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Is It or Isn’t It a STEMI - Part 1

Mel Herbert, MD MBBS FAAEM, Mike Weinstock, MD, Anand Swaminathan, MD FAAEM, and Amal Mattu, MD FAAEM
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24:37
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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03:36

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EM:RAP 2016 May Written Summary 626 KB - PDF

Sometimes, despite your best efforts at providing optimal care, there is a bad outcome and a lawsuit results. How should you document in those challenging cases? What should you do when there is a disagreement with a specialist? Mike Weinstock presents a chest pain case where a series of delays potentially led to morbidity and claims of malpractice.

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Todd C. -

Rob: you were right, this segment absolutely made me angry. The emergency physician went above and beyond. What more could she have done? Demand that the cardiologist physically see the patient at one in the morning over a questionable EKG? First, it's medically unnecessary, and second it's political/career suicide.

It's so disheartening that it was THIS case that ended up going to trial. This exact scenario (concerning history for ACS, faxing back and forth of equivocal EKGs with a cardiologist, decision on maximal medical therapy) must happen countless times each year in the United States. I've personally been witness to cases that proceeded much less smoothly than this, none of which went to peer review let alone a trial.

I love the part about documentation. "My ideal chart would be..." Ideal chart. Haha. Good one. Even with a scribe and our hackneyed EMR, I get to spend 1-2 hours after a shift buffing my charts. It's so easy to cherry pick a chart that ends up going to trial. Try this thought (or real) experiment. Go through all of your charts from the last several shifts. Look at how, despite your best efforts, many if not most are flaming piles of crap, solely constructed to bill, have incongruent time stamps, and contain a handful of discrepancies the scribe left in you didn't catch. Now throw a dart at which one you'll have to defend in a trial.

The greatest irony of this segment is that it is followed by one regarding unnecessary cath lab activations. You know, the one about false positive activations leading to higher mortality. One thing I know for sure: not a single one of the patients harmed by an unnecessary cath lab activation ended up suing their doctor.

Kevin M., MD -

Todd. I agree with you 1000%. Each and every word. This poor doc provided excellent care and it makes me angry that she had to go through people beseeching her actions. And the perfect chart simply does not exist. If the defense attorney thinks that anyone is going to document to the level he stated would be appropriate, he's just not being realistic.

Alexander D. -

Hi guys, thanks very much for sharing the case, one can learn a lot from what happened there.
The thing that upset me the most was what the lawyer said when asked if the EP should consult the specialist to discuss cathlab activation: "absolutely not, the EP physician should be fully capable to interpret the ECG for STEMI criteria"
what *** is that?
ECG is by far not 100% sensitive or specific for determining the need for cathlab activation, so what that lawyer said is nonsense in my opinion.
And although I didn't see the ecg's, from the description it sounds a lot as if the first ecg's were not clearly indicating a cathlab. Even the cardiologist didn't recommend the cathlab activation, how can the lawyer then make the argument that the EP should have??

QUESTION 1
Were the guideline defined ecg STEMI criteria even met? I would be curious to know that.
I guess not, and then the answer to that lawyer should have been: YES a EP is capable of checking if there are STE in two consecutive leads, and they were not there!

QUESTION 2
Would it be possible to see the ECG's?

Thanks for all contributors to EMRAP for the great site.
Best wishes from Vienna,
Alexander Dejaco

Ian L., Dr -

The HEART score is validated as a Prompt and having Prognostic use .
In this patient H gets 2 points E one point A 0 points R risk factors are not mentioned and that is a lapse .T would get a 1 point .
So it's a minimum of 4 for mine and no Risk factors very unlikely .
The score likely 4 Moderate Score - MACE 12-16%
Refer range Backus et al Int J Cardiology 2013 2153- 2158
If Time is muscle for mine suboptimal care PCI justified .
Don't like the Spinning Legal Eagle Process .
Bad for morale .
Need a far better way .

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Snake Bites and The Missed MI Full episode audio for MD edition 256:35 min - 298 MB - M4AEM:RAP 2016 May Aussie Edition Australian 42:06 min - 58 MB - MP3EM:RAP 2016 Mai Résumé en Francais Français 64:00 min - 88 MB - MP3EM:RAP 2016 Mayo Resumen Español Español 78:00 min - 107 MB - MP3EM:RAP 2016 May Canadian Edition Canadian 25:09 min - 35 MB - MP3EM:RAP 2016 May German Edition Deutsche 107:44 min - 148 MB - MP3EM:RAP 2016 May Board Review Answers 172 KB - PDFEM:RAP 2016 May Board Review Questions 159 KB - PDFEM:RAP 2016 May MP3 329 MB - ZIPEM:RAP 2016 May Written Summary 626 KB - PDF

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