Case summary:

An ALS crew responded to a 70s man who clicked his medical alarm.  They arrived to find him complaining of chest pain that had been going on for the past day.  He reported that it comes and goes but has started to feel like his previous heart attack so he became concerned.  The crew obtained the following vitals as well as the following EKG:

Vitals: BP 117/67,  HR 52,  RR 18,  99%,  GCS 15

The patient reported to the crew that his pain has now gone away and he no longer wants to go to the hospital.  The crew explained to the patient that they were very concerned about his intermittent pain that reminded him of a previous heart attack and that it is very possible he is having one now.  The crew was eventually able to convince him to be transported for further evaluation.  The crew gave the patient full dose aspirin and then loaded him in the ambulance.  After being secured in the ambulance, the patient started reporting pain again so the crew obtained a few other 12-leads over the next 8 minutes.

The crew noticed that the patient was developing ST elevation in the inferior leads and called the receiving facility to activate a STEMI alert.  The patient went for emergent percutaneous coronary intervention (PCI) and was confirmed to have an occlusive myocardial infarction (MI) and was successfully treated.

Highlights of the case:

Dynamic changes on EKG are very concerning for an MI.

Evolving ischemic change on an EKG is very specific for an acute occlusive MI and often predict impending STEMI.  The patient’s initial EKG showed a bifid T wave in aVL, but otherwise was a very unremarkable EKG.  A bifid T wave can be an early sign of ischemia, but this in itself is not enough to act on.  The repeat EKG then showed a full T wave inversion in aVL.  This is concerning for an acute MI given this change occurred over a very short duration.  T wave inversions in aVL are often the earliest sign of an inferior wall MI.  The 3rd EKG is showing subtle ST elevation in III and aVF.  The 4th EKG shows worsening ST elevation in those leads as well as ST depression in aVL consistent with STEMI.  Even before the 4th EKG which confirmed the STEMI, the evolving changes in the first 3 EKGs tell us that this patient was having an acute MI.  IF you ever see dynamic changes on an EKG in a patient having symptoms of an MI (chest pain, shortness of breath, vomiting, ect), be very worried this patient is having an MI and consider repeating the 12-lead every couple minutes to diagnose STEMI as early as possible.  All 4 EKGs included her occurred over the span of 12 minutes.

Always advocate for your patient if you are worried.

This patient was initially refusing transport despite having a life-threatening medical emergency going on.  It would have been very easy for the crew to say OK and have the patient sign off; however, the crew was worried about him and emphasized this concern to him.  If this patient did not go to the hospital, he very easily could have died of something that was 100% preventable.  This patient had capacity to refuse so the crew was not able to force him to go unless he would go willingly.  By advocating for him and convincing him to go to the ED, the crew saved this man’s life.