Friday, January 25, 2008


Elderly patient comes to ER for "feeling my heart pounding."

Patient seen my emergency room doctor, who does "physical" from EKG and recommends admission (it was thought to caused by his heart, after all).

Patient admitted.

Nurse notes slow heart rate. Recognizes intermittent complete heart block on telemetry. Asks electrophysiologist if he has been consulted.

Electrophysiologist has not been consulted. It is Friday.

Electrophysiologist notes patient is to receive the blood-thinner Lovenox and was presribed warfarin (Coumadin). Reviews EKG - Intermittent complete heart block and Mobitz II AV block on EKG from evening prior.

Electrophysiologist wonders "Why would anticoagulation be prescribed for person who might need pacemaker?"

So he signs on the Emergency Medical Record (EMR) system to write order to stop lovenox therapy until decision is made regarding pacemaker implant.

At which time he the orders algorithm of the EMR suggests that "patient's age and risk factors warrant use of DVT prophylaxis."

Electrophysiologist is enlightened.



SeaSpray said...

I loved the show tonight and I am blogrolling you.

BTW - You sounded just like I thought you would sound. Good interview. :)

Anonymous said...

i wonder if the emr algorithms would fall under the same category as the icu checklists that have recently been forbidden

Anonymous said...

I am a little confused, was the lovenox ordered at DVT prophy dose or full anticoagulation dose? Who admitted the patient? Was it the ED MD after discussing the case with the admitting MD ( ? internist) over the phone from home or a hospitalist who was called by the ED MD to admit? I agree if the patient was known to have heart block a cardiologist ( preferably EP trained) should have been consulted. But what time was it? Where I work, most of the cardiologists would not mind a phone call at 2:00 am, but some are quite miffed to come down at 2:00 am. " Just put zoll pads on and I'll see them at daybreak" would be a common respone for some of the cardiologists I work with. Its funny, at midnight I am the smartest physician in the world, it is only apparent that I don't know what I am doing at 8:00 am, when the well rested specialists arrive in their luxury sedans, sipping their first cup of coffee of the day.