Don’t think late presentation STEMIs are that common to begin with for your argument to have logical sense, this is the worst form of a “heart attack”.
From this single center study presentations > 12 hours only comprised 10%.
https://www.ingentaconnect.com/content/wk/jcarm/2017/0000001...
Another possible factor could be the fact that doctors tend to make more mistakes during operations on Fridays compared to start of week.
STEMI centers (this is picked up by EMS and these ambulances are redirected to appropriate centers) have 24/7 cath lab coverage and any major one will have an ER bypass even during afterhours to expedite care.
In fact more and more hospitals (and all the major ones) announce a “Code STEMI” overhead either when the ambulance is dispatched or as soon as the ECG showing ST elevations is discovered in triage/ER to activate the team and reduce door-to-balloon time.
This doesn't seem that surprising to me, or at least I expect we should also see an increase on Saturday. People like to do harder work, like lawn projects on the weekend, and things like drinking that can affect the heart.
So it wasn’t so much about dreading the coming week but being still from the previous week and being sad about what they actually accomplished (or didn’t).
I don't think that seems surprising. People working office jobs through the week go out and drink more on a Friday and Saturday night, and those of a more sporty bent will often push their bodies more at the weekend because that is when they can find the time for longer or multiple training sessions, and it is where you find organised events (the highest proportion of runs are on a Sunday, with the second highest being Saturday).
Edit: aha--https://www.nature.com/articles/s41467-020-15432-4
When I was an intern I was 100x better than I am at this point in my career.
The basic atrial fibrillation and STEMI is something any doctor can interpret with confidence (I used myself as an example as I'm probably the least competent because I haven't looked at an ECG in 10 years). I doubt non-cardiac surgeons are much better on average as they don't really look at these themselves that often other than for basic things.
An ER or general internal medicine physician is expected to be competent in more advanced but common stuff like bundle branch blocks, left ventricular hypertrophy, non ST elevated MI.
Weird arrhythmias or conduction abnormalities is really only for cardiologists, and even then typically a subspecialist electrophysiologist.
US/Can healthcare systems still pay a cardiologist a couple of bucks to "finalize" the interpretation whenever they get around to it. It's a bit ironic, someone could have an MI on Friday, get treated and discharged and we're still paying someone on the Monday to read 40 ECGs (note these would have been acutely interpreted by the cardiologist treating the patient, most places have rules against self-referrals so you can't formally interpret anything you order yourself).
Just knowing the pathology of STEMI it's hard to buy that an effect of this size (in the Ireland study) is largely due patient's not seeking care on weekends unless you're somewhere extremely rural as this isn't your average heart attack.
If this was about ACS (acute coronary syndrome) in general I'd be more suspicious that patient delays are a relevant confounder, but we have other literature to support the trend (granted with some conflicting studies).
from [1]: > Many studies have shown an excess of cardiovascular events on Mondays (1,3,10,16,18,19). A relative trough has been seen on Saturdays and Sundays I compared with the expected number of cases. A similar pattern was seen in most subgroups irrespective of age, gender, cardiac medication, and in-fart characteristics (first or recurrent, Q or non-Q, site). The frequency of morning infarction is greater during the working week than on weekends, suggesting a superimposition of work-related stress on endogenous circadian rhythms.
>Circadian variation is found on all days of the week including weekends' when the morning peak is less obvious.
I haven't looked at the methodology of the cited studies but they include 6 references for your perusal.
[0]https://onlinelibrary.wiley.com/doi/abs/10.1002/clc.22 [1]https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.4960261... [2]https://europepmc.org/article/med/12061302
Honestly, when I have an ICU nurse providing procedural sedation for me I essentially just defer to their expertise on the rhythms and if they're worried I activate the mobile response team.
That matches with my impression about a lot of things in her job. I'm always a little surprised when she talks about calling the doctor saying I need X, Y and Z and the doctor just being like cool I'll put in the order. Obviously, not all doctors are like that but it seems like the vast majority defer to the nurses in a lot of situations. This is completely different than the conception I had of healthcare before I met her.
> I'm always a little surprised when she talks about calling the doctor saying I need X, Y and Z and the doctor just being like cool I'll put in the order.
This is the best part. A lot of decisions like sleeping aids, antipsychotics, antiemetics don't have evidence to choose from the various options so it's a bit of trial and error. An ICU nurse typically covers 1-2 patients and knows them very well, so if the recommend/ask for something it's usually the right decision and reduces the cognitive burden on the physician. We obviously still do a safety/sanity check but ballpark estimate I'd say I disagree or order something else < 5% of the time.
Similarly I'd say the proportion of bullshit overnight pages (e.g. I fondly remember a 4am call that a patient has leg cramps) I've received from ICU nurses are even less than that.
General ward nurses on the other hand... A very heterogeneous bunch with high turnover (worse in academia, at my last hospital average career length was ~2 years before they leave for greener pastures) so the relationship is very different.
Not that I don't appreciate them or their work, but far less trust in decision making and they need more oversight.
We already had evidence that the time shift increases heart attacks.
I’m planning to just ignore DST this year. I’ll show up a little early for work half the year, and a little late for the rest.
I suppose it’s a nice problem to have but still uncomfortable. Congratulations on your retirement and hope you get to figure it out and find a new mountain to climb.
Other weekday numbers will also have delayed presentations included so you can't just "subtract 3.1" from one day and declare statistical insignificance.
What you can do is subtract it from every day as we know that 97% of STEMIs present within 12 hours.
As this is just an abstract we don't know what the authors did in this particular example but it's not the first study to suggest Mondays have the highest ACS rates.
Anxiety due the the looming work week?
I maintain enough competence to know when it looks like it could be critical so I can call for help, but realistically that's happening anyway as soon as someone gets unstable as I haven't resuscitated someone in years.
I haven't looked at a real patient's ECG in probably 7 years now. If you were the patient, would you even want me to? I'd rather just do the smart and safe thing, call for help.
No subspecialist (or even specialist) can maintain competence in all areas of medicine, it's hard enough keeping up my general radiology skills. It's a good thing none of us practice in silos by definition.
You have basically agreed with me. I made no statements about subspecialisation or attempt to reconcile the breadth of medical knowledge that is required as you progress through medical training into consultant status with that original knowledge, or implied that we're expected to be able to definitively diagnose and manage a patient with a ECG that implies an imminent threat to life.
Frankly I think that everyone should still be able to recognise a STEMI - it's pretty characteristic; the more severe or subtle AV blocks definitely take some familiarity; but the bedrock principle of ACLS is calling for help, and medicine is certainly a team sport