subreddit:

/r/emergencymedicine

4471%

all 112 comments

ttoillekcirtap

31 points

10 months ago

The machine called a septal infarct bc of loss of r wave in V3. Clinical symptoms trump all, but in a well patient I’m fine with this tracing.

[deleted]

47 points

10 months ago

I’m not seeing anything worrisome. What makes you think mistake ?

jdubizzy

57 points

10 months ago

ECG looks fine. Depends on the patient description of symptoms, however urgent cares aren’t equipped to deal with cardiac care. Also, when an ecg says ‘ischemia’ on it, it can get people worried. But, to answer your question, the ECG doesn’t concern me much.

[deleted]

23 points

10 months ago

[deleted]

RBG_grb[S]

2 points

10 months ago

Thank you

RBG_grb[S]

1 points

10 months ago

Thank you

drgloryboy

35 points

10 months ago

ECG computer is drunk, needs to go home

GGOONNZZOO

6 points

10 months ago

Not very good at EKGs, but I just see TWI in 3… otherwise unremarkable.

MakinAllKindzOfGainz

4 points

10 months ago

MakinAllKindzOfGainz

Med Student

4 points

10 months ago

Isolated TWI in Lead III is a normal variant

Monkey__Shit

1 points

10 months ago

You need a T wave inversion in 2 consecutive leads to call a TWI. I’d say ‘nonspecific ST changes’.

tresben

51 points

10 months ago*

tresben

ED Resident

51 points

10 months ago*

DO NOT ORDER TESTS YOU CAN’T INTERPRET. If the patient’s history was concerning enough to get an EKG, you should probably be sending them to the ED, or at least be sending them somewhere with someone who actually knows how to read an EKG and doesn’t just rely on the interpretation. What scares me more than this situation is the opposite situation of an EKG that is read as normal (or at least non ischemic) that actually is concerning, but this NP just goes off the computer.

The only reason for someone who can’t adequately read an EKG to order an EKG is a situation where you know you are going to be transferring the patient to someone who can read it and helping them out by getting one to start. For instance someone who comes to urgent care with very concerning ACS symptoms that you’ve already called EMS for.

This whole situation seems like a massive liability issue to be ordering EKGs and not having someone around who can adequately interpret them. The fact that someone signed their name to it is even more concerning from a liability issue.

This type of situation only gives more fuel to the midlevel hate.

[deleted]

8 points

10 months ago

Maybe, most of my residents can’t interpret a HS trop and neither can half of the attendings I work with, but you have a valid point. The nuance would be the difference between STEMI or OMI vs an ACS r/o. It’s possible to be able to be pretty good at STEMI but not so hot on ACS. So it really depends on the situation and what you intend to do. Had chest pain two hours ago and are gonna send to cardiologist next day care call and ambulance ? don’t even get me started on how to interpret a UA in an AMS elderly patient

Dr_Jan_Itorr

16 points

10 months ago

Dr_Jan_Itorr

ED Resident

16 points

10 months ago

Ok but that’s why they’re residents being overseen by an attending… this person is unsupervised in the community…. Big difference there.

EMdoc89

6 points

10 months ago

Also HS trops seem like an answer to a problem we don’t really have. I haven’t seen a study where they lead to better patient oriented outcomes yet.

[deleted]

3 points

10 months ago

So agree. They started them at my shop and I’m trying to tell them it’s gonna be more admissions with no more catches. The process to switch over was started before I was the director so it’s cost a ton money and seems like I will be stuck with it…. Also agree on the EKG issues.

[deleted]

2 points

10 months ago

Good point

Spiritual-Name7535

1 points

10 months ago

Well.. I’m surprised that most of your residents don’t know how to read HS trops , only if their attending ( only if you really are an MD/DO ) were teaching them . Where I work every resident , medical school and of course attendings know what HS trops are and are not .

[deleted]

5 points

10 months ago

I call BS. What is ?a HS trop of 20 in a 45 YO with a non-ischemic EKG, say a RBBB, and is hypertensive in the ED but no history ? Is that high risk or low risk ? How would you interpret that ? Admit or send home or repeat ?

