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ZLW DO's avatar

I don’t claim to be an EKG expert, but this EKG is pretty clearly abnormal and warrants at the very least a repeat EKG or comparison with previous. additionally, even in 2011, a single troponin of the low sensitive variety would not have been standard of care for discharge from the ED.

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Ethan Ross's avatar

Gotta say, even in 2011 this reads as a miss. I finished EM residency in 2011 and at that time a single troponin in someone with chest pain after “2-3 hours” would not have been standard of care. It was pretty well accepted at that time that it takes at least 3-5 hours for a troponin to be detectable on laboratory evaluation after the onset of pain. Additionally, while a troponin value of 0.06 was within the reference range, unless you had a baseline troponin (in the 2011 era) most people considered that value a gray zone. All of this is to say a second troponin would have been standard of care in this case. A single troponin was being done in a performative manner as a way to quickly discharge the patient and not actually to evaluate chest pain. That is the miss.

There are many aspects of this case that read as a miss but I want to echo that this EKG was simply misread. It is not normal in any way. There are easily seen depressions in V4-6 as well as lead I (admittedly a bad baseline but still the ST segment is not normal). Unless there is a baseline EKG for reference that show those changes as baseline you either need to repeat the EKG to confirm those morphologies or assume those are new findings.

For me reading this case, it appears the physician thought this was BS chest pain and in turn did a BS work up just to assuage the patient of his assumption. We all do this from time to time and this physician lost that gamble this time. Even in 2011 this was a miss

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