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.
I think the repeat EKG is definitely the play here. There's enough artifact between the wandering baseline and the beat-to-beat variation in morphology in some leads that it would have left me both worried and a bit baffled.
Disclaimer: EKGs are not my strength. However, it wouldn't have cost anything but time to wait for a second troponin for trending. I would have felt more comfortable discharging after a second troponin since MIs in women tend to be atypical. She is fairly young and not long menopausal. This case had a lot of red herrings for distraction.
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
I think you really hit the nail on the head with the troponin being "performative" and the doc thinking it was BS chest pain. We see so much BS chest pain that if you get mentally lazy you can start to miss things. I will sometimes document that chest pain has been going on for X number of hours so only one troponin is needed, but this case is a reminder not to flirt with those time cut offs, especially if you have the old style troponins.
I really don't understand the defence witness' claim that "there is no appreciable or significant ST depression". It looks to me like there is clearly ST depression in V4-6 and aVF at least.
Agree. I think the defense expert was being pretty dishonest. I see a lot of bad plaintiff expert opinions but this is a great example of bad behavior on the defense side.
That EKG is not normal AT ALL. There are clear but small ST elevations in V1 and aVR, and ST depressions in several leads including V5, V6, aVF, and maybe even I. aVL also looks sketchy though could, in isolation, be judged as motion artifact. It doesn't meet criteria for STEMI but it definitely warrants cardiology consultation, admission, further workup, and maybe even heparinization. All the mental masturbation from the defense expert witness is just trying to obfuscate the underlying issue which is that EKG was clearly abnormal and highly concerning in context of chest pain. The toradol could have made things even worse.
The other thing I forgot to mention, is if I was going to try to defend this guy (I wouldnt, but for the sake of argument), I'd try to highlight that the patient coded in the morning and she wouldn't have been cathed by then. You'd try to beat the plaintiff on the argument that the outcome would have been the same in the end no matter what, NOT that it wasnt a miss in the first place. Its also not a good argument but would be more honest than trying to say nothing got missed.
Totally agree. My eye caught the V4-V6 ST depressions very quickly. The elevations in aVR are interesting, they're definitely there in the 1st, 3rd, 4th beats, but the 2nd beat looks isoelectric to me. This is one of those EKGs that if you scan it in <5s you will miss subtle findings.
While I agree there was no obvious stemi, it was an abnormal EKG with depressions in the lateral leads, mild elevation in aVR, and significant motion artifact making inferior leads difficult to interpret. At the very least, there should have been a repeat EKG and repeat troponin. I also find it odd their defense is that patient should have disclosed her risk factors? How many times you ask patients for their medical conditions and they say nothing only to find out they are on multiple medications? When trying to establish chest pain risk, asking specifically for the major risk factors should be a part of the HPI. I also find it disingenuous to say it wasn't typical chest pain, when it's an older female with chest pain radiating to the neck, who seemed distressed on arrival and hypoxic to 90%. Reading the initial story made it clear from the get go that this was a higher risk patient with a concerning story and a questionable EKG. It would be a lot easier to defend had the Dr done the bare minimum of repeating EKG, repeating troponin, and recommend or schedule outpatient stress test.
"Objective signs of sunburn" don't cause pain radiating to the jaw, low sats, high RR and abnl EKG. A man with the same presentation would have been admitted.
My main quibble is I would have gotten a second troponin on this patient, especially since the initial one was detectable, even if it was normal.
That AI must be looking at things I don’t even know about because that EKG doesn’t really scream acute ischemia to me.
My personal practice is to discharge most chest pain pts with negative trops unless the EKG or the story are very concerning. Don’t have HS trop where I work.
Thats part of the reason I really am excited to see what this AI algorithm can do in clinical practice, I think its pretty good at picking up the subtle ischemia findings. They're there if you look for them, but the AI is really great at teasing them out.
I'm impressed, it caught an EKG that I wasn't suspicious about at all. So far pt has NSTEMI but we'll see what the cath report shows, initial trop was 0.25 and then ended up going all the way up to 6. I sent you a message on Facebook because I can't attach pictures here.
