EMS is called to the scene of a 58 year old male complaining of chest pain.

On arrival, the patient is found tripoding in a chair. He is pale, diaphoretic, and appears acutely ill. He is anxious but alert and oriented to person, place, time and event.

Onset !ain started after carrying luggage up stairs. !rovo"e #othing ma"es the pain better or $orse. %uality !ain is described as &burning&. 'adiate !ain is across the center of his chest and poorly locali(ed. !atient denies radiation of the pain but complains that the )! cuff is hurting his right arm, even $hen it*s not inflated. Severity +,-.. /ime 0bout -5 minutes prior to EMS arrival.

He admits to mild dyspnea. He admits to nausea but has not vomited. #o 123 sitting upright. #o pedal edema.

2ital signs

!ulse 45 'esp 6. )! -++,+8 SpO6 +5 on '0

)reath sounds clear

!ast medical history dyslipidemia Meds 7ipitor

/he cardiac monitor is attached.

0 -6 lead E89 is captured.

3ue to e:uipment and,or net$or" problems, the E89 is not able to be transmitted to the 7ifenet 'eceiving Station for physician evaluation ;a common occurrence these days<. =pdate #o longer much of a problem $ith the ne$ $eb>based 7?@E#E/.

Ahat is your impressionB

Ho$ $ould you treat this patientB

'elated !osts 0cross the @ireEMS )logs #et$or" 8alling 0ll EM/Cs ;0 3ay ?n /he 7ife Of 0n 0mbulance 3river< Six /ric"s Dou 8an =se /oday to ?mprove Dour EMS #arrative 'eport ;7ife =nder the 7ights< Story of mother rescuing babies from fire goes viral. =nfortunately all such stories arenCt created e:ual. ;S/0/ter+--.com< -4 3ays of @ree S$ag from @ire 8ritic ;/he @ire 8ritic< !osted by /om )outhillet on May E-, 6..+ F @iled under ems>topics, patient> management F /agged acute inferior S/EM?, case study, EMS, EMS -6>7ead, ems-6lead.com, inferior S/EM?, !aramedic, !rehospital -6>7ead E89 blog, S/EM?, /om )outhillet -5 8omments

So8al Medic says 7uggage upstairsB 3id he Gust get bac" from a trip or Gust cleaning up the houseBAhen you post the blood pressure, is it hypertensive for himB

on May E-, 6..+ H -- .4 pm. Shaggy says O", Gust :uic"ly glancing at it $hile at $or" normal axis, and obvious inferio>lateral M?, $ith reciprocal changes seen in ? and a27. )ut seeing the S/ depression in the right precordial leads leads me to believe there is posterior involvement as $ell. ?f the patient is hypertensive, ? donCt see $hat ? $ould do differently for this M? than any other usuall M?, even considering the inferior involvement.Ho$ever, there must be some catch or you $ould not post it. <

on May E-, 6..+ H -- 6- pm. 0mbulance 3river says Shaggy beat me to it.So $hat else is there to it that $e arenCt seeingB

on 1une -, 6..+ H - 54 am. )ob 1ester says ? agree $ith ShaggyCs interpretation of the -6 lead and li"e this patient for an evolving inferio>lateral $all M? and that there might be some '2 involvement. ? $ould $or" li"e hell to convince the patient that a !8? capable hospital is a better choice then the local and begin transport that $ay. Most of our base docCs $ill activate the one call system based on our re:uest if $e canCt transmit. 0s far as treatment, the standard oxygen to patient comfort, aspirin to che$ and s$allo$ ;$e use E65 mg<, ? $ould hold nitro until ? got at least one ?2 as large a bore as the patients veins $ould tolerate, preferably t$o $ith normal saline hanging at I2O until $e dump his pressure $ith sublingual nitro. 0t the patients rate ? donCt thin" ?Cd give any beta bloc"ers, and fentanyl $ould definitely be on my order re:uest to O7M8 ;no standing orders for narcs here in the peoples republic of ne$ Gersey<.

on 1une -, 6..+ H 6 .6 am.

