All I can say is "OK Boomer", to use Chlöe Swarbrick's apt phrase (New Zealand MP).  First of all, I'm sure the generation of doctors previous to you complained about your generation's work ethic.  And believe me,  I'm the same generation as the docs in these posts. 

I would politely suggest that most of the commenters to this post get over themselves.  I survived two residencies back in the day, and you do NOT need those horrific hours and living conditions to "learn the craft".  That's ridiculous. Everyone knows that your learning curve is the steepest your first year or two of practice, as the sole doc responsible for your patients.  

For a group of people who apparently "follow the science", you seem to ignore the vast literature documenting the negative mental and physical health effects of sleep deprivation, microtrauma, abuse by the patient, etc. Are we really going to take advice on what is a healthy learning environment from a group of professionals that:

1)still looks down its nose at part-time practitioners, or those wanting only to ever work part-time, in spite of the data on burnout and flexible work schedules?

2)has one of the highest suicide rates among working groups?

3)complains about how difficult the current state of Medicine is to work in, but doesn't even THINK about changing to part-time work to ease personal stress (in fact, why don't more docs change to part-time work?  I would suggest it's partly due to greed, and being locked into a high-spending lifestyle, etc.)

We should celebrate this generation's willingness to critically examine the abuse that previous weak, fearful, generations took for granted without a single complaint.  

Furthermore, this bragging about "putting in the IV's and doing the meds and doing the ECG's"...is this really the clinical work we think was necessary in our traditional legacy medical school rotations and residencies?  In my medical school and residency, those jobs were done by the nurses and technicians, and I was in the ER assessing patients, or on the ward seeing ward problems.  The latter was much more significant for my learning, whether it was in the day, or at night.  it is possible to learn during the day hours!  Imagine that!

If the training and lifestyle were more hospitable, maybe more would be attracted to Medicine as a profession.....oh wait, though, that would dilute our income...we can't have that.  Better abuse them to discourage them from becoming competitors.

I couldn't agree more. I finished my Urology residency in 1989, and most of my three month rotations in Halifax were 24/7. Days started at 6-6:30 with rounds and  putting in all the IV's, starting all ther pre-op meds, doing ECG's On call every day and night. I'd have to ask for permission to have an evening off with my wife. I had a 6 month stint in Saint John NB where instead of 4 residents for this back  breaking service we were down to 2. I was on call 1 in 2 for 6 months; working 36 hours on, 12 hours off. Covering a huge surgical service, ER, Surgical ICU and presenting teaching rounds weekly. It took me 6 months to get over that assault on my body and mind.

Current residents have no idea how much more humane their training is now, to the point they d an extra year or two just to get the exposure to enough clinical work to be competent in their field. 

Dear Rafael Martinez,ha 2 anos não apresentava tal alteração ao ecg,agora esporadicamente,aos esforços,apresenta dor toracica.alguma sugestao de investigação?

As an anesthesiologist, I make the sound volume of music so low that we can listen to ECG beep.

I send to internist to put hotter fo 24 hours with ECG

Mais , il ne faut pas être gêné que du contraire , en tant que généralistes nous ne faisons pas des ECG tous les jours et il est normal de revoir la théorie, des exemples  quand nous nous retrouvons à des choses plus "rares" pour nous surtout dans certains troubles du rythme. C' est d' ailleurs très important pour un médecin généraliste de connaître ses limites , c' est aussi un critère qui fait partie de ses qualités .Bravo à vous de vous renseigner devant un problème, cela montre votre intérêt envers les connaissances et augmente ainsi votre expérience et votre efficacité comme médecin traitant. 

Dear עדו תמרי, very much agree with you. I have yet to meet a colleague who will say they are very comfortable with reading ECG. Technologies are changing and we should take advantage of them. 

Primero, felicidades por tu interes en aprender. Segundo hay cursos autodidacticos en intrnet que te pueden ayudar. Tercero, reliza ECG a todos los que puedas y cominza a interprtarlos y Cuarto comentalos con tu Cardiologo de confianza. Adelante.

You should check out www.ecgmadesimple.com

EKGs Interpretation is endless. May I compare it to The Bible -

you may read and learn all over your life and still not getting to

its end because it's endless.  "Physicians at all training levels had deficiencies in ECG interpretation even after educational

interventions "( JAMA 2020 Nov, 180(11):1-11.).

Try the help of Autonomic Intelligence (AI) whenever of difficulty

or consultation with an electrophysiologist in complicated EKG presentation, particularly when there is arrhythmia or any

conduction problem.

Je ne vois pas pourquoi seriez-vous embarrasé pour ne pas avoir l'impression d'aisance à la lecture d'ECG, je pense au contraire que cela vous pousse à approfondir votre connaissance et c'est une bonne chose.

L'excès de confiance est "une machine à tuer" pour nous même et pour nos patients, c'est pour ça que nous avons des discussions pluridisciplinaires par rapport à nos patients ! Les médecins "dieu" et "omniscients" sont des dangers publiques !

SOLVED

ECG changes in hypokalemia include: ST-segment depression, T-U wave fusion, and prolonged QT interval. 

In some cases, hypokalemia can result in widespread ST-segment depression in more than 6 surface leads and ST-segment elevation in lead aVR, which may often be confused with NSTEMI, especially in a patient with associated cardiac biomarker elevation. 