Wandering baselines make interpretation difficult but there is a hint of inferior injury (or at least ischemia), and the ST depression in V4-6 jumped out. Also, poor R progression across V1-3 is worrisome. The presentation of neck and chest pain in a 58 year old female would have warranted, in order, admission with referral to interventional cardiology, and activating the catheter lab, repeating the EKG while waiting for the cardiology fellow to call and complain, repeating the troponin and CK-MB. I’m pretty conservative in treatment of a woman of this age with almost any presentation including chest pain and even just an “odd” EKG.
There is enough with the ECG and the history here to prove negligence. If you have CP and any kind of ST change, especially with the reciprocal depression here, it has to be admitted
that’s an abnormal EKG. Most of us neglect elevations in AVR. Anyone that has attended Dr. Mattu's course remembers his slide with Rodney Dangerfield saying “I get no respect”. AVR is Rodney Dangerfield. AVR elevations plus elevations in either V1 or AVL should result in some concern. Regardless of those leads, this EKG had ST depressions elsewhere. I get not sending them straight to cath, but this patient is not being discharged to home from the ER, regardless of troponin.
Yep, aVR has gotten a ton more attention the last 5-10 years. I think the play here was to wait for a second troponin, do at least one more EKG, then call cardiology. I think the doc had already mentally decided it was a sunburn and was just doing a trop/EKG to "prove" it wasnt cardiac, which really extraordinarily back fired on him. The EKG and troponin fell into the gray zone of "worrisome but not absolutely diagnostic". If either had been diagnostic (STEMI or trop above normal range), she likely would have been admitted. The question is if she would have survived to cath or not. Might have coded in the hospital prior to cath, who knows.
EKG demonstrates ST depressions inferiorly and laterally. Pretty classic for an RCA lesion. Age, smoker, hyperlipidemia in a woman, with atypical presentations being “common”. It would be interesting to see the records that were available but not reviewed by the physician. A clear miss, bad outcome, and preventable. As an expert witness, this is one that I would not be a witness for the defense— I always tell the truth. As a plaintiffs witness, I would encourage them to take it to a jury trial, with the expectation that the big checkbook would roll out either immediately before trial or in the first day or two. Also curious as to the physician’s training, experience, and entire history. Unfortunately, I’ve seen too many cases mishandled by physicians who lacked the training and experience to be working in the environment they were in.
I'm not saying this to throw any training regimen under the bus but apparently was a surgeon in Europe, then came to the US and is board certified through American Board of Family Medicine.
Thanks for the input. As expected. This would factor in heavily both on the expert testimony, and the cross of the defendant, if they chose to testify. The deposition would factor in heavily. Depending on how the deposition went, defense may just get their checkbook out then. Seen it happen.
I hope I would have ordered the 2nd EKG c R sided leads, based on aVR and V1 questionable elevations and the inf lat ischemia. Having just become an EMT, the mixed reports on their performance is interesting. Were the plaintiffs worried about a possible "empty chair" defense?
I'm not sure what the thinking was about the EMTs, it appears the main criticism was that the family didn't think they did things fast enough. Its not clear to me if that was a valid criticism or not. Unfortunately the lawsuit just hinted at it and didn't go into details, and they got dismissed before there was any additional info given in the court records.
Tricky case, shows unfortunately how fickle chest pain can be. By the way, this is a tangent, but in previous cases you have commented that settlements/rulings vary by state, as some states have a measure of 'below standard of care' while others have a more generous 'gross negligence' standard, and that it's easier to win cases in the former category. Do you happen to have a list of how this varies state-by-state? Would be useful info to read about.
I don't have a list, but off the top of my head both Texas and Georgia have gross negligence at least for cases that are truly emergencies (but not necessarily for all med mal). Some states have some level of disclosure about settlement amounts but it varies widely. I believe if the US government is sued (VA care for example) that settlements are often public info. But overall its a minority that we ever know the settlement amount.
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.
I think the repeat EKG is definitely the play here. There's enough artifact between the wandering baseline and the beat-to-beat variation in morphology in some leads that it would have left me both worried and a bit baffled.
