Intern Report Collection, Vol. 4

For your Friday afternoon, here’s another batch of excellent write-ups from the EM interns at UT Southwestern. Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

[Note: These are PDF files.]

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Not just S1Q3T3: Look at the other 10 leads!

It was a slow morning in the ED, so I was able to catch the medic as she came in with the patient. “Hey Leigh, what do you have for us? Got an interesting ECG?”

“Well, maybe,” she replied as she wheeled by with a comfortable looking middle-aged male, “here, take a look at it while I give report to the nurse.” She handed me the 12-lead:


After leaving the patient with the RN, Leigh came back. “This is a guy with a history of CHF, with an AICD placement. He’s had shortness of breath for 4 days, worse when he walks. He passed out today when he was walking, so his family called us. He looked fine when we got to him, just needed 2 liters of O2 to keep him at 98%. No chest pain.”

“Yeah,” I said, “he certainly looked fine when you rolled past. Okay, so probably just a CHF admission. I’ll go see him right now.”

“Yeah, it’s probably just his CHF,” she continued, “but I expected worse. His lungs sound just fine, totally clear. Plus, he says it doesn’t get worse when he lays flat. Seems funny for CHF… Plus, I didn’t like my ECG – did you notice the S1Q3T3?”

“Well, I pulled his old ECG, just done a few weeks ago in fact, and I see it looks like there’s a S1Q3T3 too. So, probably doesn’t mean much.” I showed her the ECG I had dug up:

“Okay, Dr Walsh, maybe the S1Q3T3 is old, but I still see…” She paused, and appeared to be looking for a diplomatic way to phrase her thoughts. “How about using the ultrasound, checking to see if there’s any CHF?”

“Good idea Leigh! I’ll go show you how we do those, especially since some EMS systems are using this these days.”

After introducing myself to the patient, gathering a history, and finding that the lungs were, indeed, completely clear, I wheeled over the ultrasound. A quick check of the lungs confirmed that there was no edema in the lungs. I then took a look at the heart. (The image quality is not great, I realize.)

Just so you know what is what:

Legend for Dil RV clip-1

I then turned to Leigh and asked her “What else did you see on your ECG that you were too polite to point out to me?”

What is the infarct artery? (Complex analysis, in this case)

This case was put on Twitter by Elisha Targonsky, who has a nice EM blog (  He provided it for posting here.  On Twitter, he asked for an analysis of the infarct artery.

Analysis of the infarct artery is mostly an academic exercise.  The patient clearly needs cath lab activation.  However, it is of some clinical value: interventionalists like to know what artery is affected because it often determines which artery they will investigate first with angiography.

So it does have some value, but is not critical.

But moreover, it is an exercise which helps one understand all the ST vectors at play in an ECG.
What is your analysis?  See mine below.

Notice this is a 15 lead ECG, with posterior leads V8 and V9 and also Right sided lead V4R.

Here was my Twitter response without any other information:
Tweet 1: Prox large RCA, also to lateral and posterior walls. Ant MI is RV, not LV. V2 less STE b/o posterior MI.
Tweet 2: In other words: pseudo anterior MI (RV: V1-V4) from large RCA, to post & lat also. V2 STE attenuated by post

One must explain several findings:
1. Inferior ST elevation
2. Anterior ST elevation (V1 and V3), but very little in V2
3. ST elevation in V4-V6 (but also ST depression in aVL)
4. Posterior ST elevation
5. ST elevation in V4R

--One is tempted to call this LAD occlusion with anterior MI and wraparound LAD to the inferior wall.  But then how do you get a posterior STEMI also?

--One might say: OK, it is left main, and that is why there is BOTH anterior (LAD) and Posterior (Circ) STEMI.

Why the inferior STE?  Maybe it is a left dominant system, so the circ also goes to the inferior wall.

But then one must still explain 2 findings: the patient is still alive AND there is ST elevation in V4R.

ST elevation in V4R can conceivably be caused by LAD occlusion, as some individuals have the RV supplied by rightward branches of the LAD.  This is a possibility, but you would expect such a patient to be in shock.

What was the clinical scenario?

A middle-aged male with h/o CAD, HTN, DM, hyperlipidemia.
Previous LAD stent, then 2 years later had bare metal stent to RCA.
Presented without shock, with 10/10 substernal CP.  Diaphoretic and nauseated.

