Read your CTs, folks.

[gamerEMdoc]

Should never and will never are different. I have not missed a STEMI but I know good docs who have, particularly inferior. When you get handed your 20th EKG in a shift where you’ve seen3 pph, I see how it can happen to a good doc.

I agree. Saying you should NEVER miss something is absurd, there is no test that is 100% sensitive and part of the reason why is human error. We all screw up at some point. There is no perfect doctor who has never missed something. Should you miss a STEMI, no you shouldnt. Can it happen when someone is handing you the 10th ecg to sign in an hour while trying to resuscitate and think about a sick crashing neonate? Absolutely. Cognitive errors happen all the time, because of constant interruptions and the other cases you have going on.

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[Renaissance Man]

Also "missing a STEMI" is usually shades of gray. Looking at the sweaty, fat, 60 year old guy holding his chest and saying his STE is a STEMI is quite easy...Try making that same decision on activating the Cath lab (or transferring the patient) in a mid-80's woman with dementia, who is "not acting right" and might have mentioned her chest pain "this morning" at memory care and has 1 mm of elevation in V1 and either 1.4 or 1.5 mm of elevation in V2. depending on how much you squint.

Just my two cents.

 

[TooMuchResearch]

I agree, I think Epic doesn't Port my free text indication to the rad in a way that's easy for them to review, which completely defeats the purpose of me free texting a reason for the study (which I still do because I'm hopeful it might help). Our rads do call frequently to ask for clarification and give results by phone, which is greatly appreciated.

Point well taken. I try to enter a helpful reason but sometimes I'm busy or lazy just like everyone else. I do think that my EMR/Ordering system buries by reasons. If I choose an item off the drop down it's easier for them to see but if I choose "Other" and enter an actual description in the free text box I don't think my rads see it unless they really look meaning click through some menus to see it.

It also seems like it's harder to get the techs to do stuff to point out things on plain films. We used to have radio opaque dot stickers we could put near abscesses or wounds to try to help. We used to tape paper clips with one leg pointing at what we were trying to look at. I've been told we just don't do that any more.

 

[TooMuchResearch]

Or when triage hands you another ECG on a middle aged person with normal vital signs whose chief complaint isn't chest pain while you're on the phone with a consultant, the HUC is trying to send you another call, the charge nurse is telling you about a critical patient 1 minute out, and your lunch is getting cold. It's not really a STEMI but it's not exactly normal, there is no prior in the EMR, and "hey doc, that ambulance is here they really need you in room 1."

Also "missing a STEMI" is usually shades of gray. Looking at the sweaty, fat, 60 year old guy holding his chest and saying his STE is a STEMI is quite easy...Try making that same decision on activating the Cath lab (or transferring the patient) in a mid-80's woman with dementia, who is "not acting right" and might have mentioned her chest pain "this morning" at memory care and has 1 mm of elevation in V1 and either 1.4 or 1.5 mm of elevation in V2. depending on how much you squint.

Just my two cents.

 

[thegenius]

Guys...ER docs should never miss this STEMI, ever. I don't care how good you are. You will kill the patient and lose your license.

ER docs might miss this EKG...which shows an occlusive MI but NOT a STEMI

wait long enough and this will turn into a STEMI. This patient is probably going to die too but he isn't as far along as the guy in #1. The EKG above not a STEMI technically speaking.

Big difference between the two and I, along with other docs on this board, have missed the second EKG or not taken it seriously.



I'm trying to find subtle free air imaging but I can't. Sometimes subtle free air could be mistaken for tics, but nevertheless a ditzel of free air from perfed diverticulitis needs to be admitted with Abx and serial exams, but doesn't necessarily need emergent surgery. In fact they don't need emergency surgery depending on their vital signs, labs, and physical exam.

 

[gamerEMdoc]

I saw a STEMI last night, called a STEMI alert. My colleague said she wouldn't have called it. Cards was even on the fence. 100% acute LAD occlusion. Sometimes this stuff is super subtle.

 

[RustedFox]

I saw a STEMI last night, called a STEMI alert. My colleague said she wouldn't have called it. Cards was even on the fence. 100% acute LAD occlusion. Sometimes this stuff is super subtle.

I've had my share of these. It's all about the timing of the EKG vs. infarct.

 

[gamerEMdoc]

I've had my share of these. It's all about the timing of the EKG vs. infarct.

Plus actually seeing the patient and knowing their symptoms. These subtle ones get missed when ECGs are being handed to you from triage all day long for anyone from 10 years old to 100 years old with chest pain, abdominal pain, weakness, dizziness, etc. When you have no clinical idea what the patient is there for, it's super easy to blow past a subtle MI.

 

[USCDiver]

Best case I had demonstrating this was a few months ago. Saw a patient with cc: rectal bleeding. When I go to examine the guy, he's got tons of bloody pus draining from his perianal area. I said "well, sir, I don't think this is intestinal bleeding, it looks like you probably have an abscess there. Have you had rectal pain recently?" He replies, "yes, I was here for rectal pain 2 days ago and had a CT scan then that was normal".

"Hmm," I think, "that doesn't seem right". I go back to look at the CT and there's a huge peri-rectal abscess staring at me.

Had a talk with both the radiologist and the doc who had seem him the time before. Biggest challenge was figuring out how to document that without throwing anyone under the bus. I can't remember, now, what I wrote at the time.

 

[gamerEMdoc]

@USCDiver I can't look at your profile pic without thinking about central cord syndrome.

 

[thegenius]

For what it’s worth, I’ve gotten much better and picking up subtle MI after reading Stephen smiths blog. I read it all the time. It’s worth it

 

[docB]

I've had my share of these. It's all about the timing of the EKG vs. infarct.

By "timing" you mean 2 am with the cardiologist in bed vs. 2 pm when the cath lab is finished for the day but the crew is still in house?

I know I've had identical EKGs that resulted in "This doesn't look ischemic. Just admit it to medicine and have them consult the group that comes on in the morning." at 2am and "OH MY GOD! Why was I not called immediately on this?!? (You were. They just got here. The EKG is from 8 minutes ago and you took 7 to call back.) Send him to the lab instantly! What's his insurance again?" at 2 pm.

 

[TooMuchResearch]

Our interventional cardiologists like to cath STEMI and wait a day on everything else. I don't think me getting that much better at ECGs is going to do much for my patients. That said, I like Steve Smith's ECG blog.

For what it’s worth, I’ve gotten much better and picking up subtle MI after reading Stephen smiths blog. I read it all the time. It’s worth it