Dr Patricia Pangaud de Gouville , cardiologue , France , 

 Bonjour à vous  ,

Erratum certain : je pense qu’il faut lire EEG ….et non ECG dans ce cas clinique 

Bien sur , cela n’a rien à voir !! Mais vous l’avez tous compris …Erreur de frappe ( ou de traduction  !! )  

what would you all think about an ecg watch so he could do many many checks prior to stop ?

I'm assuming the question is:  immediate surgery and hope for the best? or a stop in the cath lab en route to the operating room and hope for the best?

He needs surgery if he is to survive but realistically he is not likely to, with a long ICU stay and loss of functional independence if he does survive.  Is that consistent with his wishes and values/preferences?*  Is he optimized medically in the short time you have?  You might be tempted to revascularize something ahead of surgery but do you have a candidate artery, given no ST segment elevation that would predict clear benefit from PCI (if he didn't also need a laparotomy of course)?  If he has triple-vessel disease (Hx of CABG + PCI) with NSTEMI now, any survival benefit from further revascularization will be small, and you have to think about risk of kidney injury from contrast, recalling that he's diabetic, has just (I'm presuming) had contrast for his abdominal CT, and will surely get antibiotics which may be nephrotoxic.

Two lines of thinking:

1)  This NSTEMI could be what we called a "Type 2" MI, sometimes called "asymptomatic troponin-itis" meaning a supply-and-demand shortfall owing to high O2 demand (sepsis, tachycardia) and fixed supply (obstructive coronary disease plus aortic stenosis.)  Long differential Dx for this.  There might be no ruptured plaque/occluding clot to put the balloon into.  Hypotension from surgical anesthesia will be poorly tolerated of course.  Communication with anesthesiologist and surgeon is essential.  Remember, before troponin assay was developed, we would have had no basis to make a Dx of MI in this presentation:  no chest pain, nonspecific ECG changes, and (maybe) negative CK-MB.  Trop of 800 is very very high unless you are using different units from what we used in Canada.  (5 - 50 ng/ml would be high, but the point of cTnI is not how high it goes but how quickly it rises reliably above limit of assay (0.04 ng/ml) to become diagnostic, allowing prompt decision-making in chest-pain syndromes that aren't dictated purely by ECG, i.e., are not STEMI.)

2)  Emergency revascularization even for uncomplicated STEMI has statistical benefits over medical Rx on reduction in 30-day mortality but it took large trials to demonstrate this benefit.  Compared to revascularizing this NSTEM if indeed there is anything to revascularize, the benefit of definitive bowel surgery is likely to be much larger if not delayed.

So based on information presented and the usual practice before I retired, I would go for immediate emergency surgery (if surgeon and patient were both willing) and pick up the pieces during anesthesia and in ICU afterward.  Source control might fix his supply-demand imbalance!  Could consider semi-elective coronary angiography during this admission (if he survives and if it is still consistent with his over-all wishes and preferences by then.)

Did I miss anything?

----------------------

* I had a patient much younger than 85 with peritoneal carcinomatosis who perfed small bowel and declined to have surgery, just pain control.  She lived nearly a week with good comfort and was able to interact with family until the last day..

Prinzmetal (plus frequent chez les hommes mais on en vient au diagnostics des infarctus blanc , c'est à dire sans caillot = anémie  hémoglobine inférieure à 6 , intoxication au monxyde de carbone,  au cyanure, methémoglobine (sulfite) les hypotensions séveres , tachycardie  ventriculaire épisodique encore plus rare vol aortique

Reste à savoir si les infarctus sont détectés par ECG ou par enzymologie

Si enzymologie = DD élévation troponine non cardiaque !! 

Attached is a paper that reviews the pathophysiology of nitrous oxide abuse https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925601/#:~:text=Nitrous%20oxide%20irreversibly%20oxidizes%20and,vascular%20endothelial%20injury%20and%20thrombosis.

It negatively affects Vitamin B12 levels.  “Nitrous oxide irreversibly oxidizes and inactivates vitamin B12, which in turn leads to demyelination, megaloblastic anemia, etc. In addition, the accumulation of homocysteine is closely related to vascular endothelial injury and thrombosis”

the paper includes a very thorough case study 

the case study states the following:  patient’s examination upon admission revealed poor mental status, however he was alert and cooperative during the exam and his vital signs were all normal. His proximal and distal limb muscle strength was grade 4 and 3, respectively, with extensor muscle tension being greater. He could not complete the finger-to-nose test, rapid alternating movement test and heel-knee-tibia test. He had systemic hyperalgesia in a glove and stocking pattern, slightly diminished perception of rough touch below T12 plane and diminished perception of position and fine touch. He had diminished bilateral tendon reflexes and lower abdominal reflexes, as well as bilateral Babinski sign (+). The patient’s psychiatric examination revealed that he was conscious, had inappropriate deportment and normal orientation. His answers to questions were on point. Perceptual disorders including hallucinations were not present. He had illogical thinking, presented with suspicion, relational persecutory delusions, stable emotions, occasional negative ideation, diminished consciousness, as well as partial insight loss. Laboratory tests revealed RBC count: 4.94X1012/L [(4.09-5.74)X1012/L], HB: 157 g/L (131-172 g/L), WBC count: 10.37X109/L, ALT: 164 U/L (0-50U/L) and B12: 602.1 pmol/L. The rest of his blood routine, biochemical, ECG and EEG results were normal. Spinal cord MRI examination revealed an inverted V-shaped long T2 signal shadow in the posterior segment of the cervical spinal cord C2-C6

hope you’re find this helpful