--So left main is very unlikely.

--What then?   The ST elevation in V4R is the big clue.  This is almost always due to Right Ventricular MI.  RV MI also may cause anterior ST elevation mimicking anterior MI ("Pseudoanteroseptal MI").  In these cases, the maximum ST elevation is in V1 or V2, and becomes less as one goes out to V3, V4, etc.

So the IRA is the RCA.

--What does this RCA supply besides the RV?  It supplies the inferior wall, the posterior wall, the inferolateral wall (STE in V4-V6 without high lateral STE in aVL)

--Why is there less STE in V2 than in V1 or V3?
1. The posterior ST elevation is exactly reciprocal to V2 and is attenuating the STE in V2.
2. That downward pull is not as opposite V3 as it is opposite to V2.
3. The RV ST elevation is greater in V1 than in V2
4. The lateral ST elevation has more "upward" pull on V3 than there is downward pull from posterior.

--Why is there ST depression in aVL but ST elevation in precordial lateral leads V5 and V6?
V5 and V6 are situated more inferior than aVL.  Many inferior MI have ST elevation in V5 and V6.  And all inferior STEMI have ST depression in aVL.  In our series of 150 inferior STEMI, 27 had ST elevation in V5 and V6.  All had ST depression in aVL.

What direction is the ST vector?
There is diffuse ST elevation, except towards leads I, aVL and V2:
To the right
Left inferolateral
Left anterior
Right anterior

Angiography Results:

No disease in LAD or circ
RCA dominant with acute thrombosis
Thrombectomy and stent.

Good outcome.

Dr Eddy Lang: Making the Most of Chart Reviews

Screen Shot 2014-11-13 at 10.41.42 PM



A few months back Dr Eddy Lang [Co-editor of the Royal College Research Guide [link]] graced us with his kind and friendly personality and dropped some pearls on retrospective chart reviews.

Medical Record Review [MRR] Research in General

“Chart reviews don’t get  the respect they may deserve” Dr Lang

Dr Lang lamented the fact that MRR doesn’t get the street cred it deserves. This is large part because of a historical pattern of:

  • Wrong questions
  • Poor methods
  • Action/Documentation Divide = what happened vs what was documented
  • Missing Data
  • Case identification

Gilbert and others. 1996. Chart Reviews in Emergency Medicine [Pubmed link] showed that 25% of EM publications between 1988-1995 relied on chart reviews. However, although inclusion citeria were present 98% of the time, important data regarding methodology was generally absent:

  • abstractor training, 18% (95% CI, 13% to 23%)
  • standardized abstraction forms, 11% (95% CI, 7% to 15%)
  • periodic abstractor monitoring, 4% (95% CI, 2% to 7%)
  • abstractor blinding to study hypotheses, 3% (95% CI, 1% to 6%)
  • Interrater reliability was mentioned in 5% (95% Cl, 3% to 9%) and tested statistically in 0.4%

In their article – Gilbert et. al. lay out their solutions

The 7 Key Ingredients of good MRR:

 1. Abstractor Training: Need to convince the reader that the people pulling the charts

  • Describe the Qualifications and Training procedure for the data Abstractors
  • before the study begins pull some Trial charts to Test the data abstraction process

2. Case Selection: Needs to be explicit and well described

  • Administrative codes is a start but has flaws
    • Often this can lead to a substudy [i.e do the ultimate codes reflect the Dx?]
  • Clear inclusion/exclusion criteria
  • Screening procedures must be solid

3. Definition of the variables: Need to be done well

  • Dictionary – define things e.g. vitals signs … at triage? by the EP? on reassessment?
  • Timing and Source of the info needs to be described
  • Adjudication – how are you going to categorise contradictions and inconsistencies?

4. Data Abstraction Tool: Make it good

  • need to have a standardised data abstraction tool – use your research staff here
  • need to have a uniform process of handling missing data  – need to think about what to do with missing or unclear data
  • Consider using software to manage data [e.g. Using Redcap Software [link]

5. Blinding:

  • Are the abstractors unaware of the study hypothesis? – consider quizzing them afterwards to see!