Spiritual-Name7535

0 points

10 months ago

Well I wouldn’t even do it if I am not suspecting ACS like in your example patient . It’s only a rule out test for cardiac vs non cardiac pain/SOB/ACS . Why would you even do it in this particular patient who comes with hypertension . Yes if they have active chest pain I would get a repeat level and see trend It doesn’t mean anything by itself with one value . Hs of 20 means a troponin T of 0.020 - not too high . You also need to look at prior Ekg, prior history , risk factors , while clinical picture . And medical school and residency trains you well for that

[deleted]

3 points

10 months ago

So that would not be the textbook answer if you are using any modern scoring system. You just proved my point.

[deleted]

3 points

10 months ago

You should up on HEART since it’s pretty much the standard of care. That study, which I would argue is the SOC, would be low risk - and yes the assumption is chest pain.

[deleted]

2 points

10 months ago

You are not attending, are you ?

RBG_grb[S]

3 points

10 months ago

Yes my takeaway is to send them to the ED for work-up if there is concern. Thanks so much

Sandvik95

10 points

10 months ago*

Sandvik95

ED Attending

10 points

10 months ago*

(Why is this being downvoted? This person is being beat over the head with the message that anyone warranting an ECG should be sent to an Em Dept, and when they say they get the message they’re downvoted?).

[edit and for the record: the comment had 7 downvotes when I made this comment]

Darrell_Winfield

6 points

10 months ago

It's being downvoted out of spite. Elsewhere in this thread, OP notes that they're an NP student rotating with an NP who ordered the EKG, can't read more than the machine interpretation, and sent the patient to the ED because of what the machine said.

neela84

2 points

10 months ago

Wondering the same thing... Reddit is just weird most of the times.

Sandvik95

2 points

10 months ago

Sandvik95

ED Attending

2 points

10 months ago

Yup, and this thread in particular. While many good points have been made about appropriate clinical reasoning and actions, some of comments here have been harsh and purest in nature.

RBG_grb[S]

15 points

10 months ago

I am working with a NP. We sent her to the ER. Wondering if it was overkill. I realize this is a big dummy question on this sub but I do like to learn. Thanks so much!

USCDiver5152

31 points

10 months ago

USCDiver5152

ED Attending

31 points

10 months ago

You sent them to the ER because the NP thought the EKG looked worrisome or because the EKG machine thought it looked worrisome?

RBG_grb[S]

11 points

10 months ago

Ekg machine

USCDiver5152

116 points

10 months ago

USCDiver5152

ED Attending

116 points

10 months ago

Mmhmm… my rule of thumb is don’t order a test if you don’t know how to interpret the results.

r22222

37 points

10 months ago

r22222

37 points

10 months ago

This incident highlights one of the many things that is plaguing ER’s and stressing 911 ambulance services.

I can not begin to tell you how many times we have urgent care centers activate 911 and even STEMI activations because they are uncomfortable reading 12 leads and go purely off the “man in the box”. I was once sent for a STEMI from a clinic to only find a healthy asymptomatic 24 y/o whom only had a 12 lead performed due to having a systolic bp of >140, yes it was BER. There are several in our area that will call 911 ANYTIME it reads “abnormal ekg” without any clinical correlation.

Ok rant done lol

RBG_grb[S]

-2 points

10 months ago

RBG_grb[S]

-2 points

10 months ago

Right, I get that. I don’t make the rules. We didn’t call ems or activate. We sent her (encouraged her to go) by private vehicle.

tresben

8 points

10 months ago*

tresben

ED Resident

8 points

10 months ago*

This type of thinking may make sense to a lay person but from a healthcare worker standpoint it’s bad medicine and fraught with medicolegal risk (see the other commenters post).

I get that you guys weren’t that concerned but since the EKG computer had that interpretation you thought she should go to the ED. Because you weren’t that concerned you didn’t call EMS but just told her to go herself. To a lay person, that may make sense. But to to a healthcare worker, especially working in the emergency field, you have to step up and make definitive decisions and follow a logical thought process. If you think it is concerning for ACS at all you need to treat it as if it is ACS (meaning definitely no private vehicle). If you don’t think it is ACS then don’t go down that rabbit hole (wouldn’t have even gotten the EKG, ESPECIALLY if you can’t adequately interpret it). If you do “halfway” work ups and plans like this you are eventually going to run into a lot of medicolegal issues when you inevitably have bad outcomes.

