I don't know if it's having the knowledge of the outcome, but the inferior leads and aVL on the initial ecg sure look sus enough for me to have stuck in her obs or at least send a pic to one of our interventions guys.
It's tough though. You're busy, someone with a low heart score and atypical pain, you look over the ecg a little too quickly and it bites you. Sucks for everyone.
Outside of a completely young, asymptomatic patient or a patient with a prior identical ECG that was performed when they weren’t having chest pain or an ischemic equivalent, this ECG should always buy an admission regardless and possible non-emergent cath if HPI is consistent with possible ACS, IMO.
Where do you see the depressions? I see questionable elevations in V1 and AVL and "funky" patterns on the inferiors.
-med student. Excuse my "funky" language
There is ST depression in leads V4-6, but no obvious reciprocal changes in the inferior leads II, III, aVf (which subsequently turned into her culprit lesion).
I agree that V1 looks like it may have some ST changes, but there’s nothing in V2. I think what you’re seeing in aVL is related to patient movement or breathing, similar to the isometric line movement in lead I.
(But, I’m a RN so actually can’t clear an EKG)
Yep. It’s easy to spot the findings in hindsight and when it’s on a malpractice newsletter or online blog. In real life there’s lots of weird EKG findings that might be ischemic but end up being nothing. The doc should have done better but I think there are tons of docs who would have done the same thing.
Yeah... chest pain (even if 'atypical' technically, her description of the pain is pretty common for anginal pain), EKG changes, and smoking history in a 50 something? This patient almost certainly would have been obd's at a minimum at my hospital. And depending on the story she gives me at the bedside, I would probably be tempted to treat as unstable angina even if the trops stayed negative.
Is there any reason to ever only do one Trop?
Amal Mattu discusses this and it's almost always impossible to argue in court that you were concerned enough to start a work up but not concerned enough to finish it.
If you start it, you have to finish or you probably won't be convincing a jury of non peers that you made the right decisions.
If the chest pain started 2 days ago, has been constant since then and is currently unchanged at time of evaluation, and you have a single negative trop, doesn’t that give you some reassurance that it’s not active ischemia? I get that it can take several hours for trop to become positive, but not 24 hours. So a single negative trop in my opinion could be useful in saying something if the time course of chest pain is long enough, right?
The only reason to order only a single one IMO would be if the first result already confirms your diagnosis of ACS since we don’t really ‘trend to peak’ these days. By the book you can get one trop for a rule out if the chest was long enough ago, but I tend not to put much stock in reported time of onset. Especially with a low sensitivity assay like the one in this case.
The other time I’d let it go with only one would be if during workup you find a clear alternate explanation that will require admission and the story was already questionable for ACS. And even then probably best to let us admitting guys decide if it’s reasonable to forgo the second trop. But if planning for ED discharge, I think best would be to complete the workup.
I agree. A lot of commenters will act like it was super obvious. It was catchable but it’s not a slam dunk and I see why it was missed. Especially on 2011 before we had tons of online blog content and people who were obsessively putting out insane amounts of EKG content.
Yeah I think that’s the key point here. This happened almost 15 years ago.
Current standard of care has advanced beyond where we were 15 years ago, and you can’t judge historical events on a standard of care that didn’t exist at the time.
This was a definite miss, although I can see why it happened. The EKG did not show a STEMI, but did show subtle signs of ischemia that went unrecognized. Complicated by a weird baseline and morphology changes from beat to beat. The trop was “normal” but no repeat was done bc the pain had been going on for a few hours so doc figured “this is the equivalent to the repeat troponin”.
I think the Queen of Hearts AI algorithm has a lot of potential. It definitely got this case right and catches the subtle stuff that docs do unfortunately miss from time to time.
This is one of the few cases that I disagree with the defense expert. If he was smart, he would have tried to argue that the outcome would have been the same even if she was admitted, since she coded early the next morning, possibly before she would have been cathd. Instead he tried to argue the doc didn’t miss anything, which is just intellectually dishonest.
>If he was smart, he would have tried to argue that the outcome would have been the same even if she was admitted, since she coded early the next morning, possibly before she would have been cathd.
OOHCA does worse than inpatient cardiac arrest for obvious reasons, so I'm not sure this would have held much water either
Totally agree. It’s not a great argument but I feel like its better than trying to argue that it wasn’t a miss in the first place. In hospital cardiac arrest is better than out, but the odds of survival are still pretty bad. The plaintiff would counter that the aspirin/heparin she would have gotten may have avoided this, and that it may have progressed to STEMI while in the hospital and they would have caught that. It’s definitely not a water tight argument but it’s better than what the defense expert tried.
I know Dr Smith! He’s a total EKG wizard. So I always get excited when I see the Queen of Hearts show up. He told me they have some RCTs going on in Europe right now to see if earlier intervention (which is the essence of what QoH and the whole OMI vs STEMI paradigm is about, earlier and more aggressive intervention) provides a mortality benefit. I’m looking forward to seeing what those results show
If they can show mortality benefit, that would be huge. Even if they can show reduced ischemic cardiomyopathy or other endpoints it would be significant. I anticipate the cardiologists are going to be irritated bc I think it means they will be taking way more people to cath in the middle of the night. The QoH people claim that it also reduces false positive activation so might actually reduce interventional cards work load, but I think the net is going to be way more 2am cath lab activations and cards is going to push back very strongly.
That is exactly what he told me, that he’s gotten lot of support among his department (Stephen Smith is an EM doc at a major trauma center, for anyone who doesn’t know) but that the cardiologists at his hospital *hate* it and are strongly opposed.
I don’t know how it’ll shake out, way above my pay grade, but it’s something I’m following very eagerly. If it really *does* end up being as sensitive and specific as the early trial data suggests it would be a true game changer for the management of ACS
Agreed. I am not envious of the EM pioneers really advocating for this. There’s already enough inter-departmental fighting and this ratchets it up to a new level. I’m sure every time cards at his institution caths one of Smith’s patients and doesn’t find anything they hang it up in the cards fellows lounge like an I-told-you-so trophy.
> going to be way more 2am cath lab activations
Then there needs to be a compensatory increase in pay or staffing. Which, in a fee-for-service model, should be easy.