6. Quality Control

  • regular meetings to ensure standard process
  • need to monitor the abstractors work – consider audits
  • resolution of conflicting assessments

7. Inter-rater reliability: Report inter-rater reliability – it’s eKspected …get it?

  • reported on a sample of charts reviewed by another [blinded] reviewer

Eddy then introduced another landmark article by Jansen and others who created a guideline on how to conduct MRR – [Pubmed Link]

Criteria to Follow

Screen Shot 2014-11-13 at 11.44.07 PM

Dr Lang finished by giving us some examples of good MRR

Instructive Examples – MRR CAN change practice!

Answer questions that change local practice … e.g. Eddy’s 1995 Publication on the prognostic value of amylase in the evaluation of the abdominal pain patient. [Pubmed Link]

  • Pulled lab results
  • Showed that there was no difference between patients with intermediate levels of amylase and normal patients

Answer questions that change global practice e.g. Ross Baker et al Canadian Adverse Events Study [Pubmed Link]

  • Retrospective review of 3500 charts from 5 provinces in Canada
  • Sowed an AE rate of 7.5 % which translates into 70, 000 annual AE’s in Canadian hospitals
  • placed the spotlight on patient safety

Good MRR Questions

How are we doing? [care practices, quality of care e.g. Look at time to analgesia after intro of new acute pain protocol for say... renal colic]

What does this condition look like? [e.g looking for key word search "Rugby" ... pull charts associated with rugby injuries]

Derivations Models  [e.g. Risk Factors for Hospitalization after Dog Bite injury [Pubmed Link]]

Ethics of MMR?

  • Are there ways to bypass ethics? Yes! If it’s labeled as “more QI” may not require full ethics look and have “expedited review”
  •  Consider using the ARECCI Ethics Screening Tool [Link]

Last word on our guest speaker:

I have known Eddy for a few years, having collaborated on a couple of occasions putting on workshops at SAEM and CAEP. He is one of Canada’s best researchers, a solid ER doc, a great dad and family man and a true ambassador for Emergency Medicine. Thanks Eddy for letting me replay your words of wisdom.

My Ideas/Homework:

  1. Buy that Royal College Guide
  2. Start in on a Project:
    1. Renal Colic after new pain protocol – time to analgesia
    2. Time to EKG after New Protocol
    3. Reduction in Flex/Ex Ordering after journal club on C spine
    4. Reduction in Time in ER after New HS Trop
    5. Change in medication use in migraine after Journal Club
    6. Management of abscesses [packing vs loops] after our Journal CLub



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It’s a Patient Hand-Off Miracle

Transitions of care – more frequent now in medicine than ever before – are fertile opportunities for error and miscommunication.  Most institutions have developed, at least, informal protocols to exchange patient information during hand-off.  But, certainly, everyone has some anecdotal tale of missed information leading to a near-miss or actual patient harms.

This study tells the story of I-PASS, a handoff bundle implemented and measured as an error prevention strategy by a pre- and post-intervention study design.  Across 9 pediatric residency training programs, residents were observed for six months for time spent in hand-offs, time spent in patient care, and a variety of classifications of preventable and non-preventable errors.  Then, the I-PASS bundle was introduced – a structured sign-out mnemonic, a 2-hour workshop on communication skills, a 1-hour role-playing and simulation intervention, a faculty development program, direct-observation tools, and a culture-change campaign with a logo, posters, and other promotional activities.

Following the intervention, residents were, again, observed for six-months.  And, in general, preventable medical errors decreased a small absolute amount, along with a larger absolute decrease in near misses.  2 of 9 hospitals had increases in medical errors after the interventions, and the bulk of the effect size was a result of improvements at two hospitals whose baseline error rate was double that of the other 7 facilities.

The authors, then, are very excited about their I-PASS bundle.  But, as they note at the end of their discussion: “Although bundling appears to have been effective in this instance, it prevents us from determining which elements of the intervention were most essential.”  And, on face validity, this is obvious – the structured sign-out sheet was only one of many quality improvement interventions occurring simultaneously.  A decisive change in culture will trump the minor components of implementation anytime.

The final takeaway: if your institutional audit reveals handoff-related errors are pervasive and troublesome, and if reductions in such errors are prioritized and supported with the correct resources, you will probably see a reduction.  The I-PASS tool itself is not important, but the principles demonstrated here probably are.

“Changes in Medical Errors after Implementation of a Handoff Program”