EMS 12-lead Case – Ischemia and Failure

If you haven’t been to www.EMS12Lead.com, Tom Bouthillet’s wonderful EMS educational blog… well then I’m going to just come out and say this:

What are you doing here when you should be over there reading his stuff??

Considering how Tom dwarfs my humble traffic numbers (which is something I always kind of knew he did, but didn’t really know how much until I had a few drinks with him at EMS Today and weaseled his numbers out of him) I’ve figured that I’m going to have to do something. I’m going to straight up steal his shtick and write an “educational” EMS 12-lead EKG post of my very own for your reading enjoyment and educational purposes. Heck, I might even be able to make a point or two. Let’s find out.

I keep an archive of interesting tidbits from my EMS career locked up in a vault in my basement and among the oddities and whatnot I have a binder full of 12-leads. I blew the dust off of the old tome and pulled the EKG that I’m using for this story out of the archives. Oh my, this was a doozy. As always with my stories about patients, I may not have ran this one myself and even if I did, I don’t remember where it was that I ran it nor do I remember the age, location, or even the gender of the patient in question. I also have taken the liberty of lying about all of that stuff just to make it even more confusing and difficult for me to write. So, if you think I’m violating the female Hippo, you’re mistaken.

As I recall, the call was toned out with the dispatch information of a “64yo M Pt unable to breathe”. It wasn’t a long distance away and Our Intrepid Paramedic (OIP) responded in a response vehicle being followed up by an ambulance which arrived shortly after He did. It was a nice, well kept residence and the wife of the Pt let OIP in the door as he entered the home. She indicated that the Pt was in a back bedroom of the house and motioned down the hallway. OIP made the trek and found the Pt sitting upright on his bed, Conscious, Alert, and Oriented times 3 (CAOx3) with somewhat increased work of breathing. The patient stated that he had been experiencing pain that he indicated began at the level of his mandible and continued to his epigastrum (his Jaw to his Gut). He stated that the pain had simply become too much for him this evening and that it became very hard to breathe when he laid down for bed. A good look at him was all it really took for OIP to make a working diagnosis after feeling the patent’s weak and irregular radial pulse and pale, cool, and moist skin. OIP placed the patient on 6-LPM oxygen via Nasal Cannula and told the ambulance medic to break out a 12-lead. The initial rhythm strip showed a sinus bradycardia with an IVCD and lots of multifocal ectopy, including multifocal couplets and triplets. The 12-lead was no better. It showed bad, bad mojo. This poor guy was sick.


As the ambulance crew was packaging up on the stretcher to take the Patient to the ambulance, OIP had a few moments to speak with the patient’s wife. She told OIP that the patient had been experiencing pain in his jaw for the last week. She also told OIP that the patient had gone to see his Primary Care physician two days prior and had been told to take advil for the pain in his jaw. She told OIP about how the patient had been very lethargic lately and about how he would become winded when taking out the garbage and walking even shorter distances. She told OIP about how the pain had been getting steadily worse… and also how the doctor said he was fine.

And with a symptom profile of exertional fatigue, difficult breathing, jaw pain,  substernal chest pain, and diaphoresis… what doctor wouldn’t say that… right? Oh wait… hopefully most of them.

The patient wasn’t having a heart attack… he had been having a heart attack for days and now the damage had been done. This was a clear case of the patient not being educated to the symptoms of a heart attack… or of ignoring them in the hopes that they’d just go away. The physician did not obtain a 12-lead nor do lab work and did not diagnose the problem as being cardiac ischemia (Heart attack) when the patient presented for care.

But OIP did… about 2 minutes after meeting the patient he woke up the cardiologist and the cath lab team at a hospital a half-hour’s drive away to help take care of the man. You’ve seen the 12-lead above. It indicates a heart that is in serious trouble. The patient was treated per protocol, which included high-flow o2, bilateral IVs, NTG tablets and paste, and I’m not sure what else the ambulance paramedic did because OIP didn’t accompany the patient to the hospital. That,  and it was too long ago for me to remember what happened… I just know the patient made it there alive to find out whatever his prognosis was going to be from the cardiology team at the ER.

Here’s the deal, once this patient called the ambulance, his care was stellar. OIP and the other EMTs did a fantastic job at rapid recognition, appropriate stabilizing care, and swift transport to an appropriate care facility as none of the local hospitals had the capacity to care for this guy. The EMS people did what they were trained, equipped, and supposed to do. The problem is they were called way too late to make much of a difference in the patient’s continuing quality of life.

I can understand that patients don’t necessarily know when they’re having a heart attack. To a layperson, jaw pain and fatigue could just be the flu. Chest pain could just be heartburn, and exertional dyspnea could just mean that a person has been “pushing themselves too hard lately”. All of those symptom profiles could mean any number of things… but they could also be a heart attack. I can understand how people want to think that they’re not having a heart attack. I get that no one wants to have one. They’re not fun and we as a society may hype them up too much so that people think there is a stigma to the diagnosis. I don’t know if that statement is true, but it sure seems that way sometimes to me.

What I can’t understand is how a patient can present for treatment at a physician’s office with clear symptoms of cardiac ischemia (heart attack) and not be checked for it. I’d like to think that a paramedic would rule it out first and foremost… and I don’t understand why someone wouldn’t.

