Archives for September 26, 2009

I sent a guy with a normal EKG to the cath lab (Updated)

9/30: Update: due to popular demand, I have added the EKG to the end of the post, with some follow-up.

I sent a guy with a normal EKG to the cath lab.  Let me tell you my side of the story.

Dude was minding his own business when he started having crushing, substernal chest pain.  I see dude by EMS about 45 minutes into his chest pain.  He’s had the usual: aspirin, 3 SL NTG’s an IV, a touch of MS (I can abbreviate here, as it’s not a medical record) and is continuing to have pain.

He describes it like you’d expect (elephants have a bad rep in the ED), and looks ill.  Frankly, he looks like a guy having an MI.  Sweaty, pale, uncomfortable, restless but not that ‘I’ve torn my aorta’ look.  The having an MI look.

Every EM doc knows the look.  I didn’t ask about risk factors.

On to the proof: the EKG.  EMS EKG: normal.  ?What?  Yeah, maybe there’s some anterior J-point elevation, but not much else.  Our EKG: Normal.

Normal EKG’s, patient who clinically looks like he’s having the Big One.

I’d like to tell you I agonized over the decision, but I didn’t.  Cath lab called, Interventional Cardiologist says he’ll meet the patient in the cath lab.  (Insert excellent nursing and tech care here; time to cath lab 28 minutes, no labs back yet).

Excellent tech comes to me after transporting patient to cath lab.  “The cardiologist wanted to know why you sent him a patient with a normal EKG”.  ?Are they going to do the cath? I asked.  “Yes, but he wasn’t happy”.  Supportive team thinks I did the right thing, but, sending a guy with a normal EKG to the cath lab?  I don’t blame them for some averted gazes.

Cardiologist comes looking for me an hour later.  Doesn’t look happy.

C: Why did you send that patient to the cath lab?
Moi: He was having an MI.
C: He had a totally normal EKG.
Me: Yes.
C: What made you think he was having an MI?
Me: He looked sick.

(An aside: I could have whipped out some BS about some minor historical feature, blathered on about his elevated J points, etc, but I’m stupid and just said what I meant).

C: After I started the cath, another cardiologist looked at the EKG, and agreed it was normal.
Me: (Sinking feeling) And?
C: 100% LAD occlusion, high proximal.  I stented it and now he’s good.
Me: So, good?
C: It’s the first patient with a normal EKG I’ve cathed, and he had a 100% LAD occlusion.

Some small talk later, the cardiologist leaves.  I have no doubt the cardiologist cannot decide if I’m an idiot or a savant.

I’m neither.  I’m an ER Doc.  Who got lucky.



First troponin was normal; second, several hours later, was nearly 30 (with our high normal being 0.05).