#ic" 9 says um yeah loo"s li"e an obvious inferior $ith possible '2 involvement.. ? thought $ith posterior 2->5 all leads need to have depressionB So does this mean its an evolving posterior or could it be a bloc"age off one of the marginal,diagonal branches of the right coronary arteryB 0ny$ay im a year into this paramedic student buisness so be niceJJ Either $ay i $ould be extremely careful of nitrates due to the heart rateKhope im in the ball par"J 9reat blog too im addictedJ

on 1une -, 6..+ H 5 5E am. /om ) says 8hristopher L 0ctually, he had Gust arrived for a tripJ Hilton Head ?sland is vacation resort. Ae receive about 6.65 million visitors a year.? donCt "no$ if the pressure $as normal for him, but ? doubt itJ ?t $as in the neighborhood of -88,+6.? $as home earlier today but ? forgot to loo" at the code summaryJ /om

on 1une -, 6..+ H -- EE am. /om ) says Shaggy $rote MN/Ohere must be some catch or you $ould not post it. <MShaggyJ Dou hurt my feeling. <0ctually, this oneCs a horse.Sorry to disappoint you gentlemenJ /om

on 1une -, 6..+ H -- E5 am. /om ) says )ob L ? thought prehospital beta bloc"ers $ere no$ out of favor for S/EM? patients. 3o you have standing orders for thatB=nfortunately, the P8ode S/EM?M $as not called for this patient until after the patientCs arrival in the E3 ;and it $as the $ee"end<./hereCs no guarantee the P8ode S/EM?M $ould have been called, even if the E89 $ould have been transmitted, but $eCre $or"ing on it./om

on 1une -, 6..+ H -- EQ am. /om ) says #ic" 9 L /han"s for the positive feedbac".0ny S/ segment depression in the right precordial leads should ma"e you suspicious for posterior involvement, especially $hen

the S/ segment depression is do$n$ardly convex as it is here in leads 2- and 26./he posterior descending artery divides off the '80 and supplies the posterior $all of the left ventricle in many patients, so itCs not uncommon to see posterior extension $ith inferior S/EM?./om

on 1une -, 6..+ H -- 5. am. So8al Medic says /om, #ormal axis, Elevation ??, ???, a2@, reciprocal changes in ?, a27, poor r $ave progression $ith 3epression in 2-, 26 and elevation in 24. ?nferio!osterior Aall M? ;possibly lateral, difficult baseline in 25<. Oxygen, 0S0, #itro ;after ?2 $ith careful monitoring of )!<, Morphine for pain and obtain 2Q>2+, obtain 25' as $ell because ??? is higher than ?? for confirmation. Rofran for nausea, transportation to the cath lab. Aould also use the capnography and monitor his air$ay, my thought is he may have thro$n a clot because of the trip, he could thro$ another and affect his respiratory.

on 1une -, 6..+ H 5 .. pm. )ob 1ester says /om Arote ? thought prehospital beta bloc"ers $ere no$ out of favor for S/EM? patients. 3o you have standing orders for thatB=nfortunately, the P8ode S/EM?M $as not called for this patient until after the patientCs arrival in the E3 ;and it $as the $ee"end<.0nd ? replied Standing orders here in the peoples republic of ne$ Gersey are very limited, communication failure protocols are a bit more liberal. )eta bloc"ers are an O7M8 option.0ny $ord on ho$ the patient made outB

on 1une -, 6..+ H -- 6E pm. /om ) says 8hristopher L 2ery thoroughJ ? hadnCt even considered the possibility that prolonged travel could lead the patient to thro$ a clot.)ut then, clots thro$n during travel are generally !Es, not S/EM?s or stro"es, rightB /hat is not my area of expertiseJ 0s for placing additional leads ;25', 2Q, 28, 2+<, ?Cm certainly not against it, but ? probably $ouldnCt do it, simply because thereCs enough information on this -6 lead E89 to implicate the '80 as the culprit artery, and in the setting of inferior S/EM?, S/ segment depression in the right precordials is all the confirmation ? need for posterior involvement.0t this point, the S/EM? has been identified, and the heart rate, heart rhythm, and physical exam become more important for the P#/9,no>#/9M decision in the setting of possible '2 involvement, ?MHO.Having said that, thereCs nothing $rong