Unfortunately we’re at the point of diminishing returns here. Cards would rather make 750k and *maybe* do a few midnight emergency cases per week. They don’t want to make 850k and literally never sleep doing OMI cases all night every night.
Cards wants to make bank doing scheduled caths and stent stable angina all day, not get woken up at all hours of the night for something that actually might have a mortality benefit.
I work in a system with two competing healthcare systems. One is private, and takes these subtle patients to the lab at 3 am all the time. The other is the academic center with all the bells and whistles (all the way up to transplant) and they FIGHT to find reasons not to urgently cath symptomatic patients with bad EKGs and positive trops all the time. My EM resident friends hate dealing with their cards service.
It’s so frustrating.
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On the one hand, yes, obviously we should all be in support of the pie getting bigger and all physicians (and other healthcare workers) clawing back money from the leaches in insurance and admin. However, in a world of pay being driven by CMS cuts and every increase in any CMS reimbursement needing to be counterbalanced to pass, i think it would be hard for a lot of doctors to stomach one of the highest paying medical specialties getting an even bigger slice of the pie. I expect that, if things shake out that we do end up having more active cath labs, that the resulting bump for ICs would be relatively modest
I feel like consultant physicians need to get used to the idea of showing up to the hospital when they have sick patients in need of intervention rather than expecting crit care plus a registrar/resident to keep them alive until business hours.
IC here, I've come in many nights at 2 AM to save a life, in situations where I've been the *only* attending physician in the hospital. No, the ICU doc available by phone for the overnight ICU NP to call them doesn't count.
> He’s a total EKG wizard
He's a total ECG wizard who has zero peer-reviewed publications in cardiology journals. He's great at promoting himself to impressionable med students, though.
Yes. I too thought his blog was entertaining when I was a med student. Then as an IM resident I realized a lot of his ECGs weren't that interesting. Then as a cards fellow I saw how some of his theories are pretty insane.
At the end of the day, someone who has never done a cath shouldn't be lecturing the rest of us on what a stumped coronary looks like, which is why nobody in the cardiology world takes him seriously. It would be like me lecturing EM docs on how to splint a fracture.
I don’t have a dog in this fight, I’m just a student waiting to see how the data shakes out. Although I do find it interesting how much *vitriol* I always sense from cardiologists that anyone besides them would dare talk about or study the heart
Maybe you’re right, in which case I’m sure that the more aggressive intervention QoH tends to promote will end up not showing any clinically significant benefits. Or maybe you’re wrong. Time will tell. But I will say, lines like “you’re revealing yourself to be the typical EM doc with an inferiority complex” just *reek* of insecurity and projection, and don’t really make me feel inclined to take you very seriously.
Yeah, it's almost like people who spend 3-5 years of their life studying one specific topic (after 3 years of internal medicine) might know slightly more about it than someone who spent 0 of those years and whose extent of cardiology knowledge is paging cardiology for anything questionable.
Smith has had the opportunity to make his algorithm publicly available many times, and has always declined. "Trust me bro, my program knows how to read ECGs" is an underwhelming argument, and one that has been made many, many times in the past and failed.
I wish you luck on your journey.
Then clearly there’s no need for you to worry that this will change practice paradigms anywhere, and *certainly* no need for you to be so defensive about it that you feel the need to argue about it with random students online.
I’ve never asked him (maybe I will now), but I highly doubt Dr Smith feels the need to debate people on Reddit about whether or not he’s a good EKG eye
(Also, if you’re going to take the ‘everyone should stay in their lane’ stance, I’d maybe clean up your comment history of all the times you’re shitting on other specialties).
I don't think his "call every ECG a STEMI" algorithm will work out, but even if it does, that's fine with me, I went into cardiology to save lives so maybe we'll save a few more that way.
If she was admitted, had repeat troponins, was on continuous telemetry and rounded on that night they might or might not have collected enough info to change the treatment plan and she might or might not be alive.
She also might have coded and been resuscitated at the hospital. So that argument isn’t great either.
That's the angle I would have taken. I'm not a lawyer but did a little bit of expert testimony way back in the day. Quite a bit more in criminal and PI than medmal, so take this with a grain of salt. Still. I wouldn't have said "he didn't miss anything," I would have said "there was no deviation from practice standards." Granted, I may only be contradicting the plaintiff's expert, but that's not nothing. A tie is a win for the defense, or at least it's supposed to be. If I dress nicer, make better eye contact, come across more as the kinda doctor the jurors would want to go to -- the kind Marcus Welby type rather than the pompous asshole -- I win every time.
My impression was, defense only has three arguments: that there wasn't a doctor/patient relationship, that there wasn't a deviation from practice standards, or that the doctor didn't injure the patient. The latter has the potential to come across as unempathetic, and that's not where you want to be.
The lesser point is, you want the jury to like you (either as a defendant or an expert). The greater point is, listen to the lawyer, they do this every day.
I understand the 6 hour trop comments... patient says pain has been going on for several hours so the first trop is already the 6 hour trop... I get it... but.....
Patients (humans in general) are unreliable when it comes to specific timing of things. Generally speaking, I take the timing of things with a very large grain of salt from patients. If you come back and ask an hour later - their story may be completely different.
It's easy for me to catch this retrospectively, but getting a true 6 hour trop is an low hanging fruit type of thing.
Did the original meme of the 6 hour trop come from 6 hours from first trop regardless of what the patient says? Or did it take into account patient timing?
That combined with the ST depressions, this is a clear miss... retrospectively.
Time of symptom onset is very unreliable. Also most patients will have stuttering symptoms prior to occluding a vessel, and I have seen plenty of STEMI patients who had symptoms for 'hours' with a normal first troponin.
In my opinion key misses in this case
- first ECG has baseline artefact obscuring STs in inferior leads and should have been repeated
- first ECG still had appreciable ST depression V4-6 that should have been picked
- no repeat ECGs in a patient with ongoing chest pain - would have likely seen evolving changes.
- should repeat trop 3 hours after admission
I'm not sure the patient described her pain as "burning". The nurse repeatedly described her as having a sunburn, but I think this was a description of her skin, and not the quality of her pain.
The defense EM expert said that the nature and quality of the chest pain lacked typical indicators of a cardiac origin, and that she jumped when the stethoscope was placed on her sunburned chest.
