This case illustrates both how good modern EMS can be at expediting emergency cardiac care, but also the challenges that still confront us. Yes, there is a “twist,” but only a small one.
Note: I never saw this patient, but the ECGs and outcome were brought to my attention by a colleague, Dr K. Thrace, who moonlights at a number of EDs in the region. Paramedic Tim Y. also generously shared his recollections of the patient.
EMS was called for a 45 year-old man with chest pain. The patient was initially reluctant to talk with the paramedic, Tim, since “my girlfriend called for you guys, not me.” He was eventually persuaded to discuss his symptoms, however, and stated that he had been out shoveling snow when the chest discomfort started He rated it at a 5/10, and also described “numbness” in both of his hands, saying he couldn’t move them, but denied nausea or sweating.
- PMHx: Anxiety, opioid abuse
- Meds: Methadone
- Shx: Smoker
- SaO2-99% RA
- Gen: Anxious, unable to sit still. Hyperventilating.
- Skin: pink/warm/dry
- Pulm: Clear lungs
- Cardiac: No JVD, RRR
- Chest: Tenderness over the precordium
An ECG was obtained:
The symptoms persisted, and and the chest pain worsened to a 10/10. A second ECG was obtained:
Upon seeing this ECG, the paramedic immediately notified the a local PCI center that the cath lab should be activated. There were no extrication issues, and the drive to the hospital took only 9 minutes. Because of the early activation, the D2B time was only 37 minutes.
- First, what is the likely culprit artery?
- Second, are there any early signs of MI on the first ECG?
- Lastly, even though “time is muscle,” the very short D2B time probably did not improve his outcome. Why?