Then again, I don’t know the information the physician was working with. Perhaps the patient wasn’t honest with his symptoms and tried to minimize what was going on. That’s possible too, as this patient was a proud man who has lived his life like he could handle anything. People do that. Nobody wants to be sick.

The lesson here is to have a high index of suspicion. Patients sometimes minimize their symptoms, and sometimes they over-dramatize them. Some people don’t want to be sick… and some people want to be sicker than they are. I personally will buy into false drama from someone who’s not as sick as they want to be than chance missing the minimized symptoms of someone who’s sicker. I tell my patients that as a paramedic my job is to “Treat for the Worst, and hope for the best.”

But for this guy, OIP never got the chance. This was too late for that. The damage had been done.

This patient’s quality of life was greatly impacted by the fact that he didn’t call 911 at the first signs of his illness. Had he done so, his prognosis would be much different. A quick exam, 12-lead, and appropriate care would have made this guy’s story quite a bit different. Where was the failure? Was it the patient’s fault for not recognizing and/or minimizing his symptoms? Was it the fault of “health education” in general for not reaching the patient in a manner in which he could understand? Does the fault lie with OIP for not spending enough time educating the public about the symptoms and danger of heart attacks? Does the fault lie with this patient’s doctor for missing the diagnosis and/or not providing proper education beforehand?

I don’t know the answer to the above question either. I just know that OIP and the EMS team treated him well once the call came in. I just wish that something different would have happened in the chance of events that lead up to all of this. It would have made the above 12-lead a lot different.

Be vigilant out there.

  • Good meeting you at EMS Today! Love the 12-Lead. Elevation in aVR and V1, looks like Left Main occlusion! This is a STEMI. Talk about big sick.

  • Christopher always beats me on these. Ditto the LMCA occlusion (or three-vessel disease), although the global depression (instead of elevation), combined with the relatively gradual onset, suggests to me that it’s not complete. Otherwise he’d have been free from this mortal coil before you got the call. Perhaps when he saw his PCP the ECG and clinical presentation were not yet nearly this pronounced. Either way, remember that these folks need either cath or bypass (the debate continues about when to choose which), but NOT thrombolytics, so try to get them to a STEMI center!

    • Agreed on the gradual bit. My understanding of LMCA occlusions is that if your patient is still talking it was a gradual narrowing otherwise it’s a SCA you’re working. Although the post states the PCP didn’t run a 12-Lead. I’d wager if he had there would be some “Non-specific ST-T Wave Abnormality,” which is my favorite (rolls eyes) computerized interpretation.

      • I like “abnormal ECG.” Gee thanks, is that what all these squiggly lines and the other nine interpretations you gave me mean?

  • Asystole360

    Wow, it is a good thing you put in there the “his Jaw to his Gut” and “heart attack” part. I would have probably never figured out what the mandible, epigastrum, and cardiac ischemia parts were. It really appeals to your readers when you treat them like idiots.

    • Unitwas

      not everyone is a medical professional… some people read these things to decide if it’s something they want to go into,
      I don’t think you should knock on someone else,,,, if you feel like you’re an “idiot” don’t read it!

  • Asystole360

    Let me see if I can explain my point in simple terms because I don’t want one to become premenstrual (emotionally sensitive) or experience a cortisol dump (a stress mediated hormone). That can cause an Acute Myocardial Infarct (heart attack) and water retention, hypertension, atherosclerosis, immunological compromise, and insomnia (other bad stuff). However, when one publishes an article in the JEMS-EMERGENCY MEDICAL SERVICES (that’s where I found the article) one can presume the intended target (the reader) is going be a medical professional. My point is “don’t talk down to your reader”. *whisper* they might get offended. Talking down to your readers is, in a simple term, bad. I really hope this helps you to understand my point. Also, if this article was originally written for the laypersons, then don’t be lazy by “cut and paste” or add a link to the article. Modify it for the selected audience.

    • Ckemtp

      Hi there Asystole360! (If that is your real name…)

      My name is Chris and I wrote the above article. In fact, I write a ton of EMS-type articles on here, in my bi-monthly JEMS column, and in other places around the EMS media. If you haven’t been reading me for the years I’ve been writing about my profession (as I suspect you haven’t) then you probably don’t know that I’m a 12-year full-time and volunteer paramedic that has been a passionate advocate for our profession.

      I have a diverse audience here on this site that hovers around 10k people per month. This audience consists of all-types of healthcare providers as well as laypeople (including my mother). I try not to write above anyone’s head so that I can provide quality information that everyone can take something from. The take-home message for laypeople from this article, for example, is “Call 911 for chest pain” with supportive reasoning. For EMS, it is all about being vigilant and also provides an interesting EKG to look at and study.

      JEMS links to my stuff quite a bit, and I’m thankful for that. It provides a diverse cross section of new eyes on my humble writings. I’m glad you’re here reading and I’m glad you took the time to comment. Feel free to click around at the 300-plus other articles on this site, I’m sure you’ll find something that’s to your liking.

  • Great article ! I was enlightened by the information – Does someone know where my company might be able to get ahold of a sample a form document to complete ?