you come in at 3am.

 

[Birdstrike]

Of course I am not sorry but I do feel bad.

I never understood the concept of having to feel guilty for calling (for a legitimate reason) a consultant. I'd be up all night and have to call a consultant at 3 am. I'd already have gotten my throat kicked in for the last 5 hours while the consultant slept. The consultant will (often) go back to sleep sometime after I call them, while I'm still awake being tortured on my shift for 4-5 more hours.

Yet I'm supposed to "feel bad" and apologize to the emotionally upset consultant who's 8 hours of sleep that night cut got shortened slightly, while I got none?

It's just one more part of EM where you're you're told to smile and agree that up is down, left is right and crazy is sane.

 

[Siggy]

1. People sometimes take a damn long time to call back. 30-60 min+ Happens all the time, especially at night
2. Every minute “delayed” by your decision is credited to the Ed, which pisses off admin, and increases liability
3. You have an indication for cath in a high risk case.

I don’t think it’s wrong to call the cards doc directly, but those are all things you have to be aware of when you take that path.

Want to know how I know you haven't read this thread?

As I have said multiple times, I don't go through call centers for this. Hence the term "directly." Calling through a call center is not calling "directly."

Call cell phone, if answered have conversation.

If no one answers activate cath lab.

There is no delay. Thanks for playing.

 

[cardsperson]

I never understood the concept of having to feel guilty for calling (for a legitimate reason) a consultant. I'd be up all night and have to call a consultant at 3 am. I'd already have gotten my throat kicked in for the last 5 hours while the consultant slept. The consultant will (often) go back to sleep sometime after I call them, while I'm still awake being tortured on my shift for 4-5 more hours.

Yet I'm supposed to "feel bad" and apologize to the emotionally upset consultant who's 8 hours of sleep that night cut got shortened slightly, while I got none?

It's just one more part of EM where you're you're told to smile and agree that up is down, left is right and crazy is sane.

Cards fellow here. I don't think anyone should feel bad about calling a consultant overnight - any doc who signed up to be an interventional cardiologist basically agrees to be at the hospital with a balloon in the patient's coronaries within 90 minutes of receiving a call from the ED, and the same is true (to a lesser extent) for anyone who signs up to be a vascular surgeon, neurosurgeon, etc. But I do take issue with your argument regarding sleep and hours worked because it's a pretty bad argument - EPs work shifts, while the cardiologist is working every weekday. It's not like the night cardiologist is someone in-house who only works nights - it's someone who worked that day, and is probably working the next day too, and being woken up several times over the 6-8 hours they have to sleep is pretty miserable. And don't @ me with "but shift work still averages out to 40 hours a week!", people have studied this and the average cardiologist works about 10 hours more per week than the average EP (Annual Work Hours Across Physician Specialties).

And FWIW, I was a night hospitalist for a while before fellowship, so I absolutely know what it's like to call grumpy consultants overnight with questions that they could often answer in less than a minute, and I usually did start the conversation with apologizing for waking them up.

 

[dadaddadaBATMAN]

Want to know how I know you haven't read this thread?

As I have said multiple times, I don't go through call centers for this. Hence the term "directly." Calling through a call center is not calling "directly."

Call cell phone, if answered have conversation.

If no one answers activate cath lab.

There is no delay. Thanks for playing.

I idly browse this thread while I’m on the can. I certainly don’t wait with bated breath for what siggy will say next.

If you have the cell phone for the stemi cardiologist, and you trust them enough to not call them on a recorded line, good for you.

In case you aren’t aware, most hospitals don’t operate on a direct cell phone directory

“Thanks” for being an unnecessarily abrasive clown.

 

[Birdstrike]

Cards fellow here. I don't think anyone should feel bad about calling a consultant overnight - any doc who signed up to be an interventional cardiologist basically agrees to be at the hospital with a balloon in the patient's coronaries within 90 minutes of receiving a call from the ED, and the same is true (to a lesser extent) for anyone who signs up to be a vascular surgeon, neurosurgeon, etc. But I do take issue with your argument regarding sleep and hours worked because it's a pretty bad argument - EPs work shifts, while the cardiologist is working every weekday. It's not like the night cardiologist is someone in-house who only works nights - it's someone who worked that day, and is probably working the next day too, and being woken up several times over the 6-8 hours they have to sleep is pretty miserable. And don't @ me with "but shift work still averages out to 40 hours a week!", people have studied this and the average cardiologist works about 10 hours more per week than the average EP (Annual Work Hours Across Physician Specialties).

