ACS Help...

[SCER2005]

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Apologies if this had been done before. I'm too damn lazy to do a search. How do you guys handle your low to moderate risk ACS's? I'm particularly addressing this to those of you in "the REAL world". As a resident at a large academic center I admit just about anyone who uses chest and pain(pressure, tightness, ache, etc) in the same sentence.

I recently began moonlighting in a small 6 bed rural ER. It is ~1 hour by ground to the nearest referral center. Like anywhere else we see our fair share of chest pain. The problem arises when my little 50 bed hospital is full and no one will accept my transfer no matter how I sell it (EMTALA who?). My solution has been to repeat EKG's intermittently and obtain a second set of cardiac markers after 4-5 hours. If all is normal and patient is pain free, they go home. If no contraindications I instruct them to take an aspirin daily, avoid exertion, and follow-up with PCP in 2-3 days. Of course return to ER for return of pain. Is this reasonable?

The next problem is when I get 2-3 of these going at once I have cut the available ER space in 1/2. Even for a small ED the volume can be significant. For instance, the day after the super bowl I saw 42 patients in 12 hours. Don't be too impressed because a lot of it was urgent care but I was still exhausted.

I am strongly considering not moonlighting at this facility in the future because of these limitations. Unless, of course, you guys tell me that this is just the way things are.

I would love to hear any and all thoughts from you guys on the extensive rant above. Particularly, how you deal with ACS patients of this nature.

 

[EMT2RN2MD]

I worked in almost the same ED enviornment for 3yrs as a RN. Our closest transfer would be 40mins by ground. However, we also had about 5 available hospitals within the 1hr transport range. For us the key was working the phone lines. It was not always successful. Although, when our EP would get on the line, it did seem to grease the wheels, so to speak.

In the end, the doc's at our 22 bed hospital (all 3 of them) didn't mind admitting the low risk ACS patients (esp. the freq. fliers) w/ serial CE's/EKG's/telemetry for an over night stay.

 

[kungfufishing]

go someplace else.

 

[txterp98]

I'm only a couple of years out, so take the following with a grain of salt....

You've hit on a great question that really comes into play every day. You're right...you can't admit every chest pain. It's just not possible. Your internist'll hate you, you'll fill every tele bed, and you'll just log jam your ER with holdovers.

It sounds like you're on the right track. I know the literature won't support 1 set of enzymes and discharge. Getting another one 3-4 hours later may be helpful if they bump, but otherwise I'm still not sure of the utility. If they stay negative, you still haven't ruled out unstable angina. You know what I mean...if the patient comes back with a bad outcome, though 2 negative sets may be viewed upon slightly better than 1 negative set, a bad outcome is still a bad outcome.

In a nutshell, in my experience, risk factors are the best thing going for you. (And obviously EKG changes...dynamic changes even better). Out there in a rural community, maybe you can contact the PCP to let them know their patient was in the ER and should be seen in the morning? I'll do that here in Austin. And sometimes, I'll even call a cardiologist to see if they can see them in their office the next day if I think the patient's story is atypical and only has a couple of risk factors.

It's a tough job. This may sound weird...but in the end, do what you can to get a good night's sleep. If you think discharging a patient is going to make you think about them all the next day, talk to your internist about the R/O MI admission.

Good topic. I'm curious to see what others do. Learning definitely doesn't stop after residency.

(Oh yeah, if it's someone with a known history of ischemic disease and comes back with recurrent chest pain, I pretty much admit all of those. I just figured this discussion is about someone without known CAD)

 

[ERMudPhud]

I'll try to dig up references later but there are some papers out there that try to measure outcomes over weeks or months following negative enzymes in "low risk" chest pain patient. Low risk of course being fairly subjective. The incidence of acute MI or other ACS in the week or two after rule out is quite low but not zero and the papers sometimes suffer from methodologic issues (low sample numbers and selection biases). Using that sort of evidence many places follow a strategy of putting low risk patients who have ruled out on aspirin and beta-blockers and having them follow up as an outpatient for their stress test. You could certainly do that on your own in the ED but most of those papers used 3 sets of enzymes over 16 hours so that would certainly constipate your ED. In practice many cardiologist use 2 sets over 6-8 hours and many of mine will take a patient straight to the stress test with one negative set more than 4 hours after the onset of chest pain-thats the private world

 

[ERMudPhud]

I saw 42 patients in 12 hours. Don't be too impressed because a lot of it was urgent care but I was still exhausted.

I agree with KungFu. Thats a heavy load for a moonlighter even if it is urgent care. If they're not paying major bucks (>$200/hr) go somewhere else