Computer misses it, but the medic catches it.

True fact: I failed out/dropped out of grad school in mathematics. But despite having little enthusiasm for topology or complex analysis, nothing drives me more nuts than people who say stuff like “I’m not good at math – just not a math person, I guess.” This attitude is not just incorrect, it’s harmful. Most mathematics is quite straight-forward, if you practice and study conscientiously. Same with ECGs.

Stratford EMS was called for a (quite) elderly woman who wasn’t feeling well. And of course, she lived on the 5th floor of a building with narrow, twisting stairs. Nonetheless, the paramedic Jay and his crew humped all their gear, including the Like-Pak, up those stairs. Good thing too.

There was a small language barrier, but Jay ascertained that the woman was complaining of a “burning” in her epigastrium that she also felt in her back. This had started within the last hour. VS were normal, as was the exam, except that she “didn’t look right.” Time for the 12-lead!

screenshot1194

Does it meet STEMI criteria? There’s a bunch of ST segment depression in the inferior and lateral leads, but (as you all know) that doesn’t usually count for field activation. There is ST segment in aVL, but it is < 1mm, and aVR shows only minor STE, while lead I shows none.

V2 and V3 show some STE, but it isn’t much, and it would have been easy for Jay to tell himself that, since the computer didn’t “see” it, it wasn’t really there. Instead, he turned his attention to V4….

screenshot1198

… and noted that the T wave seemed pretty darn tall, relative to the R wave. Along with a hint of STD in V3, it triggered Jay to consider a de Winter-ish pattern.

http://lifeinthefastlane.com/ecg-library/de-winters-t-waves/

http://lifeinthefastlane.com/ecg-library/de-winters-t-waves/

The strict de Winter criteria require more ST depression, however, at least 1 mm, and we already have minor (but significant) anterior STE, so this ECG isn’t a “pure” example. However the morphology of V4 is pretty similar to that seem in a number of cases that Dr. de Winter evaluated, and who all turned out to have proximal LAD occlusions:

From http://dare.uva.nl/document/2/90500

From http://dare.uva.nl/document/2/90500

This pattern convinced Jay to call this in as a STEMI, activating the cath lab from the field. To be specific, activating it from the 5th-floor back bedroom.

Good thing too – it was “after-hours,” and the cardiology team needed time to get in to the lab form home. Also, extrication turned out to be a flail, squeezing the patient down narrow, winding stairs.

A second ECG obtained 10 minutes later, during the perilous descent to the rig:

screenshot1195

The computer still doesn’t get it, but the ST segments in both lead I and V3 have started to straighten and move up, suggesting that the first diagonal is occluded, likely because the proximal LAD is blocked.

screenshot1196

The Life-Pak finally made the call 15 minutes after the initial ECG. By this time, however, the patient was starting to look a lot worse, and the pressure was dropping. A fluid bolus was given, keeping the SBP barely above 90.

screenshot1197

By the time the rig was pulling into the ED, 30 minutes after the initial ECG, the 12-lead wouldn’t have been missed by an EMT-B student during their ED observation time. At this point, however, the patient was in frank cardiogenic shock, and the Stratford EMS team was directed to bypass the ED, since they had given the cath team sufficient heads-up to prep the lab. Without the “bedroom-activation” that Jay made, this patient could have arrested while waiting in the ED.

Lessons:
Bring your gear in on every call. Every call.
Navy SEALS don’t leave their gear behind while they “just go check it out first,” and neither should EMS. A paramedic without their gear, and especially without their monitor/defib, is not that helpful.

Get serial ECGs when you suspect something.

Don’t be satisfied if the computer “didn’t say there was a STEMI.”

Practice, practice, practice your ECG skills! Jay felt comfortable committing to the early activation because he has worked hard at reading 12-leads, seeking feedback, and pushing his skills. He has developed a “gut sense” after hours of study, and hundreds of ECGs. He hasn’t been afraid to ask questions, accept criticism, and learn.

10 Comments

  • Jered Sharp says:

    Great catch. That last 12-lead was so obvious for STE It should be in the books teaching us what it looks like!

  • Morrison says:

    The first EKG is pretty obvious too. This is why I look at the tracing first and form my own impression and then see what the computer says.

  • Olivier says:

    I’d like to add to the above comments that epigastric pain in a elderly patient is quite suspicious for ACS.

  • Mike O'Regan says:

    Turn off the interpretation. Makes people lazy and you will miss it. If we are to be taken seriously in the medical profession we need to stop taking the easy way. If that’s the way you interpret 12-leads your not treating your patient.

  • Susan James says:

    I need help. I’m an RN and I have tried and tried and tried to learn how to read 12 leads accurately. It’s just not clicking. I’ve read two different manuals, looked at several different websites, and practiced till I’m blue but I need something else. Can anyone recommend a good bare bones EKG training system or literature for the EKG challenged like me??

    • Joseph Gadoury says:

      Susan, keep an eye out for Tim Phalen’s seminar on 12-lead interpretation. Usually sponsored by Medtronics. He does a great program.

  • Nathan says:

    I would also highly recommend trying to attend a seminar by Bob Page, or at least buying his book “12 Lead ECG for Acute and Critical Care Providers”. I found it to be incredibly helpful!

    • Well this blog is a great place to start! We cover most every aspect of emergency electrocardiography, with a variety of authors, and multiple perspectives, usually in a clinical context.

      If it is a book you are looking for, I prefer Ken Grauer’s. I started with Dr Grauer as a paramedic student and I still re-read his books now. In addition, he has been generous with his teaching pearls through the EKG Club page on Facebook.

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