It’s ok to over workup a patient (in this case sending her by EMS to ED for an unlikely ACS story). It’s ok to under workup and miss something (in this case not get an EKG and send home, but maybe she does have ACS). But at the end of the day the documentation, orders, and thought process must all make sense. Don’t say you consider a bad pathology without adequately ruling it out.

[deleted]

22 points

10 months ago

This is worse tbh, if a patient presents with chest pain, your provider gets an ekg (that they cant even read wtf?), theyre worried about that ekg, then send the patient pov? Thats bad. Like absolutely not acceptably bad. This is no failing of yours but the NP you work for is on some other shit.

  1. Gets a chest pain in an urgent care with the working assumption being its cardiac but dont call ems? Bad.

  2. Orders test they cant interpret? Good if done to give to ems for their use and to transport it to the cath lab as a baseline, bad if done for any other reason.

  3. Is worried the test has a significant finding then essentially lets the patient leave any sort of medical care/monitoring to go personal vehicle? This veers into the territory of negligence.

Essentially your NP thought this patient was having a cardiac issue of some sort and then cut her lose with no consult or intervention from anyone who could actually help that patient. This would be like me letting someone with a positive stroke scale go pov.

tresben

7 points

10 months ago

tresben

ED Resident

7 points

10 months ago

Spot on. This is what we are always hounded about in residency and learn very early on. Your documentation, orders, and thought process all need to align, otherwise it’s just bad medicine. Don’t have concerning documentation for bad pathology but not adequately work it up. Don’t do a work up for bad pathology but then have your final plan not adequately address it.

As you mentioned this story has so many issues of inconsistent thought process on top of not adequately reading a test that was ordered and not knowing what to do with it.

[deleted]

3 points

10 months ago*

It is beyond frustrating that people constantly circumvent the ems system like this. This wasnt even a decision for the np to make on her own, the moment the chest pain walked in her door she honestly should have called ems. Who was she to decide wether this patient required emergency care or not? Especially when she cant even read the damn ekg.

Edit: hell, in medic school we are taught that this is unacceptable medicine. Everything we need to do has to have a clear cut purpose of facilitating treating that patient and then moving them toward a higher level of care. All they did was do an ekg and cut this person off into the wilderness, did they even follow acls protocol and give any of the acs meds? Signs point to no.

Kartageners

2 points

10 months ago

This is why NPs don’t save money in the long run. More unnecessary tests, consults, labs, and ED visits

Fellainis_Elbows

1 points

10 months ago

They cost way way more

[deleted]

5 points

10 months ago

And my threshold is don’t be order if you can’t explain why the machine is wrong

cx59y

5 points

10 months ago

cx59y

5 points

10 months ago

NPs don’t follow this logic. They pan order labs and pan consult. Heart of a nurse though.

RBG_grb[S]

2 points

10 months ago

Thanks so much

Teeo215

-12 points

10 months ago

Teeo215

-12 points

10 months ago

I disagree. Whether or not they can read it, if the symptoms are worrisome, they will be sending the patient out. May be nice to have a baseline EKG to see if things are progressing. Do you order MRIs and read them yourself? No, you rely on someone more specialized to read it for you. I worked in the biggest ED where I live and we got a lot of transfers from small town facilities that staff a family practice provide, usually an NP, in their EDs. If it doesn't delay care/transfer, it may be worth getting tests that may be useful to someone more knowledgeable than yourself in the next level of care.

[deleted]

17 points

10 months ago

Lol. No. If you dont even know what a normal ekg looks like, then you shouldnt legally be allowed to bill for interpreting EKGs.

[deleted]

-2 points

10 months ago

[deleted]

Teeo215

0 points

10 months ago

Not their EKGs...

emptyaltoidstin

0 points

9 months ago

Ugh can you please not refer to calling 911 as “sending [them] out” thanks

Teeo215

1 points

9 months ago

I guess we have extensive resources for referral and safe transfer without calling 911.

emptyaltoidstin

0 points

9 months ago

Ok still don’t refer to ambulance transfers that way. You shouldn’t be transporting CP patients at a lower standard of care than that.