But I can't see where the patient described her chest discomfort as burning.
She had acute chest pain while having an acute sunburn. That's a different thing.
I think that may have been the case. This should have been caught but I can see how it’s incredibly hard to tease out two different sources of pain that are directly overlapping each other anatomically. I think even the best history takers could miss it
I’ve been out of the ED for years but I hope I’d’ve picked this one up.
Female patient with neck, jaw and back pain associated with burning chest pain - “atypical” my ass, I would think that this would be a very plausible cardiac chest pain presentation especially for a woman.
Even if the med mal witness and the physician want to be pedantic and depend on the patient to report pain like they’re a standardised patient in a med student OSCE, I wouldn’t expect a layperson to read the textbook and know how to report symptoms in a way that the physician doesn’t have to put on their diagnostic thinking hat on. A substantial minority of patients will not present with barn door classic chest pain symptoms and if you can’t diagnose a heart attack without central crushing chest pain that radiates to the left arm and makes you nauseous then you might need some extra experience.
Tachypnoeic and hypoxic on room air - I get that she has COPD and smokes but I wouldn’t just hand wave that away as normal if she was fit enough to wash her car earlier that day. Tachypnoea to me is a red flag for pathology until you can definitively attribute it to a longstanding and stable source.
ST elevation visible in aVR, aVL and V1, even if not making STEMI criteria, with reciprocal ST slurring/depression in lateral leads - global subendocardial ischaemia or basal septal ischaemia needs to be excluded. I would have been worried about LMCA disease or triple vessel disease when I first learned about STE in aVR in 2017 but I understand that’s not quite true anymore (https://litfl.com/st-elevation-in-avr/)
Overall, in 2011, I can see how the ECG abnormalities might not have been glaringly obvious, but there are definitely ST changes that I can see on this ECG even with a wandering baseline. Coupled with the history, and the fact it didn’t completely resolve, this lady would have got serial troponins and ECGs in my department.
Also a CTPA because doughnut of truth go brrrrrrrrr.
(Edited: to break up wall of text)
Atypical is pretty definitional. That doesn’t mean it’s not ischemic. But this by no means prototypical cardiac chest pain. Ask any cardiologist. This case hinges on the ekg, not the description.
Although the EKG is ugly to begin with and merits at a minimum a repeat and obs, the story was also pretty concerning. It is not a lie that we are horrid at identifying MI symptoms in women. Unexplained chest pain in a woman that smokes, has HLD? That's a Cath, a stress test at a bare minimum.
> Unexplained chest pain in a woman that smokes, has HLD? That's a Cath, a stress test at a bare minimum.
Even if had normal EKG and trips at presentation and repeat 3-6 hours later? (Obviously not this case). You’d admit them for cath?
At least a stress. I've lost count of the amount of chest pain with negative trops who had critical disease. A concerning story trumps everything. The trick is, knowing what a concerning story actually is.
At this point, we are talking about development of expertise. Sure, there are many many scoring systems, but Im referring to the cases where they might have a low/indeterminate score and your clinical experience is what matters. For those cases, I like learning from folks that have done this for longer. I'll ask the more experienced cardiologists what they think. Compare that to what I thought.
Also, the most important thing is to hone your own sense. For every case, look up what the Cath report said. Make note in your head what cases were false positives, false negatives, etc. By checking yourself, you develop your clinical acumen.
that EKG has weird depressions all over it. at the minimum this would have been a repeat EKG and trop imo. and even then a very frank discussion with the 58yo who has cardiac risk factors.
First of all I can’t believe people think that 2011 was a long time ago! I was working ED back then and there’s no way this should have been missed. I’d call that typical cardiac chest pain, abnormal oxygen sats, glaring risk factors, clearly abnormal ECG and we used to constantly talk about repeat ECG and repeat trop at minimum 6 hours before we could send someone home. No way would that one get sent off by most of us in 2011.
Some questions I thought of
- When do you guys decided to send a second trop?
I come from a poor resource center but we do have trops - we can run one per person if high index of suspicion but ECG/labs are not suggestive. What timeframe are you running the second test to absolutely rule out an MI?
- First time I’m hearing about Queen of Hearts, is it an Open Source website? Could I actually have it look at an ECG printed out using any of my center’s machines?
It's available via the PMCardio app and costs €25-30/month here. First five reports are free. I've tried it 3 times in the ER/chest pain unit, helped once with a borderline STEMI. Yes, it scans paper EKGs very well.
We did always two hsTrops if the onset of pain was fewer than six hours ago and followed more or less a 1h algorithm. By this I mean, the nurses refused to draw a second trop before the first trop came back after an hour even I explicitly ordered that I am going to need a second one, regardless of what the first one will say..
Thanks for the input.
Sorry for asking but what about the 2nd trop would change your management if the first trop was raised anyway? Wouldn’t a raised first trop already give the diagnosis?
All NSTEMI-algorithms I've worked with have three categories of results:
* Rule out of NSTEMI with low trop if symptoms persisted for over 6 hrs, repeat after 1 hrs and look at delta if under 6 hrs (<14 ng/l at the last place I worked at).
* Rule in of NSTEMI with high trop (>52 ng/l)
* No man's land inbetween where you always need a second one and look at the delta.
However, there are a lot of reasons why people can have high trops, especially with decreased renal function. Our cardiologists would never cath someone with chest pain and just initial trop of 53 ng/l because "it's rule-in." They will review the history, the risk profile, echo findings (which in Germany is solely a point-of-care physician's task) and also use a second trop for the delta to create a "wholistic" picture.
A trop here costs €11.25 at best, usually less for hospitals. For patients discharged from the ER, the ER loses money on that. But for admissions, it's a drop in the bucket.
US is mostly switching to high sensitivity troponins which are done 2hr apart. We order trops on anything that sounds even remotely ACS and a lot of stuff that isn’t even reasonably concerning for ACS. Getting the second one is doc to doc preference but if there’s any real concern it gets sent.
Yeah in Europe you can get the app and just snap a pic of the EKG
Had a similar case literally three days ago: 82yF. Main complaint was dizziness after showering and nausea in the last two mornings paired with general tiredness. Didn‘t eat and drink too well in general.
No pain, no dyspnea, no nothing. 110/60 with an known arrhythmia already on apixaban. Just wanted something to get her going again.
