Teleprompter Demo: Indian Accent

Welcome

0:12Good evening, colleagues. And thank you, thank you for coming on a Thursday. I am told this slot used to belong to the pharmacology quiz, so, uh, I have already improved your evening. [chuckles]

One patient

0:23Tonight I want to talk about one patient, a fifty-eight-year-old schoolteacher from Coimbatore, because her case changed how our unit thinks about the first ninety minutes of an acute um, coronary syndrome. She walked into our emergency department on twenty-third August twenty twenty-three at four forty in the morning, complaining of nothing more dramatic than indigestion and a strange tiredness in her jaw.

0:48She had lived with type two diabetes for sixteen years, mind you, with a glycated haemoglobin of eight point two percent, and hypertension treated with telmisartan and amlodipine. [exhales]

The first tests

1:01The first electrocardiogram was read as non-diagnostic. There was subtle S T segment depression in leads V one through V three, and nobody in that room was negligent for reading it that way.

1:13High-sensitivity troponin I came back at forty-six nanograms per litre, just above our ninety-ninth percentile cut-off, and the registrar quite very... sorry... reasonably planned a repeat at three hours.

A resident asks for posterior leads

1:27But a junior resident, in her second month with us, asked for posterior leads.

1:36V seven, V eight and V nine showed S T elevation of more than half a millimetre, which is to say an isolated posterior myocardial infarction, hiding behind a reciprocal pattern on the standard twelve-lead. [sighs] You know, I have been reading these tracings for twenty-two years, and I did not think of it. She had been qualified for about five minutes. I did not sleep very well that week, I can tell you.

Treatment and recovery

2:03Coronary angiography showed a thrombotic occlusion of the dominant left circumflex artery, with Timmy grade zero flow. We performed immediate percutaneous coronary intervention through the right radial artery, with a three point zero by twenty-eight millimetre drug-eluting stent, and her door-to-balloon time was seventy-four minutes.

2:23Had we waited for the second troponin, it would have been well over four hours. By day five her ejection fraction was back to fifty-two percent. She went back to teaching eleven weeks later.

What the wider data showed

2:36Now, I can see, I can... Now, I can hear the cardiologists in the back row. One case proves nothing, and you are right. [laughs]

2:46So we went back through two thousand three hundred and sixteen consecutive chest pain presentations at our centre between January twenty nineteen and December twenty twenty-three. Women with diabetes waited, on average, on average, thirty-eight minutes longer than men for a first cardiology review.

3:05Atypical presentations, meaning jaw pain, epigastric discomfort, breathlessness or simple fatigue, accounted for forty-one percent of their infarctions, but only seventeen percent of the men's. After adjusting for age, renal function and the Killip class at arrival, the hazard ratio for thirty-day mortality was one point four six, with a ninety-five percent confidence interval of one point one two to one point nine one.

Three changes

3:32What did we change? Three things, and none of them was expensive. And I say this for the benefit of our finance office, who I believe have sent somebody to sit at the back. Yes, sir, good evening. Nothing here will cost you any money.

3:46Every chest pain patient with diabetes now receives posterior leads within ten minutes, and the nurse may order them without asking a doctor. Every non-diagnostic tracing is repeated at fifteen minutes, not sixty.

4:00And the word atypical has been removed from our triage form altogether, because if forty percent of a group presents in this way, then it is not atypical, it is simply a presentation we were not trained to hear.

The result

4:13Our median door-to-balloon time for these patients has dropped from one hundred and twelve minutes to eighty-one in eighteen months.

Look at who waits

4:22But I would ask you to go back to your own units on Monday and pull your own numbers. Look at who waits.

4:29Look at whose pain, whose pain gets called indigestion.

4:34And the next time a quiet resident asks for one more tracing at five o'clock in the morning, please say yes. Thank you.