Disclaimer: EKGs are not my strength. However, it wouldn't have cost anything but time to wait for a second troponin for trending. I would have felt more comfortable discharging after a second troponin since MIs in women tend to be atypical. She is fairly young and not long menopausal. This case had a lot of red herrings for distraction.
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
I think you really hit the nail on the head with the troponin being "performative" and the doc thinking it was BS chest pain. We see so much BS chest pain that if you get mentally lazy you can start to miss things. I will sometimes document that chest pain has been going on for X number of hours so only one troponin is needed, but this case is a reminder not to flirt with those time cut offs, especially if you have the old style troponins.
As a long retired boarded ER doc my concern is the neck and jaw pain in a woman.
I really don't understand the defence witness' claim that "there is no appreciable or significant ST depression". It looks to me like there is clearly ST depression in V4-6 and aVF at least.
Agree. I think the defense expert was being pretty dishonest. I see a lot of bad plaintiff expert opinions but this is a great example of bad behavior on the defense side.
That EKG is not normal AT ALL. There are clear but small ST elevations in V1 and aVR, and ST depressions in several leads including V5, V6, aVF, and maybe even I. aVL also looks sketchy though could, in isolation, be judged as motion artifact. It doesn't meet criteria for STEMI but it definitely warrants cardiology consultation, admission, further workup, and maybe even heparinization. All the mental masturbation from the defense expert witness is just trying to obfuscate the underlying issue which is that EKG was clearly abnormal and highly concerning in context of chest pain. The toradol could have made things even worse.
The other thing I forgot to mention, is if I was going to try to defend this guy (I wouldnt, but for the sake of argument), I'd try to highlight that the patient coded in the morning and she wouldn't have been cathed by then. You'd try to beat the plaintiff on the argument that the outcome would have been the same in the end no matter what, NOT that it wasnt a miss in the first place. Its also not a good argument but would be more honest than trying to say nothing got missed.
Totally agree. My eye caught the V4-V6 ST depressions very quickly. The elevations in aVR are interesting, they're definitely there in the 1st, 3rd, 4th beats, but the 2nd beat looks isoelectric to me. This is one of those EKGs that if you scan it in <5s you will miss subtle findings.
I agree with Jason.
While I agree there was no obvious stemi, it was an abnormal EKG with depressions in the lateral leads, mild elevation in aVR, and significant motion artifact making inferior leads difficult to interpret. At the very least, there should have been a repeat EKG and repeat troponin. I also find it odd their defense is that patient should have disclosed her risk factors? How many times you ask patients for their medical conditions and they say nothing only to find out they are on multiple medications? When trying to establish chest pain risk, asking specifically for the major risk factors should be a part of the HPI. I also find it disingenuous to say it wasn't typical chest pain, when it's an older female with chest pain radiating to the neck, who seemed distressed on arrival and hypoxic to 90%. Reading the initial story made it clear from the get go that this was a higher risk patient with a concerning story and a questionable EKG. It would be a lot easier to defend had the Dr done the bare minimum of repeating EKG, repeating troponin, and recommend or schedule outpatient stress test.
Agreed
"Objective signs of sunburn" don't cause pain radiating to the jaw, low sats, high RR and abnl EKG. A man with the same presentation would have been admitted.
Ekg with inferior and lateral depression. And a Smoker. This was an admission even back in 2011.
My main quibble is I would have gotten a second troponin on this patient, especially since the initial one was detectable, even if it was normal.
That AI must be looking at things I don’t even know about because that EKG doesn’t really scream acute ischemia to me.
My personal practice is to discharge most chest pain pts with negative trops unless the EKG or the story are very concerning. Don’t have HS trop where I work.
Thats part of the reason I really am excited to see what this AI algorithm can do in clinical practice, I think its pretty good at picking up the subtle ischemia findings. They're there if you look for them, but the AI is really great at teasing them out.
Just got it. Looking forward to using! I doubt that’ll it’ll convince any cardiologists but would definitely make me admit the pt
Awesome! Let me know what you think... its not 100% perfect, but I think its really quite good
I'm impressed, it caught an EKG that I wasn't suspicious about at all. So far pt has NSTEMI but we'll see what the cath report shows, initial trop was 0.25 and then ended up going all the way up to 6. I sent you a message on Facebook because I can't attach pictures here.