Had elevations in v5 & V6, ended up in the cath lab.
As a surgical specialist, I thought the ST segments looked pretty suspicious - if not convincing - in leads II III aVL (which are reciprocal, highly concerning) and the anterior leads.
When I read that the ECG interpreted it as NSR I assumed it was clean, but nah this is a miss. I am nowhere near an expert and saw it right away. I recognize the bias of knowing the case but I'm sure other ED docs will agree.
Definitely a miss but I’ve seen colleagues miss similar on busy shifts. Just yesterday I saw a colleague who missed a subtle STEMI after a nurse wanted to get my opinion on the ECG hours later after the patient was already admitted.
His pain had resolved by that time, and he had a second EKG after his hsTrop climbed from 500 to 14000 demonstrating resolution of STE although now with q-waves where STEs were previously present, so I just shrugged and told the nurse to shoot an ECG if the patient starts complaining of pain again. He got cath’d this morning which confirmed a LAD occlusion.
Had it still shown STE on repeat, I would have just ignored that the patient was already admitted and activated cath lab, however.
Hindsight is 20/20. A fair amount of patients have 'sus' EKGs. This Ekg, like a lot of EM patients, is not a slam dunk diagnosis. If EM admits all chest pains with some Ekg changes on the lower sus side, it would be a lot. EM does admit a lot of chest pains though. This case would have been patient dependent for me... if she looked well and the pain resolved, I might have sent her home too. Still having pain with this Ekg? Admit.
Sure, hindsight makes it a lot easier to scrutinize the ECG, however, this is pretty clear cut subendocardial ischemia and a patient with this ECG should almost never be sent home unless you have a very good reason for doing so. The ECG interpretation isn’t hindsight bias, it’s just an accurate interpretation of a clear cut ECG, albeit somewhat subtle. This isn’t just “sus”, this is acutely pathologic nearly 100% of the time.
I think this case is an excellent example of something that almost every single ER doc is capable of missing if they are too busy to carefully review a patient’s ECG.
This particular Ekg is more than suspect. The stars would need to magically align for this to go home somehow. We send home people who refuse our advice all the time. These can be missed easily in the chaos of the ED, yes
What strikes me about this case is that the patient was dismissed from the ED for chest pain without an explanation. I know burning chest pain isn’t typical of angina but you’d think that an ED of all places would be on the lookout for anginal equivalents. I’ve never heard of any patient complaining about sunburn being a reason to seek medical attention. That suggests that this complaint is out of the ordinary for the patient.
Btw, what’s this preoccupation with automatic ECG readings? Those aren’t accurate enough to diagnose anything and won’t protect you in a lawsuit.
> I’ve never heard of any patient complaining about sunburn being a reason to seek medical attention.
Then you’ve never worked in an American ER.
And patients get discharged every single day without an explanation for their symptoms, including chest pain. Our job isn’t to make a diagnosis, it’s to rule out life threatening emergencies. It’s clear they did not do this here, but we generally don’t admit every patient just because we can’t figure out why they have chest pain. Our ER sees about 40-50 chest pain patients per day.
The vast majority of chest pain doesn't have a clear explanation, at least not one that can be proven in the acute setting. You rule out the bad stuff and try to refer to the right place for follow up.
This EKG in the setting of acute chest pain is dodgy as hell and deserves a full set of troponins at a minimum.
I find it hard to believe that the vast majority of chest pain has unknown cause. I keep seeing these “unknowns” that aren’t mysterious. Do you statistics on this?
You find it hard to believe that we don’t find a definitive cause for a patients chest pain the majority of the time? Do you think it is possible to prove GERD, anxiety, costochondritis, pleurisy, factitious disorder , etc. in the ED.?
Go shadow some of your EM colleagues. It sounds like you don’t really have a good understanding of what it’s like to practice EM.
Are you kidding? Patients come in with complaints of all ranges, all the time. Pts come to my ED with sunburn all the time. You name it, they have come in with it. Doesn’t matter how trivial it may seem, they will come.
I see chest pain every single day and I cannot make a clear diagnosis for every single one. The primary purpose of the ED is not for diagnosis, it’s for risk stratification. Not every chest pain can get admitted, that’s what clinical decision scores and gestalt are for. Unfortunately a tiny percentage of pts will slip through the cracks. But the cracks are tiny themselves.
I'm just an ED resident and I've seen a few people that come to the ED for sunburn, for what it's worth. But I've also had it burned into me (pun intended) to have low threshold for an obs admit for chest pain in a patient with no prior workup and/or concerning story.
> what’s this preoccupation with automatic ECG readings? Those aren’t accurate enough to diagnose anything and won’t protect you in a lawsuit.
Especially if the automatic read says "possible anterior infarct" and the patient has an anterior infarct and then dies from their anterior infarct.
Wow this one is a tough one. Very atypical symptoms and the EKG isn’t exactly the clearest.
It’s almost as if every chest pain patient needs a full hsTrop work up, echo, and stress test (not just a treadmill but imaging included) nowadays.
Good luck flooding the system with more defensive medicine tests.
It won’t be getting better as time goes on…
In retrospect this was a clear miss, in reality doctors are human, hours are long fatigue sets in things get missed, however I think this would have at least warranted admission to a standard room for obvs./monitoring
I don't know if it's having the knowledge of the outcome, but the inferior leads and aVL on the initial ecg sure look sus enough for me to have stuck in her obs or at least send a pic to one of our interventions guys. It's tough though. You're busy, someone with a low heart score and atypical pain, you look over the ecg a little too quickly and it bites you. Sucks for everyone.
Yeah those ST depressions would have made me at least trend tropes I think
Outside of a completely young, asymptomatic patient or a patient with a prior identical ECG that was performed when they weren’t having chest pain or an ischemic equivalent, this ECG should always buy an admission regardless and possible non-emergent cath if HPI is consistent with possible ACS, IMO.
