The Bait and Switch

[tbouthillet]

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Imagine you are an emergency physician working in a medium-sized community hospital’s emergency department.

It’s a busy day in the emergency department. You are the only physician on duty.

One of the nurses has called in sick, there is no tech, and the weakest unit secretary is on duty.

All the rooms are full, the waiting room is packed, the ambulance bay is jammed, and there are overflow patients waiting to be admitted.

The policy in the emergency department is that the emergency physician shall review the 12-lead ECG of all chest pain patients within 10 minutes of the patient’s arrival.

You are suturing a large laceration in a patient’s leg when a nurse walks in, holds up an ECG and says, “We have a walk-in chest pain patient in bed 4.”

It’s going to take you another 20 minutes to suture up the patient’s laceration.

What are your orders?

 

[name?]

I'd start with a repeat EKG checking lead placement.

 

[deleted109597]

Limb leads wrong. Repeat.
Baseline a little wavy, but I don't see anything that jumps out as ST elevation or depression.

 

[Venko]

Imagine you are an emergency physician working in a medium-sized community hospital's emergency department.

It's a busy day in the emergency department. You are the only physician on duty.

One of the nurses has called in sick, there is no tech, and the weakest unit secretary is on duty.

All the rooms are full, the waiting room is packed, the ambulance bay is jammed, and there are overflow patients waiting to be admitted.

The policy in the emergency department is that the emergency physician shall review the 12-lead ECG of all chest pain patients within 10 minutes of the patient's arrival.

You are suturing a large laceration in a patient's leg when a nurse walks in, holds up an ECG and says, "We have a walk-in chest pain patient in bed 4."

It's going to take you another 20 minutes to suture up the patient's laceration.

What are your orders?

Repeat ECG
Old ECG
Portable CXR
Troponin, CBC, lytes, PT, Type and screen
Aspirin
Oxygen

 

[quicknss]

how do you know the leads are wrong?

 

[turkeyjerky]

Look at aVR--either wrong placement or dextrocardia

 

[tbouthillet]

This patient was experiencing an acute inferior STEMI and reperfusion was delayed.

Those of you who predicted that the white and red electrodes were switched were exactly right. The frontal plane axis in the right superior quadrant (no man’s land) is unusual and should tip you off that there’s an error with lead placement.

What’s really unfortunate about this case is that physical inspection of the leads would have shown them to be placed properly. That’s because the leads themselves weren’t misplaced.

The leads were “plugged in” to the machine backwards.

The result was the transposition of the white and red electrodes.

In reality, you can still see the STEMI if you know what to look for. One of the “tricks” I teach students to help them identify acute posterior STEMI is to ignore the limb leads for acute inferior STEMIs and look only at the right precordial leads (V1-V3).

This helps “train the eye” to see subtle signs of acute posterior STEMI and this case demonstrates why having a “trained eye” could be potentially life-saving.

In this case, there is a slight downsloping of the ST-segment in lead V2.

Throw in the “classic” appearance of lead aVL and this 12-lead ECG is highly suspicious for acute inferio-posterior STEMI.

So remember to check both the leads and the connections!

 

[Arcan57]

It's suspicious, but it doesn't meet criteria for a STEMI. What did the repeat EKG show?

 

[SFO-IST]

Is it just me, or does the ECG look like Istanbul's skyline?

 

[Birdstrike]

Super interesting (and unfortunate) case. One of those good old land mines out there you just don't see coming until it's too late. Score one point for "the chaos" of the Emergency Department.

 

[fiznat]

You should give credit to the source when you repost material like this. I assume you are not the original author...

http://ems12lead.com/2011/01/24/the-bait-and-switch-conclusion/

 

[Flopotomist]

You should give credit to the source when you repost material like this. I assume you are not the original author...

http://ems12lead.com/2011/01/24/the-bait-and-switch-conclusion/

Hey fiznat - if you look at the bottom right hand corner of the tracing, you will see a link to the source. Unbunch those panties.

 

[fiznat]

Hey fiznat - if you look at the bottom right hand corner of the tracing, you will see a link to the source. Unbunch those panties.

That isn't exactly a proper citation by any means, but I guess this is the internet so anything goes. Not to mention there is no citation at all for the OP's 2nd post, which has also been copied directly from the author's website.

Linking to the original website gives credit to the author, and also points users of this forum to a website that they might find interesting. Also, panties notwithstanding, it is the right thing to do.

 

[WilcoWorld]

I'll agree that the lateral limb leads and the large R in V2 are very concerning, and the patient very well may have had acute coronary arterial occlusion, but the ECG provided does NOT demonstrate an STelevationMI by any criteria. Perhaps a repeat ECG with a good baseline showed a STEMI, but this tracing is non-diagnostic.

What should one do with a highly concerning yet non-diagnostic ECG? Take a history and repeat the tracing.

 

[BADMD]

You should give credit to the source when you repost material like this. I assume you are not the original author...

http://ems12lead.com/2011/01/24/the-bait-and-switch-conclusion/

I'm assuming that tbouthillet is likely also the author of the blog written by Tom Bouthillet.

 

[Dwindlin]

I'm assuming that tbouthillet is likely also the author of the blog written by Tom Bouthillet.

That is a completely baseless, and frankly crazy assumption. . .

 

[SLUser11]

That isn't exactly a proper citation by any means, but I guess this is the internet so anything goes. Not to mention there is no citation at all for the OP's 2nd post, which has also been copied directly from the author's website.

Linking to the original website gives credit to the author, and also points users of this forum to a website that they might find interesting. Also, panties notwithstanding, it is the right thing to do.

I'm assuming that tbouthillet is likely also the author of the blog written by Tom Bouthillet.

That is a completely baseless, and frankly crazy assumption. . .

Thank you. Fiznat's posts and then your responses gave me a well-needed chuckle.

It's nice to see some clinical scenarios discussed in here.

 

[tbouthillet]

fiznat -

I'm sorry if you experienced embarassment on my behalf. If I had a nickel for every time I reacted without knowing all the facts I could probably buy lunch for the entire forum, so don't feel too bad.

I reposted this here because it was a STEMI fallout and I wanted to "pass the word" that some of these connections can be plugged in backwards. It was an unfortunate occurance but hopefully some good will come of it.

Ironically, I didn't mention my blog because I didn't want anyone to think I was spamming the forum.

So, we're all still friends (but thanks for having my back).

T.B.

 

[lawj]

I just want to make sure I'm reading this right.

If the white and red wires are switched, then what you see on the 12 lead is:

Lead I is really the inverse of III
Lead II is the inverse of itself
Lead III is the inverse of I
aVR is aVF
aVF is aVR
aVL is still aVL.

So in this patient, it appears he has elevation in III, and questionable elevation in II and aVF. The reciprocal changes are in aVL and possibly lead I?

 

[fiznat]

No worries, Tom. I assumed if you were going to post here you would use the same screen name you use on other forums. My fault, just looking out for ya brother. 😉

 

[The White Coat Investor]

First order: Repeat the EKG.

Second thing I'd do: Put down the instruments and go see the patient. I've done many a laceration in two or three separate sittings. There's no rule that says a patient can't sit there with a drape on his face for 15 minutes while you see another patient. It helps if you say "I need to leave for a few minutes, there is a fellow with a heart attack in the next room." 95% of patients will absolutely understand.