Case summary

 An ALS crew was called to a 70s woman who was having chest pain.  When the crew arrived, the patient reported his pain was initially very severe when he called but has since almost completely subsided.  He reported that a few days prior he had a similar episode but never called 911 since the pain resolved then as well.  The crew obtained vitals and the 12-lead EKG included below:

 Vitals: HR 82,  BP 149/80,  RR 16,  Sat 99% on RA

The EKG showed some non-specific ST depressions in the inferior leads but was not diagnostic of an MI but did concern the crew given the whole picture.  The patient initially reported he did not want transport because his symptoms had improved so much on their own.  The crew emphasized their concern that this could still be a heart attack and that it would be best to be transported.  They were eventually able to convince him and began transport to the hospital.

As the crew was pulling into the hospital, the patient began to have labored breathing and reported his chest pain had returned.  Given the change in symptoms, the crew obtained another EKG that was shown below:

This new EKG demonstrated new ST elevation in V2 with depressions in II, III, aVF, V5 and V6 consistent with an anterior MI.  The crew immediately took the patient into the hospital given they had already arrived and notified them that this patient had developed a STEMI on repeat EKG moments before.  The patient was taken promptly to the cath lab for definitive care. 

 Highlights of the case:

EMS providers should advocate for patients if they are concerned about them.

This case shows why it is so important for EMS providers to advocate for their patients.  This patient called EMS but was refusing transport to the hospital even though that was what he really needed.  The EMS crew identified that the patient had medical decision-making capacity and that the patient was allowed to refuse care if he wanted.  It would have been very easy for the crew to leave the patient at his home, but they instead expressed their concern to the patient. By taking the extra time to have an informed discussion with the patient, they were able to help him make the decision that was in his best interest, which was to seek further medical care at the hospital.  This advocacy may have been the single thing to save this patient’s life since if this patient may very well have died if he stayed at home while having an MI.

You can never obtain too many 12-lead EKGs.

This patient’s first EKG did not show ST segment elevation, yet he still was having acute coronary syndrome the entire time.  12-lead EKGs are incredibly cheap to obtain and can show immediately life-threatening problems.  If you are ever wondering if you should obtain a 12-lead or not (or a repeat 12-lead), the answer is always yes!  Sometimes it takes time for the 12-lead to show ST elevation, and while the patient is having an active MI, it is possible that the ST elevation simply has not shown up yet.  Our goal is to make the diagnosis of STEMI as early as possible.  Specific situations where you should consider obtaining a repeat 12-lead is if the first EKG shows something concerning such as hyperacute T waves or concerning ST depressions or T wave inversions.  Another situation would be if the patient has a really good story for an MI such as crushing chest pain with risks factors, diaphoresis, radiation of the pain and vomiting.  The last situation is if the patient develops new or worsening symptoms.  The reason that this crew re-checked the 12-lead was because the patient reported his chest pain had returned.  This allowed the crew to make the diagnosis of STEMI as early as possible.

This patient was experiencing unstable angina.

This patient was reporting he was having recurrent chest pain that was resolving on its own.  This is an example of unstable angina.  This is where a patient has a thrombus in their coronary artery that is waxing and waning in size.  When the thrombus gets bigger, the patient experiences chest pain.  When it gets smaller, the pain goes away.  We take unstable angina very seriously because it indicates a significant coronary artery stenosis and often progresses to a full-blown STEMI.  The patient’s episode of pain that he had a few days prior was likely from the thrombus getting bigger (enough to cause pain), but not so big that he had a STEMI.  The same thing occurred when the crew first arrived.  Despite the patient reporting to EMS that his pain had gone away, the patient progressed to having a STEMI shortly thereafter.  If EMS providers thing a patient is having cardiac chest pain (even if it resolved), they should strongly advocate for the patient to go to be checked out since if they were experiencing unstable angina, they are at high risk to develop a STEMI at any moment.  By going to the hospital, we can prevent the STEMI or at least rapidly treat if it occurs while in the hospital.