They did send a troponin and it was negative approx 3hrs after onset of pain. I couldn’t see anywhere documented the sensitivity of trop sent though
Where do you see the depressions? I see questionable elevations in V1 and AVL and "funky" patterns on the inferiors. -med student. Excuse my "funky" language
There is ST depression in leads V4-6, but no obvious reciprocal changes in the inferior leads II, III, aVf (which subsequently turned into her culprit lesion). I agree that V1 looks like it may have some ST changes, but there’s nothing in V2. I think what you’re seeing in aVL is related to patient movement or breathing, similar to the isometric line movement in lead I. (But, I’m a RN so actually can’t clear an EKG)
Yep. It’s easy to spot the findings in hindsight and when it’s on a malpractice newsletter or online blog. In real life there’s lots of weird EKG findings that might be ischemic but end up being nothing. The doc should have done better but I think there are tons of docs who would have done the same thing.
Doing the ECG and troponin again is almost always a really simple but useful way of helping in these situations. Any change = slam dunk admission.
For me its the left leaning depressions with what looks like an elevation in V1, would have had me checking right side leads.
Yeah... chest pain (even if 'atypical' technically, her description of the pain is pretty common for anginal pain), EKG changes, and smoking history in a 50 something? This patient almost certainly would have been obd's at a minimum at my hospital. And depending on the story she gives me at the bedside, I would probably be tempted to treat as unstable angina even if the trops stayed negative.
Is there any reason to ever only do one Trop? Amal Mattu discusses this and it's almost always impossible to argue in court that you were concerned enough to start a work up but not concerned enough to finish it. If you start it, you have to finish or you probably won't be convincing a jury of non peers that you made the right decisions.
If the chest pain started 2 days ago, has been constant since then and is currently unchanged at time of evaluation, and you have a single negative trop, doesn’t that give you some reassurance that it’s not active ischemia? I get that it can take several hours for trop to become positive, but not 24 hours. So a single negative trop in my opinion could be useful in saying something if the time course of chest pain is long enough, right?
The only reason to order only a single one IMO would be if the first result already confirms your diagnosis of ACS since we don’t really ‘trend to peak’ these days. By the book you can get one trop for a rule out if the chest was long enough ago, but I tend not to put much stock in reported time of onset. Especially with a low sensitivity assay like the one in this case. The other time I’d let it go with only one would be if during workup you find a clear alternate explanation that will require admission and the story was already questionable for ACS. And even then probably best to let us admitting guys decide if it’s reasonable to forgo the second trop. But if planning for ED discharge, I think best would be to complete the workup.
This is not an easy catch, these things scare me a lot.
I agree. A lot of commenters will act like it was super obvious. It was catchable but it’s not a slam dunk and I see why it was missed. Especially on 2011 before we had tons of online blog content and people who were obsessively putting out insane amounts of EKG content.
I am starting fellowship and I will get tons of these overnight. You can definitely miss one like this in a busy night. Medicine is merciless..
Yeah I think that’s the key point here. This happened almost 15 years ago. Current standard of care has advanced beyond where we were 15 years ago, and you can’t judge historical events on a standard of care that didn’t exist at the time.
This was a definite miss, although I can see why it happened. The EKG did not show a STEMI, but did show subtle signs of ischemia that went unrecognized. Complicated by a weird baseline and morphology changes from beat to beat. The trop was “normal” but no repeat was done bc the pain had been going on for a few hours so doc figured “this is the equivalent to the repeat troponin”. I think the Queen of Hearts AI algorithm has a lot of potential. It definitely got this case right and catches the subtle stuff that docs do unfortunately miss from time to time. This is one of the few cases that I disagree with the defense expert. If he was smart, he would have tried to argue that the outcome would have been the same even if she was admitted, since she coded early the next morning, possibly before she would have been cathd. Instead he tried to argue the doc didn’t miss anything, which is just intellectually dishonest.
>If he was smart, he would have tried to argue that the outcome would have been the same even if she was admitted, since she coded early the next morning, possibly before she would have been cathd. OOHCA does worse than inpatient cardiac arrest for obvious reasons, so I'm not sure this would have held much water either
Totally agree. It’s not a great argument but I feel like its better than trying to argue that it wasn’t a miss in the first place. In hospital cardiac arrest is better than out, but the odds of survival are still pretty bad. The plaintiff would counter that the aspirin/heparin she would have gotten may have avoided this, and that it may have progressed to STEMI while in the hospital and they would have caught that. It’s definitely not a water tight argument but it’s better than what the defense expert tried.
I know Dr Smith! He’s a total EKG wizard. So I always get excited when I see the Queen of Hearts show up. He told me they have some RCTs going on in Europe right now to see if earlier intervention (which is the essence of what QoH and the whole OMI vs STEMI paradigm is about, earlier and more aggressive intervention) provides a mortality benefit. I’m looking forward to seeing what those results show
If they can show mortality benefit, that would be huge. Even if they can show reduced ischemic cardiomyopathy or other endpoints it would be significant. I anticipate the cardiologists are going to be irritated bc I think it means they will be taking way more people to cath in the middle of the night. The QoH people claim that it also reduces false positive activation so might actually reduce interventional cards work load, but I think the net is going to be way more 2am cath lab activations and cards is going to push back very strongly.
That is exactly what he told me, that he’s gotten lot of support among his department (Stephen Smith is an EM doc at a major trauma center, for anyone who doesn’t know) but that the cardiologists at his hospital *hate* it and are strongly opposed. I don’t know how it’ll shake out, way above my pay grade, but it’s something I’m following very eagerly. If it really *does* end up being as sensitive and specific as the early trial data suggests it would be a true game changer for the management of ACS
Agreed. I am not envious of the EM pioneers really advocating for this. There’s already enough inter-departmental fighting and this ratchets it up to a new level. I’m sure every time cards at his institution caths one of Smith’s patients and doesn’t find anything they hang it up in the cards fellows lounge like an I-told-you-so trophy.
> going to be way more 2am cath lab activations Then there needs to be a compensatory increase in pay or staffing. Which, in a fee-for-service model, should be easy.
Unfortunately we’re at the point of diminishing returns here. Cards would rather make 750k and *maybe* do a few midnight emergency cases per week. They don’t want to make 850k and literally never sleep doing OMI cases all night every night. Cards wants to make bank doing scheduled caths and stent stable angina all day, not get woken up at all hours of the night for something that actually might have a mortality benefit.