$ith getting used to $hat these modified leads loo" li"e during acute S/EM?J /om

on 1une 6, 6..+ H Q 58 am. /om ) says )ob L 9ot itJ #o $ord on ho$ the patient made out yet.? "no$ he $ent to the cath lab, and 36) time $as probably $ithin +. minutes, but ?Cm certain $e could have saved him at least 6. minutes of ischemic time had the trigger been pulled on the cath lab at the point of discoveryJ ?Cll find out the 36),E6) times at the next :uarterly S/EM? meeting./om

on 1une 6, 6..+ H Q 5. am. 8hes says /his to me is an obvious inferior M? $ith posterior and '2 involvement. ? $ould treat $ith high flo$ O6, 0S0 E65mg !O, morphine for pain, prophylactic (ofran for nausea ;after ',O pt is not allergic to any of these<. 0nd ? $ould definitely perform a right side -6>lead ;25', 25', 25', 24'<, because 25' alone only detects '2 M? only Q.>8.S of the time. ? "no$ this pt has '2 invo"vement due to S/E greater in lead ??? than lead ??. 0lso, try telling a cardiologist that performing a ' side -6>lead is not important, because it drastically changes the treatment modality ; increasing pre>load and after>load in '2 M? as opposed to decreasing these in non> '2 M?Cs<. 0lso the PfixM in the cath lab is very different $ a pt that has '2 invilvement. ?f breath sounds are clear ? $ould give fluids per cardiologists recommendations assessing breath sounds after every 65.cc infused.

on May -+, 6.-- H + 54 am.

uggage upstairsB 3id he Gust get bac" from a trip or Gust cleaning up the houseBAhen you post the blood pressure, is it hypertensive for himB

on May E-, 6..+ H -- .4 pm. Shaggy says O", Gust :uic"ly glancing at it $hile at $or" normal axis, and obvious inferio>lateral M?,

$ith reciprocal changes seen in ? and a27. )ut seeing the S/ depression in the right precordial leads leads me to believe there is posterior involvement as $ell. ?f the patient is hypertensive, ? donCt see $hat ? $ould do differently for this M? than any other usuall M?, even considering the inferior involvement.Ho$ever, there must be some catch or you $ould not post it. <

on May E-, 6..+ H -- 6- pm. 0mbulance 3river says Shaggy beat me to it.So $hat else is there to it that $e arenCt seeingB

on 1une -, 6..+ H - 54 am. )ob 1ester says ? agree $ith ShaggyCs interpretation of the -6 lead and li"e this patient for an evolving inferio>lateral $all M? and that there might be some '2 involvement. ? $ould $or" li"e hell to convince the patient that a !8? capable hospital is a better choice then the local and begin transport that $ay. Most of our base docCs $ill activate the one call system based on our re:uest if $e canCt transmit. 0s far as treatment, the standard oxygen to patient comfort, aspirin to che$ and s$allo$ ;$e use E65 mg<, ? $ould hold nitro until ? got at least one ?2 as large a bore as the patients veins $ould tolerate, preferably t$o $ith normal saline hanging at I2O until $e dump his pressure $ith sublingual nitro. 0t the patients rate ? donCt thin" ?Cd give any beta bloc"ers, and fentanyl $ould definitely be on my order re:uest to O7M8 ;no standing orders for narcs here in the peoples republic of ne$ Gersey<.

on 1une -, 6..+ H 6 .6 am. #ic" 9 says um yeah loo"s li"e an obvious inferior $ith possible '2 involvement.. ? thought $ith posterior 2->5 all leads need to have depressionB So does this mean its an evolving posterior or could it be a bloc"age off one of the marginal,diagonal branches of the right coronary arteryB 0ny$ay im a year into this paramedic student buisness so be niceJJ Either $ay i $ould be extremely careful of nitrates due to the heart rateKhope im in the ball par"J 9reat blog too im addictedJ

on 1une -, 6..+ H 5 5E am.

/om ) says 8hristopher L 0ctually, he had Gust arrived for a tripJ Hilton Head ?sland is vacation resort. Ae receive about 6.65 million visitors a year.? donCt "no$ if the pressure $as normal for him, but ? doubt itJ ?t $as in the neighborhood of -88,+6.? $as home earlier today but ? forgot to loo" at the code summaryJ /om

on 1une -, 6..+ H -- EE am. /om ) says Shaggy $rote MN/Ohere must be some catch or you $ould not post it. <MShaggyJ Dou hurt my feeling. <0ctually, this oneCs a horse.Sorry to disappoint you gentlemenJ /om

on 1une -, 6..+ H -- E5 am. /om ) says )ob L ? thought prehospital beta bloc"ers $ere no$ out of favor for S/EM? patients. 3o you have standing orders for thatB=nfortunately, the P8ode S/EM?M $as not called for this patient until after the patientCs arrival in the E3 ;and it $as the $ee"end<./hereCs no guarantee the P8ode S/EM?M $ould have been called, even if the E89 $ould have been transmitted, but $eCre $or"ing on it./om

