Comments on: You Just Never Know In This Business

By: Ten out of Ten

Ten out of Ten — Sun, 01 Jul 2007 14:25:47 +0000

Hallway Four,

I do it for anyone I’m evaluating for DKA to look for peaked-T’s before the chemistry comes back, even though I was 99% sure this guy wasn’t in DKA.

With your lady I doubt I would have gotten one unless her heart rate was like 130 or something and I just wanted to make sure it was sinus. I don’t really care about hypokalemia/U waves since it’s obviously not as life threatening and I’d wait for the number to come back before treating anyways.

By: hallwayfour

hallwayfour — Sun, 01 Jul 2007 04:18:21 +0000

Trismus,

What made you get this guy’s EKG in the first place? I’m not sure I would have.

(although, now that I think about it, I had a similar case in residency: 40 yo woman with diarrhea for 3 days, came in feeling “dehydrated”. NO chest pain ever. My super-conservative attending made me get an EKG and she had HUGE tombstones all across the anterior leads.)

By: LarrytheDirectTVguy

LarrytheDirectTVguy — Fri, 29 Jun 2007 10:55:37 +0000

The initial case was interesting, the rest of the banter is lame; Great everyone explaining to nurses and the like how to diagnose a MI. Keep up the great blog, Trismus1.

By: POed of 2nd,3rd,Nth guessing

POed of 2nd,3rd,Nth guessing — Fri, 29 Jun 2007 02:27:13 +0000

To nurses and the ‘curious’:

1. take MCAT, go to med school, train at least 8 more years, get licensed, take professional liability, start your doctoring inclinations

2. if u cannot handle #1, stop pestering your doctors for your continuing education; they have jobs to do aside from justifying every test they decide to get for every case they have with you; educate yourself, on your own time, effort, and dime! go drain yourself too, instead of sucking more life out of your docs!

3. especially for Nurse K: constellation of symptoms cannot be treated like a multiple choice exam, nor can they be placed in a box that you check off, to be related every time! docs get this ability from putting in training time, much more than nurses, mid-levels, and high horse riding arrogant nth guessers, are willing to get or capable of handling!

By: trismus1

trismus1 — Wed, 27 Jun 2007 13:31:02 +0000

ID,

I completely agree, as rare as a 30 year old STEMI is, at least it’s diagnosible. If he had come in 4-6 hours earlier, when his clot was still forming, I almost certainly would have sent him home (probably wouldn’t have drawn enzymes, probably would have been negative anyway.)

Then I might very well be blogging about the young guy with gastroenteritis who came back coding instead of the above. Yikes.

10/10

By: edresident

edresident — Wed, 27 Jun 2007 12:28:37 +0000

and that was supposed to say “high” index of suspicion…

By: edresident

edresident — Wed, 27 Jun 2007 10:37:38 +0000

You’re right…this is easily the guy you can miss. You’ve got to have a low index of suspicion and low threshold to check an EKG. Especially in the elderly, and diabetics, and people with multiple “vague” symptoms that could be ANYTHING…I sometimes think of an EKG in those people as a “6th vital sign”

By: idcrossroads

idcrossroads — Wed, 27 Jun 2007 04:39:12 +0000

Nice case, and good job! This patient was lucky. If he was having a NSTEMI, it probably would not have been picked up, unless your ED does routine cardiac enzymes as part of a panel. Having a ED chest pain unit is nice, but irrelevant for this patient.

By: Christine

Christine — Tue, 26 Jun 2007 21:37:05 +0000

The ED in the hospital I work at has a chest pain center. I have nothing to do with it though, and no experience what so ever with how good it is.

By: edresident

edresident — Tue, 26 Jun 2007 19:33:23 +0000

yeah, having and ED chest pain unit would be nice, and solve some of that problem.

I had a cardiologist tell me one “why don’t you stop trying to make things more than they are, and when are you guys going to take responsibility for your own f-ing patients?”

He was forgetting that it was cardiology that didn’t want us to have the ED rule out unit. I’d LOVE to “take responsibility” and get the income for it (or at least, have my attendings get the income for it…)