#1. TRUST your team members
#2. Document your ass off.
Let me explain.
Last night, I was working EMS and we ran a call for chest pains. Guy had all of the risk factors for coronary artery disease-obese, high cholesterol, smoker, hypertensive as hell-you name it. He said his pain started suddenly, while laying down and that it felt like ‘something was sitting on his chest’(this statement btw should ALWAYS raise your suspicions). It took us quite some time to get him to the ambulance because he was very anxious about finding his shoes, socks, keys…Fire department had done a 12 lead but it was unreadable due to artifact.
Once in the truck, we repeated the EKG and boom. ST segment elevation of 1mm and greater in the anterior-septal leads WITH reciprocal depression in inferior leads. The monitor interpretation did NOT scream STEMI and they looked like very early, almost…difficult to distinguish, changes to me. All the same, I felt really uncomfortable about the EKG and decided to work it as a STEMI. Aspirin, Nitro, IV lines, lights and sirens to the ER.
(It should be noted that we transmit our EKGs so hypothetically, someone at the ER looked at it already). I’ve kind of…given up on the formal ‘STEMI alert’ phone call because frankly the ER always waits to call it until they look at their own EKG anyway(again. TRUST YOUR TEAM. but thats a whole other issue), however I did speak very pointedly with the charge nurse that there was 1mm elevation in the septal leads. She kind of ‘ehhh. okay. lets put him in *insert room very far away from the trauma rooms, nurses station, everything* when you get here.
Upon arrival, he was put in his room, and this time I went up to his personal nurse who kind of half ass glanced at the 12 lead and shrugged it off. I also went to the ER doctor and pointed out the changes I saw. She too, went ‘ehhh’ and proceeded to ask the patient if he had experienced any emotional upset before developing the pain. It was 100% clear that they were looking at the patient, who was very anxious, at face value and completely disregarding the clinical assessment and intuition of the providers who had spent the past 20 minutes with him.
Today, I was called up to the office, where our director told me that the patient DID have a heart attack after all-and that it took the ER about 45 minutes to actually CALL a STEMI alert and activate the cath lab. Thankfully, the patient was going to be just fine however the delay could very well have been fatal. The hospital was now trying to deflect blame from themselves and put the blame on us for our extended scene time.
(What should have happened is that the moment I called, someone should have interpreted that EKG and a trauma room should have been cleared. A cardiologist should have been paged to evaluate, and the patient SHOULD have only spent minutes in the ER before going to the cath lab. Then the patient would have easily been within the 90 minute window…but I digress)
Here is where Lesson 2 comes in-I documented the every living daylights out of the call. I documented that we tried to get him to leave the house sooner but that he was insistent on finding his shoes and keys first. I documented that we gave him a lower dose of aspirin BECAUSE he had already taken some at home. I documented with names EVERY SINGLE TIME, ER staff was informed that he had ST changes. As a result of our documentation, my agency(and my license) were in the clear. The blame was very much on them.
Now, I understand that the ER is very busy. I understand that as a nurse, you may have multiple very sick patients(in fact, they were all super concerned about a patient with a grossly dislocated shoulder that had just come in). I understand that the grand majority of your cases are horses-not zebras and that it takes a while to get things done.
However(and this applies to everyone-nurses to EMS, physicians to nurses, ect)-you HAVE to trust the judgement and education of your team members. Its the team mentality that picks up the slack where you otherwise get overwhelmed and catch things like little early ST changes that you might otherwise miss.