on 1une -, 6..+ H -- EQ am. /om ) says #ic" 9 L /han"s for the positive feedbac".0ny S/ segment depression in the right precordial leads should ma"e you suspicious for posterior involvement, especially $hen the S/ segment depression is do$n$ardly convex as it is here in leads 2- and 26./he posterior descending artery divides off the '80 and supplies the posterior $all of the left ventricle in many patients, so itCs not uncommon to see posterior extension $ith inferior S/EM?./om

on 1une -, 6..+ H -- 5. am. So8al Medic says /om, #ormal axis, Elevation ??, ???, a2@, reciprocal changes in ?, a27, poor r $ave progression $ith 3epression in 2-, 26 and elevation in 24. ?nferio!osterior Aall M?

;possibly lateral, difficult baseline in 25<. Oxygen, 0S0, #itro ;after ?2 $ith careful monitoring of )!<, Morphine for pain and obtain 2Q>2+, obtain 25' as $ell because ??? is higher than ?? for confirmation. Rofran for nausea, transportation to the cath lab. Aould also use the capnography and monitor his air$ay, my thought is he may have thro$n a clot because of the trip, he could thro$ another and affect his respiratory.

on 1une -, 6..+ H 5 .. pm. )ob 1ester says /om Arote ? thought prehospital beta bloc"ers $ere no$ out of favor for S/EM? patients. 3o you have standing orders for thatB=nfortunately, the P8ode S/EM?M $as not called for this patient until after the patientCs arrival in the E3 ;and it $as the $ee"end<.0nd ? replied Standing orders here in the peoples republic of ne$ Gersey are very limited, communication failure protocols are a bit more liberal. )eta bloc"ers are an O7M8 option.0ny $ord on ho$ the patient made outB

on 1une -, 6..+ H -- 6E pm. /om ) says 8hristopher L 2ery thoroughJ ? hadnCt even considered the possibility that prolonged travel could lead the patient to thro$ a clot.)ut then, clots thro$n during travel are generally !Es, not S/EM?s or stro"es, rightB /hat is not my area of expertiseJ 0s for placing additional leads ;25', 2Q, 28, 2+<, ?Cm certainly not against it, but ? probably $ouldnCt do it, simply because thereCs enough information on this -6 lead E89 to implicate the '80 as the culprit artery, and in the setting of inferior S/EM?, S/ segment depression in the right precordials is all the confirmation ? need for posterior involvement.0t this point, the S/EM? has been identified, and the heart rate, heart rhythm, and physical exam become more important for the P#/9,no>#/9M decision in the setting of possible '2 involvement, ?MHO.Having said that, thereCs nothing $rong $ith getting used to $hat these modified leads loo" li"e during acute S/EM?J /om

on 1une 6, 6..+ H Q 58 am. /om ) says )ob L 9ot itJ #o $ord on ho$ the patient made out yet.? "no$ he $ent to the cath lab, and 36) time $as probably $ithin +. minutes, but ?Cm certain $e could have saved him at least 6. minutes of ischemic time had the trigger been pulled on the cath lab at the point of discoveryJ ?Cll find out the 36),E6) times at the next :uarterly S/EM? meeting./om

on 1une 6, 6..+ H Q 5. am. 8hes says /his to me is an obvious inferior M? $ith posterior and '2 involvement. ? $ould treat $ith high flo$ O6, 0S0 E65mg !O, morphine for pain, prophylactic (ofran for nausea ;after ',O pt is not allergic to any of these<. 0nd ? $ould definitely perform a right side -6>lead ;25', 25', 25', 24'<, because 25' alone only detects '2 M? only Q.>8.S of the time. ? "no$ this pt has '2 invo"vement due to S/E greater in lead ??? than lead ??. 0lso, try telling a cardiologist that performing a ' side -6>lead is not important, because it drastically changes the treatment modality ; increasing pre>load and after>load in '2 M? as opposed to decreasing these in non> '2 M?Cs<. 0lso the PfixM in the cath lab is very different $ a pt that has '2 invilvement. ?f breath sounds are clear ? $ould give fluids per cardiologists recommendations assessing breath sounds after every 65.cc infused.

on May -+, 6.-- H + 54 am.