Do let us know what the cath showed!
Multivessel disease, was urgently referred for CABG
Wandering baselines make interpretation difficult but there is a hint of inferior injury (or at least ischemia), and the ST depression in V4-6 jumped out. Also, poor R progression across V1-3 is worrisome. The presentation of neck and chest pain in a 58 year old female would have warranted, in order, admission with referral to interventional cardiology, and activating the catheter lab, repeating the EKG while waiting for the cardiology fellow to call and complain, repeating the troponin and CK-MB. I’m pretty conservative in treatment of a woman of this age with almost any presentation including chest pain and even just an “odd” EKG.
There is enough with the ECG and the history here to prove negligence. If you have CP and any kind of ST change, especially with the reciprocal depression here, it has to be admitted
lateral ST depression mandates further evaluation IMHO.
that’s an abnormal EKG. Most of us neglect elevations in AVR. Anyone that has attended Dr. Mattu's course remembers his slide with Rodney Dangerfield saying “I get no respect”. AVR is Rodney Dangerfield. AVR elevations plus elevations in either V1 or AVL should result in some concern. Regardless of those leads, this EKG had ST depressions elsewhere. I get not sending them straight to cath, but this patient is not being discharged to home from the ER, regardless of troponin.
Yep, aVR has gotten a ton more attention the last 5-10 years. I think the play here was to wait for a second troponin, do at least one more EKG, then call cardiology. I think the doc had already mentally decided it was a sunburn and was just doing a trop/EKG to "prove" it wasnt cardiac, which really extraordinarily back fired on him. The EKG and troponin fell into the gray zone of "worrisome but not absolutely diagnostic". If either had been diagnostic (STEMI or trop above normal range), she likely would have been admitted. The question is if she would have survived to cath or not. Might have coded in the hospital prior to cath, who knows.
EKG demonstrates ST depressions inferiorly and laterally. Pretty classic for an RCA lesion. Age, smoker, hyperlipidemia in a woman, with atypical presentations being “common”. It would be interesting to see the records that were available but not reviewed by the physician. A clear miss, bad outcome, and preventable. As an expert witness, this is one that I would not be a witness for the defense— I always tell the truth. As a plaintiffs witness, I would encourage them to take it to a jury trial, with the expectation that the big checkbook would roll out either immediately before trial or in the first day or two. Also curious as to the physician’s training, experience, and entire history. Unfortunately, I’ve seen too many cases mishandled by physicians who lacked the training and experience to be working in the environment they were in.
I'm not saying this to throw any training regimen under the bus but apparently was a surgeon in Europe, then came to the US and is board certified through American Board of Family Medicine.
ABFM :O
Thanks for the input. As expected. This would factor in heavily both on the expert testimony, and the cross of the defendant, if they chose to testify. The deposition would factor in heavily. Depending on how the deposition went, defense may just get their checkbook out then. Seen it happen.
I hope I would have ordered the 2nd EKG c R sided leads, based on aVR and V1 questionable elevations and the inf lat ischemia. Having just become an EMT, the mixed reports on their performance is interesting. Were the plaintiffs worried about a possible "empty chair" defense?
I'm not sure what the thinking was about the EMTs, it appears the main criticism was that the family didn't think they did things fast enough. Its not clear to me if that was a valid criticism or not. Unfortunately the lawsuit just hinted at it and didn't go into details, and they got dismissed before there was any additional info given in the court records.
Thank you
Tricky case, shows unfortunately how fickle chest pain can be. By the way, this is a tangent, but in previous cases you have commented that settlements/rulings vary by state, as some states have a measure of 'below standard of care' while others have a more generous 'gross negligence' standard, and that it's easier to win cases in the former category. Do you happen to have a list of how this varies state-by-state? Would be useful info to read about.
I don't have a list, but off the top of my head both Texas and Georgia have gross negligence at least for cases that are truly emergencies (but not necessarily for all med mal). Some states have some level of disclosure about settlement amounts but it varies widely. I believe if the US government is sued (VA care for example) that settlements are often public info. But overall its a minority that we ever know the settlement amount.