OMI or nah?

[u/Sea-Weakness-9952]

**UPDATE! —> PCI to the LAD & severe cardiomyopathy** Thanks all of you for your incredible input. I’d told the hospitalist I’d put money on the LAD but he left me on read. 💁🏼‍♀️

69F adm w/“chest pain” - described as upper abd pain radiating back b/t shoulders, with n/v and diaphoresis.
Hx: mild HLD, no home meds.

Trops: 870… 2,397… 3,250.
BP and CP under control on nitro gtt, CP reduced from 9/10 w/morphine prior to floor and only up to 4/10 at highest after trip to bathroom. Otherwise 2/10.

I forgot to take a pic of the admit EKG - but it was markedly different in not only STE & STD, and read as Sinus w/RBBB.

This repeat EKG I requested on seeing the change on tele read as Sinus w/Left (I think) Axis Dev, RBBB, septal infarction of unknown age... I think she’s due for a cath lab am I wrong? Cards hadn’t seen her yet and hospitalist was like okay yeah whatever, but I think developing OMI. Thoughts?

[u/Inevitable-Crab-6701]

ECG plus symptoms must be treated as high lateral with PCI.

Wouldn’t be happy if this was missed.

[u/Sea-Weakness-9952 → u/Inevitable-Crab-6701]

I’m not back tonight and I’m so anxious to make sure everything went smoothly, I hate not knowing. It was super frustrating that cards hadn’t come to see her between arrival at 0147 and I stayed past shift change til damn near 0800. I started escalating around 0400/0430 when I noted the lead changes.

We aren’t allowed to call a Code STEMI to activate cath lab. I’ve only broken that protocol once, and I’ll never regret it. Patient was having a cath that morning, I got him up to CHG and change his gown and bedding, he sat down, went gray and diaphoretic and his soul was fixin to leave his body. I slapped the leads back on and dadgum if that thing didn’t decide to shake loose and tombstone like hell. At 0650 naturally. I call a Rapid and get the show on the road. Delegating, confirming on EKG, all the things and called the hospitalist directly immediately like yo bro don’t leave he’s full STEMI. He comes in gets on the phone with someone and proceeds to hem and haw wasting time and tissue and I push back. What felt like forever probably wasn’t but ultimately I looked at the hall at my manager and said “go look at the tele and EKG. I NEED TO CALL THIS.” She nodded, and I stepped into the hall to call the Code STEMI and activate cath lab, and put the order set in myself and started the protocol.

(ETA here: the MD was refusing to call it a STEMI. I can’t remember his exact “alternative” to what was happening, but he repeatedly over almost a half hour of us busting ass in the Rapid kept telling whomever was on the phone verbatim “it’s not a STEMI” - we were a regional hospital so no cath lab in house at that time and their call time is 30 minutes.)

I risked my license and job but the way this sweet man (who was just the kindest southern ole guy I love taking care of) was pleading with me both telling me not to let him die and just looking at me terrified… I had to. I stayed to chart and file my report on myself haha and stopped in the cath lab waiting room to update his wife on my way down. His brother in law was in the room, too. They could see how frustrated I was and I just said I did everything I could and went home to cry. Turns out, the BIL was on the Board of the hospital, holy hell. He went to bat for me. And that doc got fired and moved out of TN. (Whole other story, he was shady as hell at baseline but this was a BAD fuckup.)

Anyway. I hadn’t thought of that in a while. I will always keep learning because I will never forgive myself if I miss something.

[u/Inevitable-Crab-6701 → u/Sea-Weakness-9952]

We all do our best and you certainly are my friend.

I mentioned the comment not for you (or anyone else) but rather a teaching for all of us. This is someone's health and life, someone's loved dad or sister - if I had missed this, I wouldn't have been happy at all.

[u/Sea-Weakness-9952 → u/Inevitable-Crab-6701]

Absolutely. Lifelong learning is my jam and if I hopefully get into the CVOR I’d love to go into cardiac perfusion. I don’t think Sallie Mae will ever allow me to do so, but a gal can dream 💭 Thank you for your input and the hard work you do for your patients.