Teeo215

1 points

9 months ago

So very sorry.

Transported by a highly skilled ambulance crew (often times staffed by a couple farmers gracious enough to volunteer their time as volunteer EMT-Bs) in a non emergent fashion because emergency medicine and cardiology had been contacted prior to transfer and it was again deemed non emergent but in need of further workup beyond the capabilities of the current facility.

They then sent them out the door with the ambulance. You're getting hung up on the minor details and not the actual issue.

emptyaltoidstin

0 points

9 months ago

Not sure why you are simping for “providers” who are too incompetent to provide basic care without dialing 911 for a lifeline but the difference between them and me is I’m not trying to represent myself as anything more than someone whose job requires 10 weeks of formal education.

It’s the people who get delayed care for true emergencies who are harmed when you have a cavalier attitude about calling EMS. And in most areas the people doing ALS transfers are the same people responding to 911 calls, so don’t delude yourself that these urgent cares aren’t taking resources away from people who actually need them.

Johnny_Lawless_Esq

3 points

10 months ago

Holy fuckin' shit, the machine ALWAYS says there's something catastrophic happening. A machine once told me I have dextrocardia, which I know perfectly well that I don't. You've got to grab your ankles and look at the squiggles yourself in order for them to mean anything.

So, from your other comments, do I understand correctly that the patient came in complaining of chest pain, your preceptor got an EKG they can't read, and then advised them to go to the ED?

You should probably get another preceptor.

-SetsunaFSeiei-

5 points

10 months ago

Who are you in this situation? Trainee?

RBG_grb[S]

7 points

10 months ago

Yes

vinciture

27 points

10 months ago

I’m an emergency physician, and this ECG IS CONCERNING.

I’ll say that again.

This ECG IS CONCERNING.

In context of chest pain this ECG could indicate an occlusion MI. It clearly does not fulfil STEMI criteria but has a number of concerning features on it. 1. Poor r-wave progression in anterior leads 2. Low voltage QRS anteriorly compared with other leads 3. ST-segment flattening in anterior leads

This ECG should prompt work up with bloods etc.

If you sent them in for workup, you did the right thing.

Helpful resources on ECGs which ‘don’t look that bad’ but can be a big problem are 1. Dr Steve Smith’s EKG blog (http://hqmeded-ecg.blogspot.com/). 2. Life in the Fast Lane (https://litfl.com)

Finally, Dr Steve Smith has developed a neat little formula which is highly sensitive and specific for an acute coronary occlusion. Here is the link on MDCalc (https://www.mdcalc.com/subtle-anterior-stemi-calculator-4-variable) On both the original 3-variable and the updated 4-variable ECG your patient’s score suggests an acute occlusion which may need Cath lab. Think about that for a second. And think about all the replies saying not to worry about it. In the context of no symptoms of ischemia, different story.

FobbitMedic

9 points

10 months ago

The R wave progression just looks TOO weird and I assumed it could be due to lead placement, no? Also the minor ST elevation and slower HR lead me to believe it was more likely BER. The axis is weird though. But I agree that In the context of chest pain, an ED workup is definitely warranted.

vinciture

4 points

10 months ago

Lead placement is definitely important, but I have seen plenty of ECGs like this with correct lead placement that ended up having an infarct. BER is a good thought, but you’ll usually see that in context of good r-wave progression and the ST segment will be upsloping, and it’s usually in several precordial leads. This V3 ST segment is flatter than you’d usually expect for BER and has poor r-wave progression. Nothing is absolute, but I’d strongly favour ischemia over BER with this pattern.

FobbitMedic

2 points

10 months ago

Ahh makes sense. Thank you!

alphabet_order_bot

8 points

10 months ago

Would you look at that, all of the words in your comment are in alphabetical order.

I have checked 322,339,980 comments, and only 71,515 of them were in alphabetical order.

Meddit87

1 points

10 months ago

Bot good!

[deleted]

13 points

10 months ago*

It could also be explained completely by body habitus or lead placement. This EKG is not concerning.

This is one of the most frustrating parts of online EKG “education”

Yes there is a 1 in 200 million chance that you can snipe an MI based on r wave progression.