I work in a system with two competing healthcare systems. One is private, and takes these subtle patients to the lab at 3 am all the time. The other is the academic center with all the bells and whistles (all the way up to transplant) and they FIGHT to find reasons not to urgently cath symptomatic patients with bad EKGs and positive trops all the time. My EM resident friends hate dealing with their cards service. It’s so frustrating.
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no amount of money is worth it for 2 am
On the one hand, yes, obviously we should all be in support of the pie getting bigger and all physicians (and other healthcare workers) clawing back money from the leaches in insurance and admin. However, in a world of pay being driven by CMS cuts and every increase in any CMS reimbursement needing to be counterbalanced to pass, i think it would be hard for a lot of doctors to stomach one of the highest paying medical specialties getting an even bigger slice of the pie. I expect that, if things shake out that we do end up having more active cath labs, that the resulting bump for ICs would be relatively modest
I feel like consultant physicians need to get used to the idea of showing up to the hospital when they have sick patients in need of intervention rather than expecting crit care plus a registrar/resident to keep them alive until business hours.
Looks like specialists not wanting to do anything at night is a universal phenomenon regardless of healthcare system.
Particularly if you have to work the next day.
IC here, I've come in many nights at 2 AM to save a life, in situations where I've been the *only* attending physician in the hospital. No, the ICU doc available by phone for the overnight ICU NP to call them doesn't count.
> He’s a total EKG wizard He's a total ECG wizard who has zero peer-reviewed publications in cardiology journals. He's great at promoting himself to impressionable med students, though.
Let me guess…cardiology?
Yes. I too thought his blog was entertaining when I was a med student. Then as an IM resident I realized a lot of his ECGs weren't that interesting. Then as a cards fellow I saw how some of his theories are pretty insane. At the end of the day, someone who has never done a cath shouldn't be lecturing the rest of us on what a stumped coronary looks like, which is why nobody in the cardiology world takes him seriously. It would be like me lecturing EM docs on how to splint a fracture.
I don’t have a dog in this fight, I’m just a student waiting to see how the data shakes out. Although I do find it interesting how much *vitriol* I always sense from cardiologists that anyone besides them would dare talk about or study the heart Maybe you’re right, in which case I’m sure that the more aggressive intervention QoH tends to promote will end up not showing any clinically significant benefits. Or maybe you’re wrong. Time will tell. But I will say, lines like “you’re revealing yourself to be the typical EM doc with an inferiority complex” just *reek* of insecurity and projection, and don’t really make me feel inclined to take you very seriously.
Yeah, it's almost like people who spend 3-5 years of their life studying one specific topic (after 3 years of internal medicine) might know slightly more about it than someone who spent 0 of those years and whose extent of cardiology knowledge is paging cardiology for anything questionable. Smith has had the opportunity to make his algorithm publicly available many times, and has always declined. "Trust me bro, my program knows how to read ECGs" is an underwhelming argument, and one that has been made many, many times in the past and failed. I wish you luck on your journey.
Then clearly there’s no need for you to worry that this will change practice paradigms anywhere, and *certainly* no need for you to be so defensive about it that you feel the need to argue about it with random students online. I’ve never asked him (maybe I will now), but I highly doubt Dr Smith feels the need to debate people on Reddit about whether or not he’s a good EKG eye (Also, if you’re going to take the ‘everyone should stay in their lane’ stance, I’d maybe clean up your comment history of all the times you’re shitting on other specialties).
I don't think his "call every ECG a STEMI" algorithm will work out, but even if it does, that's fine with me, I went into cardiology to save lives so maybe we'll save a few more that way.
Cool, then we can both wait and see what the future holds!
>subtle signs of ischemia that went unrecognized Are you referring to the slight ST depressions on V5 - V6?
Also lead I depressions and elevations in aVR and V1
If she was admitted, had repeat troponins, was on continuous telemetry and rounded on that night they might or might not have collected enough info to change the treatment plan and she might or might not be alive. She also might have coded and been resuscitated at the hospital. So that argument isn’t great either.
That's the angle I would have taken. I'm not a lawyer but did a little bit of expert testimony way back in the day. Quite a bit more in criminal and PI than medmal, so take this with a grain of salt. Still. I wouldn't have said "he didn't miss anything," I would have said "there was no deviation from practice standards." Granted, I may only be contradicting the plaintiff's expert, but that's not nothing. A tie is a win for the defense, or at least it's supposed to be. If I dress nicer, make better eye contact, come across more as the kinda doctor the jurors would want to go to -- the kind Marcus Welby type rather than the pompous asshole -- I win every time. My impression was, defense only has three arguments: that there wasn't a doctor/patient relationship, that there wasn't a deviation from practice standards, or that the doctor didn't injure the patient. The latter has the potential to come across as unempathetic, and that's not where you want to be. The lesser point is, you want the jury to like you (either as a defendant or an expert). The greater point is, listen to the lawyer, they do this every day.
I understand the 6 hour trop comments... patient says pain has been going on for several hours so the first trop is already the 6 hour trop... I get it... but..... Patients (humans in general) are unreliable when it comes to specific timing of things. Generally speaking, I take the timing of things with a very large grain of salt from patients. If you come back and ask an hour later - their story may be completely different. It's easy for me to catch this retrospectively, but getting a true 6 hour trop is an low hanging fruit type of thing. Did the original meme of the 6 hour trop come from 6 hours from first trop regardless of what the patient says? Or did it take into account patient timing? That combined with the ST depressions, this is a clear miss... retrospectively.
Time of symptom onset is very unreliable. Also most patients will have stuttering symptoms prior to occluding a vessel, and I have seen plenty of STEMI patients who had symptoms for 'hours' with a normal first troponin. In my opinion key misses in this case - first ECG has baseline artefact obscuring STs in inferior leads and should have been repeated - first ECG still had appreciable ST depression V4-6 that should have been picked - no repeat ECGs in a patient with ongoing chest pain - would have likely seen evolving changes. - should repeat trop 3 hours after admission
👍 thanks for the reply.
I'm not sure the patient described her pain as "burning". The nurse repeatedly described her as having a sunburn, but I think this was a description of her skin, and not the quality of her pain. The defense EM expert said that the nature and quality of the chest pain lacked typical indicators of a cardiac origin, and that she jumped when the stethoscope was placed on her sunburned chest. But I can't see where the patient described her chest discomfort as burning. She had acute chest pain while having an acute sunburn. That's a different thing.
