47 Year-old male who wants to AMA. What can you tell him to get him to stay?

by Jennifer Carlquist, PA-C

Mr. B was tired of waiting at the ER to be seen for his chest pain and dyspnea. He told the triage nurse he was going home as he felt better anyway and was probably making “too much out of nothing”. The charge nurse promptly asked meto sign his AMA form. However, AMA’s are always high risk. We obviously do not want a chest pain to go home without being evaluated properly. What could we tell him to make him stay for what will most likely be at least a five-hour workup when he is already tired of waiting?

If you look at his EKG, there is no STEMI. This is reassuring. However there are some widespread inverted T waves. And, he has the “s1q3t3” pattern, sometimes seen with pulmonary embolism, and is noted here on the EKG interpretation as “pulmonary disease pattern.” He also has rightward axis which is another clinical clue that he may have a PE. He has increased voltage on his EKG as well, which can mean he has left ventricular strain or significant left ventricular hypertrophy. Sinus tachycardia is an additional clue that he may have a pulmonary embolism.

I went out to see the patient at which time he said, “I will just follow up with my primary care doctor tomorrow.” I knew this was going to be a hard sell. I said, “Sir, first I am sorry you have had to wait to be seen. And I am so glad you are feeling better now. However, I am very concerned about what I am seeing here on your EKG. I am seeing inverted T waves, which have essentially three differentials: a blocked artery in your heart (MI/CAD), a clot in your brain (neurogenic T waves) or a clot in your lung (PE), and these are all life threatening and cannot wait until you see your doctor. And, as it is a Friday you will most likely have to wait until Monday to be seen. IF they have an appointment open, andif they are able to see you they will order the same tests I will, but they will have to get your insurance to authorize them, which could at best take a few days, IF they do them and don’t send you back here to the ER. If they can get your tests authorized and get them scheduled this will be another few days and by then you could be dead. I can get you an answer tonight what is going on, and yes it will be a bit longer, but at least we can make sure that it is nothing life threatening.”

Mr. B, formerly one foot out the door was all of a sudden very happy to wait for his tests, and the five hours seemed much shorter than the week it would take him to get the tests done as an outpatient –IF he survived until then. He ended up having a pulmonary embolism and was successfully treated. The take home is: the s1q3t3 pattern can be a helpful tool if it is present. About 10% of patients will have it, and the lack of it will not mean they do not have a PE, but it can give you ammo to pull the trigger on the CT to look for it.

 

You can see Jennifer Carlquist, PA-C speak at the GAPA 2019 Summer Conference in Hilton Head Island, SC.

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