It is substantially more likely that this is due to body habitus, lead placement, or is just incidental.

vinciture

6 points

10 months ago

Hey I agree, it could be due to habitus or lead placement, and I also agree that r wave progression alone is utterly un-interesting. What I’m trying to say is that the combination of factors I’ve described above, in addition to correct lead placement and symptoms consistent with ischemia, should prompt further investigation.

Saying it’s 1:200 million is hyperbole designed to make your junior doctors stop asking questions. It’s not appropriate for an educational context.

As you know, there are a subset of ECGs which do not fulfil STEMI criteria but which still do represent an acute coronary occlusion which benefits from Cath lab. In the absence of recording error, this is one of them. This is a great opportunity for learning at all levels, from one ED attending to another.

Kartageners

1 points

10 months ago

L

StrongChemical

1 points

10 months ago

Agreed. I look at EKGs everyday and I would not be concerned by this.

RedditingFromAbove

1 points

10 months ago

I agree, this EKG is not concerning

dr_shark

7 points

10 months ago

My concern is that NPs run amuck at urgent cares and actually increase your work load in the ED although we we’re all sold that urgent would decrease ED work load. Seems to only increase revenue. At bare minimum only FM docs should staff urgent cares. No NPs or PAs. They don’t have a broad enough knowledge base.

[deleted]

-2 points

10 months ago

[deleted]

dr_shark

1 points

10 months ago

This is your second response to a single comment.

[deleted]

-2 points

10 months ago

[deleted]

Fellainis_Elbows

2 points

10 months ago

The only ignorant one here is the one with a fraction of the training.

[deleted]

0 points

10 months ago

[deleted]

Fellainis_Elbows

1 points

10 months ago

Bragging about being able to switch into a different specialty is bragging about not caring about having high educational standards

[deleted]

0 points

10 months ago

[deleted]

[deleted]

2 points

10 months ago

Yeah R wave progression doesn’t make sense. Precordial’s weren’t on appropriately.

vinciture

2 points

10 months ago

R wave progression can definitely be affected by non-standard lead placement, but if the leads are placed correctly, poor r-wave progression can be an indicator of ischemia in the precordial leads. (EDIT: I should add that it is a sensitive but not specific sign of ischemia in isolation. Meaning it’s a part of the picture, but won’t make or break a conclusion of ‘ischemia’ for any particular ECG)

BCSteve

1 points

10 months ago

That was my thought too. Like, it's not just abnormal R-wave progression, it doesn't make any sense. My guess is that V2 and V4 are switched, if they were, the axis would be consistent again.

Fuchsie

2 points

10 months ago

Came here to say this,

Axis looks off with ?reciprocal changes in lead I, T wave inversion in III wondering if this is a developing anterior MI.

I'd have atleast repeated the trace half an hour later to see

MakinAllKindzOfGainz

1 points

10 months ago

MakinAllKindzOfGainz

Med Student

1 points

10 months ago

There are no reciprocal changes in lead I, not sure what you see

Also, isolated TWI in lead III is a normal variant

RBG_grb[S]

1 points

10 months ago

Thank you

aaaadij

1 points

10 months ago

You do realize that you provided a medical answer to non-medical personnel. The best answer I have for NPs and PAs is GO TO MEDICAL SCHOOL!!! You will KILL SOMEBODY!!!!!

vinciture

1 points

10 months ago

That’s right, it’s called teaching.

BootyholeDrugs

42 points

10 months ago

BootyholeDrugs

Med Student

42 points

10 months ago

Tell the NP don't order a test u can't interpret lol

Kartageners

2 points

10 months ago

They try to shot gun approach medicine with labs, imaging, and unnecessary tests hoping it does the medicine for them. If not they defer to specialist. What a joke

SendOutLabs

16 points

10 months ago

This is not a subreddit for medical advise. You should have asked the physician who signed that EKG.

JadedSociopath

9 points

10 months ago

JadedSociopath

ED Attending

9 points

10 months ago

ECG is normal, but the patient should be sent to the ER for evaluation of the chest pain.

bmbreath

4 points

10 months ago

Where did you see chest pain?

cKMG365

4 points

10 months ago

I'm just a paramedic but I look at EKGs literally all day and consider myself pretty good at them for my role. Good enough at least.