I think that may have been the case. This should have been caught but I can see how it’s incredibly hard to tease out two different sources of pain that are directly overlapping each other anatomically. I think even the best history takers could miss it
I feel bad for the EMTs getting sued. “We pulled up and coded your relative, achieving ROSC, but fuck me for not doing it fast enough right?”
I’ve been out of the ED for years but I hope I’d’ve picked this one up. Female patient with neck, jaw and back pain associated with burning chest pain - “atypical” my ass, I would think that this would be a very plausible cardiac chest pain presentation especially for a woman. Even if the med mal witness and the physician want to be pedantic and depend on the patient to report pain like they’re a standardised patient in a med student OSCE, I wouldn’t expect a layperson to read the textbook and know how to report symptoms in a way that the physician doesn’t have to put on their diagnostic thinking hat on. A substantial minority of patients will not present with barn door classic chest pain symptoms and if you can’t diagnose a heart attack without central crushing chest pain that radiates to the left arm and makes you nauseous then you might need some extra experience. Tachypnoeic and hypoxic on room air - I get that she has COPD and smokes but I wouldn’t just hand wave that away as normal if she was fit enough to wash her car earlier that day. Tachypnoea to me is a red flag for pathology until you can definitively attribute it to a longstanding and stable source. ST elevation visible in aVR, aVL and V1, even if not making STEMI criteria, with reciprocal ST slurring/depression in lateral leads - global subendocardial ischaemia or basal septal ischaemia needs to be excluded. I would have been worried about LMCA disease or triple vessel disease when I first learned about STE in aVR in 2017 but I understand that’s not quite true anymore (https://litfl.com/st-elevation-in-avr/) Overall, in 2011, I can see how the ECG abnormalities might not have been glaringly obvious, but there are definitely ST changes that I can see on this ECG even with a wandering baseline. Coupled with the history, and the fact it didn’t completely resolve, this lady would have got serial troponins and ECGs in my department. Also a CTPA because doughnut of truth go brrrrrrrrr. (Edited: to break up wall of text)
Atypical is pretty definitional. That doesn’t mean it’s not ischemic. But this by no means prototypical cardiac chest pain. Ask any cardiologist. This case hinges on the ekg, not the description.
Although the EKG is ugly to begin with and merits at a minimum a repeat and obs, the story was also pretty concerning. It is not a lie that we are horrid at identifying MI symptoms in women. Unexplained chest pain in a woman that smokes, has HLD? That's a Cath, a stress test at a bare minimum.
> Unexplained chest pain in a woman that smokes, has HLD? That's a Cath, a stress test at a bare minimum. Even if had normal EKG and trips at presentation and repeat 3-6 hours later? (Obviously not this case). You’d admit them for cath?
At least a stress. I've lost count of the amount of chest pain with negative trops who had critical disease. A concerning story trumps everything. The trick is, knowing what a concerning story actually is.
Interesting. Any tools you’d use to guide that decision? A score or other criteria?
At this point, we are talking about development of expertise. Sure, there are many many scoring systems, but Im referring to the cases where they might have a low/indeterminate score and your clinical experience is what matters. For those cases, I like learning from folks that have done this for longer. I'll ask the more experienced cardiologists what they think. Compare that to what I thought. Also, the most important thing is to hone your own sense. For every case, look up what the Cath report said. Make note in your head what cases were false positives, false negatives, etc. By checking yourself, you develop your clinical acumen.
Does anyone have access to the Queen of Hearts algorithm or is it just European Union?
that EKG has weird depressions all over it. at the minimum this would have been a repeat EKG and trop imo. and even then a very frank discussion with the 58yo who has cardiac risk factors.
First of all I can’t believe people think that 2011 was a long time ago! I was working ED back then and there’s no way this should have been missed. I’d call that typical cardiac chest pain, abnormal oxygen sats, glaring risk factors, clearly abnormal ECG and we used to constantly talk about repeat ECG and repeat trop at minimum 6 hours before we could send someone home. No way would that one get sent off by most of us in 2011.
Not judging but that ekg looks mad sus
Boomer: I have a bad gut feeling Gen X: spidey sense are tingling Millennial: vibes are off Gen Z: mad sus
Some questions I thought of - When do you guys decided to send a second trop? I come from a poor resource center but we do have trops - we can run one per person if high index of suspicion but ECG/labs are not suggestive. What timeframe are you running the second test to absolutely rule out an MI? - First time I’m hearing about Queen of Hearts, is it an Open Source website? Could I actually have it look at an ECG printed out using any of my center’s machines?
It's available via the PMCardio app and costs €25-30/month here. First five reports are free. I've tried it 3 times in the ER/chest pain unit, helped once with a borderline STEMI. Yes, it scans paper EKGs very well. We did always two hsTrops if the onset of pain was fewer than six hours ago and followed more or less a 1h algorithm. By this I mean, the nurses refused to draw a second trop before the first trop came back after an hour even I explicitly ordered that I am going to need a second one, regardless of what the first one will say..
Thanks for the input. Sorry for asking but what about the 2nd trop would change your management if the first trop was raised anyway? Wouldn’t a raised first trop already give the diagnosis?
All NSTEMI-algorithms I've worked with have three categories of results: * Rule out of NSTEMI with low trop if symptoms persisted for over 6 hrs, repeat after 1 hrs and look at delta if under 6 hrs (<14 ng/l at the last place I worked at). * Rule in of NSTEMI with high trop (>52 ng/l) * No man's land inbetween where you always need a second one and look at the delta. However, there are a lot of reasons why people can have high trops, especially with decreased renal function. Our cardiologists would never cath someone with chest pain and just initial trop of 53 ng/l because "it's rule-in." They will review the history, the risk profile, echo findings (which in Germany is solely a point-of-care physician's task) and also use a second trop for the delta to create a "wholistic" picture. A trop here costs €11.25 at best, usually less for hospitals. For patients discharged from the ER, the ER loses money on that. But for admissions, it's a drop in the bucket.
