Outpatient or Inpatient

[Melclin]

I got a job the other day that frustrated me a little and I was wondering what you all thought.

Called to a 85yrs male at home for a "confirmed MI, troponin 60" which had me scratching my noodle (hell of a hypochondriac to have his own iSTAT).

Anyway it turns out that this chap had some dizziness and an episode of syncope the previous day, been to his GP about it the following morning, the GP ordered troponin, echo and a halter monitor, but curiously no ECG. The pt then gets a phone call around 9pm from the GP saying the troponin has come back elevated and to call an ambulance, he's having a heart attack.

He was totally asymptomatic O/E. Apart from the syncope the previous day he was in remarkable health. He had that very morning walked 10kms.

Exam was unremarkable other than the ECG that showed q-waves in leads II & III.

The larger cath lab hospital in the area didn't want him and said they'd be happy for a smaller hospital (no cath lab, no cardiology, CCU) to take him unless I thought otherwise having examined him. I felt he was fine and that the larger hospital's reasoning was that the MI had been and gone and assuming he was pretty much asymptomatic, a quick look over in a small ED with an outpatient cardiology referral if anything was the go. I agreed with that reasoning and took him to the smaller hospital.

The smaller hospital then refused to take him on the basis that they didn't have a cardiologist available and no CCU beds. So we had to take him back to the larger hospital who were not impressed.

So what do you reckon? Did he need inpatient care/assessment? If he did, was a CCU bed necessary? What do reckon was going on here?

 

[usalsfyre]

I got a job the other day that frustrated me a little and I was wondering what you all thought.

Called to a 85yrs male at home for a "confirmed MI, troponin 60" which had me scratching my noodle (hell of a hypochondriac to have his own iSTAT).

Anyway it turns out that this chap had some dizziness and an episode of syncope the previous day, been to his GP about it the following morning, the GP ordered troponin, echo and a halter monitor, but curiously no ECG. The pt then gets a phone call around 9pm from the GP saying the troponin has come back elevated and to call an ambulance, he's having a heart attack.

He was totally asymptomatic O/E. Apart from the syncope the previous day he was in remarkable health. He had that very morning walked 10kms.

Exam was unremarkable other than the ECG that showed q-waves in leads II & III.

The larger cath lab hospital in the area didn't want him and said they'd be happy for a smaller hospital (no cath lab, no cardiology, CCU) to take him unless I thought otherwise having examined him. I felt he was fine and that the larger hospital's reasoning was that the MI had been and gone and assuming he was pretty much asymptomatic, a quick look over in a small ED with an outpatient cardiology referral if anything was the go. I agreed with that reasoning and took him to the smaller hospital.

The smaller hospital then refused to take him on the basis that they didn't have a cardiologist available and no CCU beds. So we had to take him back to the larger hospital who were not impressed.

So what do you reckon? Did he need inpatient care/assessment? If he did, was a CCU bed necessary? What do reckon was going on here?

An ED visit with a cards consult, perhaps an inpatient stay with a stress test and/or echo in the morning just to really rule out the badness.

Most community facilities here wouldn't have accepted him either, although I don't see in his current condition where he would need much more than a tele bed. However, if the infarct should reoccur, then it's probably not a bad idea to be at the tertiary facility.

 

[firetender]

I don't get it

Your patient was under the care of a physician who was monitoring his condition. The alarm got tripped and the Doc called in for him to be brought to the hospital.

Why wasn't the guy just admitted as Rule Out MI to where the Doc has privileges? Jockeying the guy from one hospital to the other makes no sense in this case.

 

[Melclin]

Interesting Usal, I can see it both ways. If the larger ED didn't want him, I suppose its possible they didn't know the smaller ED wouldn't have cardiology. Seems unlikely though. Telemetry bed sounds right to me.

I wonder if they saw his age and said, well if he's stable lets just sit on it. I don't totally disagree with that logic.

Firetender,
GPs can't just wander into hospitals start treating people. Is that how it works in your part of the world? If a GP decides a person needs to go to hospital, then its the hospital doc, whoever they may be who sorts the pt out, not the GP.

