u/AhmedMAbd

A few months ago, my colleagues sent me an ECG of a patient who was in the internal medicine wards and was diagnosed with meningitis complicated by diabetic ketoacidosis (DKA). They asked me what I thought about the ECG.

I immediately asked whether they had the lab results, particularly the electrolyte levels, but they said they hadn’t seen them. The next day, I went to the internal medicine wards, but unfortunately, the patient had been discharged. I tried to ask the physicians, particularly about the potassium levels, and one of the residents told me that the patient had hypokalemia. I asked him if he was sure because the ECG showed peaked T waves. He responded that those T waves were normal, and he said the only abnormality on the ECG was sinus tachycardia.

I have seen several cases of hypokalemia causing peaked T waves; however, in all those cases, the QT interval was significantly prolonged, which was not the case in this ECG.

What do you think? Could this be hyperkalemia or hypokalemia?

Unfortunately, I have no more information about the patient.

I am a final-year medical student, and in my brief clinical experience during hospital training, I have encountered many cases of OMI that were diagnosed and managed as NSTEMI. When I see these cases, I often try to inform the managing doctors that the patient may need emergent catheterization, but they often respond that it is just NSTEMI and that there is no need for urgent intervention. Then I discuss the OMI paradigm and reference examples from Dr. Smith's blog, but these discussions rarely go well, and I find that no one listens or allows me to finish my arguments.

In these discussions, I frequently ask them the following question: if you were managing a patient with NSTEMI, and you had a highly advanced device from the future that could confirm if any of the coronary arteries were completely occluded, would you still delay catheterization emergently? The answer is always yes, the catheterization would still be delayed because it is classified as NSTEMI! I then add, "What if this patient were one of your relatives?" Many doctors tend to stop engaging at that point.

On one occasion, a doctor told me, "The STEMI/NSTEMI system is older than you, and a few doctors cannot change it just because they have seen a handful of NSTEMI cases with total coronary occlusion."

I am concerned that once I graduate and begin treating real patients, if I continue to argue every time I encounter an OMI case, I may be disliked and possibly ridiculed. On one instance, a doctor remarked that I do not recognize occlusion MI on an ECG, suggesting instead that I am seeing an "illusion MI."

Do you face similar challenges?

Hyperkalemia !!