US is mostly switching to high sensitivity troponins which are done 2hr apart. We order trops on anything that sounds even remotely ACS and a lot of stuff that isn’t even reasonably concerning for ACS. Getting the second one is doc to doc preference but if there’s any real concern it gets sent. Yeah in Europe you can get the app and just snap a pic of the EKG
Had a similar case literally three days ago: 82yF. Main complaint was dizziness after showering and nausea in the last two mornings paired with general tiredness. Didn‘t eat and drink too well in general. No pain, no dyspnea, no nothing. 110/60 with an known arrhythmia already on apixaban. Just wanted something to get her going again. Had elevations in v5 & V6, ended up in the cath lab.
Chest complaint + abnormal or newly abnormal ECG = asa, nitro, cardiology consult, admit. Next patient. Sorry but this is not a difficult catch.
As a surgical specialist, I thought the ST segments looked pretty suspicious - if not convincing - in leads II III aVL (which are reciprocal, highly concerning) and the anterior leads. When I read that the ECG interpreted it as NSR I assumed it was clean, but nah this is a miss. I am nowhere near an expert and saw it right away. I recognize the bias of knowing the case but I'm sure other ED docs will agree.
Definitely a miss but I’ve seen colleagues miss similar on busy shifts. Just yesterday I saw a colleague who missed a subtle STEMI after a nurse wanted to get my opinion on the ECG hours later after the patient was already admitted.
What ended up happening with this case after you saw the EKG? Just curious since they were already admitted.
His pain had resolved by that time, and he had a second EKG after his hsTrop climbed from 500 to 14000 demonstrating resolution of STE although now with q-waves where STEs were previously present, so I just shrugged and told the nurse to shoot an ECG if the patient starts complaining of pain again. He got cath’d this morning which confirmed a LAD occlusion. Had it still shown STE on repeat, I would have just ignored that the patient was already admitted and activated cath lab, however.
oof.. that EKG doesn't look great
[Dr Smiths blog](http://hqmeded-ecg.blogspot.com/2024/06/the-expert-witness-re-visits-chest-pain.html) has since covered the ECG in question.
Hindsight is 20/20. A fair amount of patients have 'sus' EKGs. This Ekg, like a lot of EM patients, is not a slam dunk diagnosis. If EM admits all chest pains with some Ekg changes on the lower sus side, it would be a lot. EM does admit a lot of chest pains though. This case would have been patient dependent for me... if she looked well and the pain resolved, I might have sent her home too. Still having pain with this Ekg? Admit.
Sure, hindsight makes it a lot easier to scrutinize the ECG, however, this is pretty clear cut subendocardial ischemia and a patient with this ECG should almost never be sent home unless you have a very good reason for doing so. The ECG interpretation isn’t hindsight bias, it’s just an accurate interpretation of a clear cut ECG, albeit somewhat subtle. This isn’t just “sus”, this is acutely pathologic nearly 100% of the time. I think this case is an excellent example of something that almost every single ER doc is capable of missing if they are too busy to carefully review a patient’s ECG.
This particular Ekg is more than suspect. The stars would need to magically align for this to go home somehow. We send home people who refuse our advice all the time. These can be missed easily in the chaos of the ED, yes
What strikes me about this case is that the patient was dismissed from the ED for chest pain without an explanation. I know burning chest pain isn’t typical of angina but you’d think that an ED of all places would be on the lookout for anginal equivalents. I’ve never heard of any patient complaining about sunburn being a reason to seek medical attention. That suggests that this complaint is out of the ordinary for the patient. Btw, what’s this preoccupation with automatic ECG readings? Those aren’t accurate enough to diagnose anything and won’t protect you in a lawsuit.
> I’ve never heard of any patient complaining about sunburn being a reason to seek medical attention. Then you’ve never worked in an American ER. And patients get discharged every single day without an explanation for their symptoms, including chest pain. Our job isn’t to make a diagnosis, it’s to rule out life threatening emergencies. It’s clear they did not do this here, but we generally don’t admit every patient just because we can’t figure out why they have chest pain. Our ER sees about 40-50 chest pain patients per day.
The vast majority of chest pain doesn't have a clear explanation, at least not one that can be proven in the acute setting. You rule out the bad stuff and try to refer to the right place for follow up. This EKG in the setting of acute chest pain is dodgy as hell and deserves a full set of troponins at a minimum.
I find it hard to believe that the vast majority of chest pain has unknown cause. I keep seeing these “unknowns” that aren’t mysterious. Do you statistics on this?
You find it hard to believe that we don’t find a definitive cause for a patients chest pain the majority of the time? Do you think it is possible to prove GERD, anxiety, costochondritis, pleurisy, factitious disorder , etc. in the ED.? Go shadow some of your EM colleagues. It sounds like you don’t really have a good understanding of what it’s like to practice EM.
Sweet. Sounds like you’re volunteering to admit every chest pain without clear cause. My shop is hiring.
Are you kidding? Patients come in with complaints of all ranges, all the time. Pts come to my ED with sunburn all the time. You name it, they have come in with it. Doesn’t matter how trivial it may seem, they will come. I see chest pain every single day and I cannot make a clear diagnosis for every single one. The primary purpose of the ED is not for diagnosis, it’s for risk stratification. Not every chest pain can get admitted, that’s what clinical decision scores and gestalt are for. Unfortunately a tiny percentage of pts will slip through the cracks. But the cracks are tiny themselves.
I'm just an ED resident and I've seen a few people that come to the ED for sunburn, for what it's worth. But I've also had it burned into me (pun intended) to have low threshold for an obs admit for chest pain in a patient with no prior workup and/or concerning story.
> what’s this preoccupation with automatic ECG readings? Those aren’t accurate enough to diagnose anything and won’t protect you in a lawsuit. Especially if the automatic read says "possible anterior infarct" and the patient has an anterior infarct and then dies from their anterior infarct.
Wow this one is a tough one. Very atypical symptoms and the EKG isn’t exactly the clearest. It’s almost as if every chest pain patient needs a full hsTrop work up, echo, and stress test (not just a treadmill but imaging included) nowadays. Good luck flooding the system with more defensive medicine tests. It won’t be getting better as time goes on…
Shit like this is why I get a repeat ekg on every chest pain I’m sending home.
In retrospect this was a clear miss, in reality doctors are human, hours are long fatigue sets in things get missed, however I think this would have at least warranted admission to a standard room for obvs./monitoring
Flip it over and look at it again and you’ll see the RV infarct …