Not everybody with MI symptoms, and indeed, not even everybody with confirmed MI get admitted. Why just the other day I saw a woman with a confirmed inferior infarct leave hospital before the crew that brought her in even finished their shift. She'd q'd out and was stable, so why not. I figured a similar idea with this chap.

 

[jwk]

Firetender,
GPs can't just wander into hospitals start treating people. Is that how it works in your part of the world? If a GP decides a person needs to go to hospital, then its the hospital doc, whoever they may be who sorts the pt out, not the GP.

They can't wander into "any" hospital, but most are going to have staff privileges at a close-by hospital.

The same physician who called the patient and told him to call EMS should also have specified what hospital he wanted the patient taken to AND called that hospital and let either the ER doc or hospitalist know that one of his patients was being brought in. Simply dumping it in the patient's and EMS' lap for them to deal with was inappropriate care on the part of the GP.

 

[abckidsmom]

I know things work a little differently in your corner of the world, but if it was my 85 yo grandfather, who's in good enough condition to walk 10K on the morning after his MI, I would want him to go to the larger hospital, with the cardiology onsite, if for nothing more than an eval.

I don't really like taking people to hospitals who have *almost* everything they need to deal with the problems, and I know how long it takes to get in for the cards followup upon d/c from some of the smaller places. Sometimes over a week!

 

[MrBrown]

Sounds like this should have been a GP arranged admission

Is 12 lead ECG only for Intensive Care in MAS?

 

[wandering_idiot]

If his GP was aware of a pre-existing condition (i.e. LVH) that would render a 12-lead useless, that may be why he nixed the EKG. Besides, ABGs are now the definitive outside of the pre-hospital setting (i.e. in the hospital).

Still, if he had Q-waves, you would have thought he would have wanted to see if they had expanded or not (if they were physiologic vs. pathologic), or just to get a base line at a minimum.

Maybe he forgot to; he's human, after all.

 

[Farmer2DO]

While I agree that a telemetry bed is all this gentleman likely needed in the short term, he had evidence of inferior wall tissue necrosis, had a positive trop (and not a "soft" rule in; a troponin of 60 is respectable!), is 85 years old, and had a syncopal episode the day before, which is not a benign event.

I think, given the presentation, a trip to the cath lab hospital is extremely appropriate. Admit him to telemetry, medicate him appropriately and schedule an angiogram for (later that day, the next morning etc).

He is not over the acute phase of his MI if his trop is 60, and the chance for badness happening to him at a hospital that can't cath him is significant, IMO.

I wasn't there, and I'm not second guessing your judgement. I do think it was inappropriate for the large hospital to divert him without contacting the smaller hospital. "Do you have an appropriate bed and staff to manage this patient?"

In my system, 85 year olds with a symptomatic event, very positive trop, and EKG evidence of damage get admitted and go to the cath lab within 8 hours.

 

[the_negro_puppy]

So why did you call the larger hospital? was it a heads up/courtesy call due to the elevated troponin?

I would have just taken the pt to the larger hospital ED. They cant refuse a patient unless they are on bypass and it is clearly the most suitable place. I would have done a 12 lead (like you did) to rule out a STEMI and just rolled code 2 to the larger ED. Sounds like he has had a non-STEMI. Given the hx, time of onset and pt appearing asymptomatic, it ssafe to assume nothing big was going to happen in the immediate short term.

Hospitals annoy the hell out of me when they try to bounce patients around, if the hospital is open for business, can manage the pt's condition (and any forseeable complications) is close to the pt's home etc then its the place they go.

 

[Melclin]

They can't wander into "any" hospital, but most are going to have staff privileges at a close-by hospital.

The same physician who called the patient and told him to call EMS should also have specified what hospital he wanted the patient taken to AND called that hospital and let either the ER doc or hospitalist know that one of his patients was being brought in. Simply dumping it in the patient's and EMS' lap for them to deal with was inappropriate care on the part of the GP.

Doesn't really work that way here. GPs don't work in hospitals, unless its a rural type of deal. We take pts from GP clinics everyday with no prior arrangement from the docs, the secretary just rings 000 and we turn up and take a handover from the GP and sometimes a letter to the ED doc.