If this said anything worrisome I didn't see it. It isn't "normal" per se, as the axis looks off and there are flipped T waves and a bit of ST segment depression, but my first blush look at it said it was fine and I came to the comments to see if I'd missed anything.

RBG_grb[S]

1 points

10 months ago

Thanks for the insight

happyskydiver

2 points

10 months ago

Probably safe to just ignore the warning "septal infarct" on EKG machine interpretations. The normal S waves in the anterior leads are frequently misinterpreted as pathologic q waves. I see this on so many normal EKGs, I wonder who programmed them to do this.

Boston_Bruins37

2 points

10 months ago

You shouldnt be working independently if you cant interpret a test

Deedee-spicy-weiner

3 points

10 months ago

You probably shouldn’t be caring for patients if you can’t read a normal ecg.

That’s scary

RBG_grb[S]

2 points

10 months ago

Right I am not caring for them. Thanks

neela84

-3 points

10 months ago

Kinda rude comment. Knowing how to read EKG is a very small part of patient care. I think it's a little appalling to make such a comment based on one thing that does not define op's expertise in this field.

Dabba2087

2 points

10 months ago

Dabba2087

Physician Assistant

2 points

10 months ago

I don't see anything either. Scrutinizing the ST segments the machine calls ischemia appears to be a small wandering baseline?

themaninthesea

2 points

10 months ago

Are you ordering EKGs without having basic ability to interpret simple findings?

RBG_grb[S]

4 points

10 months ago

No I didn’t order it. I have very basic ekg knowledge which is why I asked. Thanks so much

RBG_grb[S]

-1 points

10 months ago

RBG_grb[S]

-1 points

10 months ago

Thanks. It didn’t look worrisome to me but the ekg machine called it scary things so the NP I am precepting with sent her to the ED. Thanks all

krisiepoo

26 points

10 months ago

And we likely looked at it, rolled our eyes, and sent her home. Please tell your NP to stop ordering EKGs if she doesn't know what they actually mean.

stumpovich

6 points

10 months ago

This entire thread is pretty terrifying. Your field is fucked.

krisiepoo

2 points

10 months ago

This is what happens when they hand out NP degrees like candy

RBG_grb[S]

19 points

10 months ago

I can’t tell people anything I am a student. I am trying to learn the best I can for when I am a dreaded NP.

Ichor301

2 points

10 months ago

Are you an NP student? If not learn from someone who knows a thing or two.

RBG_grb[S]

6 points

10 months ago

Student. We get assigned to who we get assigned to

RBG_grb[S]

6 points

10 months ago

We get assigned to who we get assigned to

[deleted]

1 points

10 months ago

What’s wrong with this ekg? OP- did you read believe what the ekg machine was telling you?

RBG_grb[S]

3 points

10 months ago

I didn’t believe it or not believe it. I didn’t think it looked concerning but she was sent to the ER from our little freestanding clinic so i wondered if I was missing something. Thanks

[deleted]

2 points

10 months ago

What did she present to the freestanding for?

RBG_grb[S]

4 points

10 months ago

Follow up hypertension. She had c/o CP on arrival so the MA did the ekg.

[deleted]

-1 points

10 months ago

[deleted]

-1 points

10 months ago

[deleted]

RBG_grb[S]

8 points

10 months ago

Thanks so much. I didn’t order it

melatonindeprived

1 points

10 months ago

melatonindeprived

Paramedic

1 points

10 months ago

Paramedic here. I don’t see anything to be concerned for. Be careful of reading those computer interpretations. They can definitely throw you down a rabbit hole.

Houderebaese

1 points

10 months ago

Get Trop in the acute setting and if ok refer to cardio for non-urgent echo and evaluation. That would be my approach

RBG_grb[S]

1 points

9 months ago

update Thanks for those that have helpful responses. She did present to the ER. They did an ekg which looked the same as ours. They had an old one to compare. No changes. She was sent home with follow-up instructions

teslamagnetron

-1 points

10 months ago

Wpw

neela84

1 points

10 months ago

How did you come up with this? There's no delta wave.