And FWIW, I was a night hospitalist for a while before fellowship, so I absolutely know what it's like to call grumpy consultants overnight with questions that they could often answer in less than a minute, and I usually did start the conversation with apologizing for waking them up.

You’re right, it’s not worth quibbling over what’s worse, working a night shift or taking call between day shifts, because they both suck, really bad. They both suck enough that I got to the point I decided I wasn’t going to spend the next 25 years of my life doing either.

For what, “cool cases”?

For money?

No way.

Maybe I’m a wimp, or maybe I got smart. But about 10 years ago, I decided I was going to do none of that, after 40. The only reason most people do such things is they get lured in by one or both of the above, then feel trapped.

I do applaud anyone that does it and enjoys it over the long haul. That’s very laudable.

 

[Siggy]

I idly browse this thread while I’m on the can. I certainly don’t wait with bated breath for what siggy will say next.

If you have the cell phone for the stemi cardiologist, and you trust them enough to not call them on a recorded line, good for you.

In case you aren’t aware, most hospitals don’t operate on a direct cell phone directory

“Thanks” for being an unnecessarily abrasive clown.

I have most of the specialists phone numbers at my hospital. It's actually much more efficient than waiting by the phone for a call back through a service and I'm willing to bet that since the call backs are through the hospitals main line, they aren't recorded anyways.

Maybe that's why it's taking 30 minutes instead of 30 seconds to get a response to stat consults.

 

[dadaddadaBATMAN]

I have most of the specialists phone numbers at my hospital. It's actually much more efficient than waiting by the phone for a call back through a service and I'm willing to bet that since the call backs are through the hospitals main line, they aren't recorded anyways.

Maybe that's why it's taking 30 minutes instead of 30 seconds to get a response to stat consults.

that’s great. Good to hear that some hospitals do believe in using 21st century tech.

ours are coordinated by a ubiquitous transfer center, which has been the case in every hospital I’ve been in. Calling directly is very frowned on as it’s assumed you are trying to escape the record, and they time stamp everything. Most people are prompt as a result, but sometimes you get someone who “sleeps” through all text pages.

Mystically they do not sleep through stemi alerts.

it is kinda nice though sometimes. When people get unprofessional they and their boss get an email with a mp3 file of their conversation…same thing happens if you yell at the transfer center

 

[Old_Mil]

71 yo man with unknown PMH BIBA undergoing CPR. He has a witnessed syncopal event in a parking lot. First rhythm was VFib and was defibrillated by first responders. He underwent about 30 mins of CPR, received numerous ACLS meds, and I was able to get a pulse. The EKG below was done about 2 minutes post-ROSC.

Do you think this is a STEMI? Would you activate? (note these are two different questions as it's possible to answer "no" and "yes")

View attachment 340339

I will later discuss what happened.

Let's say if you aren't going to activate, you had better have an insanely good reason to explain the guy's witnessed syncope and cardiac arrest.

 

[HowlPrenderghast]

Well I'm happy at least that many of my esteemed ER docs on this forum don't all unilaterally agree. Makes me feel better.

I felt this was a STEMI. And if it's not a STEMI it's an OMI (occlusive myocardial infarction). I know there is no evidence surrounding OMI and ROSC that has never been studied. Anyway I thought it was a STEMI. So I activated. I spoke to the cards interventionalist and he was a little concerned that this guy wasn't going to live anyway...and asked me to get a lactate and an ABG.

I was a little peeved when the cardiology RN who often comes to the STEMI activations looked at the EKG and said "this isn't a STEMI. This is j-point elevation." I was most pissed about that.

Anyway...he was taken to cath within about 30 minutes and he had a 100% occluded mLAD and multivessel disease. I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression." I like this cardiologist and work well with him, so I nodded and left. I don't agree...but that is OK. Anyway I believe the patient was stented. He's been in the hospital for 5-7 days with severe anoxic brain injury and I think they are going to make him comfort care.

STEMI doesn't require the presence of reciprocal depression for its diagnosis. Simply the Elevation of the J-point in 2 contiguous leads, and you're good to go. In the ECG you posted, there are multiple ST elevation in different leads in such that it obscures the the expected reciprocal depressions you might expect. In other words, you can't rule out STEMI with the absence of reciprocal depressions. In any case, with an elevated trop I, compatible history and symptoms, with an ECG showing evidence of STEMI potentially in the background of a re-perfusion arrhythmia, Activating the cath lab would definitely be the wisest option which I would have done. Also congrats on successfully managing your patient.