Sounds like this should have been a GP arranged admission

Is 12 lead ECG only for Intensive Care in MAS?

GPs don't often do direct admissions for that sort of thing unless its for private pts.

Yep, very frustrating.

While I agree that a telemetry bed is all this gentleman likely needed in the short term, he had evidence of inferior wall tissue necrosis, had a positive trop (and not a "soft" rule in; a troponin of 60 is respectable!), is 85 years old, and had a syncopal episode the day before, which is not a benign event.

I think, given the presentation, a trip to the cath lab hospital is extremely appropriate. Admit him to telemetry, medicate him appropriately and schedule an angiogram for (later that day, the next morning etc).

He is not over the acute phase of his MI if his trop is 60, and the chance for badness happening to him at a hospital that can't cath him is significant, IMO.

I wasn't there, and I'm not second guessing your judgement. I do think it was inappropriate for the large hospital to divert him without contacting the smaller hospital. "Do you have an appropriate bed and staff to manage this patient?"

In my system, 85 year olds with a symptomatic event, very positive trop, and EKG evidence of damage get admitted and go to the cath lab within 8 hours.

Negrogpuppy: I didn't actually ring them. They paged me telling me they were happy for him to go to the smaller hospital from what they'd heard. I'm not exactly sure how they found out. Either the pts doctor rang them or our clinician contacted them, I suppose, but the page was the first I'd heard of it even after talking with the pt's doctor. We didn't even discuss destination hospitals because I assumed we'd go to the larger cath hospital until I got the page and that changed things a bit.

Very interesting. Well, lesson learned. Thanks guys. One wonders if there were less than honourable motives behind the larger hospital trying to get rid of him.

 

[jwk]

Doesn't really work that way here. GPs don't work in hospitals, unless its a rural type of deal. We take pts from GP clinics everyday with no prior arrangement from the docs, the secretary just rings 000 and we turn up and take a handover from the GP and sometimes a letter to the ED doc.

GPs don't often do direct admissions for that sort of thing unless its for private pts.

Oops, sorry, didn't realize you were in a whole different hemisphere.

 

[silver]

should have gone to telemetry unit. Cardiac cath would probably be done in the next couple of days, if was asymptomatic as you said.

 

[Farmer2DO]

Why wasn't the guy just admitted as Rule Out MI

Because he's not a rule out MI, he's already ruled IN as an MI.

should have gone to telemetry unit. Cardiac cath would probably be done in the next couple of days, if was asymptomatic as you said.

He's NOT asymptomatic, though. An 85 year old with a rule IN for an MI had an episode of syncope in the last 24 hours. That IS badness. The differential diagnosis for an internal medicine physician starts with the most likely cause and progresses to the least likely. The emergency medicine physician starts their differential with the cause that will kill the patient first and goes to the least dangerous. (This is also the model for EMS.) This may turn the list of likely suspects on it's head. The MOST dangerous (and probably fairly likely, given the scenario) cause of this guy's syncope was a self terminating dysrrhythmia. That makes him a fairly high risk patient, until proven otherwise.

 

[mycrofft]

Asymptopmatic elderly male with elevated cardiac troponin

Reasons for this besides acute MI:
"...myocarditis, cardiomyopathy, congestive heart failure, sepsis, pulmonary embolism, rhabdomyolysis, chest contusion following a motor vehicle accident, coronary emboli caused by endocarditis, mural thrombi, prosthetic valves, neoplasms, inflammatory processes, including viral infections such as with coxsackie B, radiation-induced coronary stenosis; congenital abnormalities in a coronary artery, Hurler's syndrome, homocystinuria, rheumatoid arthritis, and systemic lupus erythematosus. In addition, elevated levels have been observed in marathon runners and cocaine abusers" (http://www.medscape.com/viewarticle/444137; Khan et al quoted by respondent Dr David M. Quillen). You probably hit the answer when you remembered the lady who left the hospital after the inferior MI, nothing to be done at this point.

 

[mycrofft]

Sorry, "asymptomatic for acute MI in progress".

:blush: