All I need is some Rolaids!

     Many times in the emergency room I have nurses that "think" they know what is wrong with a patient. Too often I hear comments like, "why don't you just discharge them (the patient), they were just here yesterday with the same complaint!" I look at these patients with the approach, "what did they miss yesterday?"  Some times their "thinking" is correct, unfortunately many times it is not. As the provider, I can not afford to "think", I have to "prove" my diagnosis. If I miss a life threatening or debilitating injury it is my fault. If the nurse "thinks" wrong, it really does not matter because the ultimate responsibility is mine. I make this statement as preface to a case study. This case had a positive outcome, but hopefully you will see how it could have been a disaster.

     The patient is a 67 yo caucasian male that presents ambulatory to the ER accompanied by his wife. They had eaten at a local restaurant about 40 minutes prior to coming to the ER. About 15 minutes after eating the patient developed "heartburn" and belched a few times. He denies any chest pain (other than his
"heartburn"), shortness of breath, sweating, nausea, diarrhea or other complaint. He has had no recent fever, chills, cough, or other symptoms of illness. He reports having "frequent indigestion". He advises that he only came to the ER because so his wife would leave him alone, he has Tums at home.

     He had a complete physical exam 6 weeks ago that included labs, EKG, and hemocult (all results were with in normal limits and there were no EKG changes). He takes a multivitamin, fish oil, and a baby aspirin daily. He is an only child, father died at 93 from "natural causes" and mother died at 88 from complications of a hip fracture repair.

     General appearance: CAOX4, NAD, speaking in clear complete sentences, ambulatory with out assistance.
     Initial vital signs were: BP 132/80, HR 72, RR 18, SaO2 98% on RA
     Lungs: BBS clear and equal with adequate air exchange
     Cardiac: S1, S2 RRR, no murmurs, rubs, gallops, or extra heart sounds
     Extremities: No edema

     After my initial assessment, I ordered EKG, portable chest X-ray, CBC, CMP, Troponin, 3-81mg ASA chewed, and an INT.

     Pertinent labs: WBC 13.1, Troponin I 0.00, electrolytes WNL   

     The EKG showed:

    

     The patient was having an inferior MI (STEMI). Marked ST elevation in Lead II, III, and AVF.

     While he was in out ER, he received IV morphine for pain control (nitroglycerin use in inferior MIs has a tendency to cause marked HYPOTENSION), 5000 unit heparin IV bolus followed by a heparin drip (all dosages were weight based per the hospital heparin protocol), and after consultation with the receiving cardiologist TNKase. He was transferred emergently to a tertiary facility where he underwent cardiac catherization. The cath revealed a 100% occlusion of his right coronary artery. He received angioplasty and stenting which resulted in total re-profusion.

     This is an example of why we treat everyone like they have the worst case scenario, then do everything we can to prove they really did just need "Rolaids".