Years ago my favorite calls were the traumas– the shootings, stabbings, high-speed MVAs. You were on the clock and there was a task list. You had to c-spine immobilize the patient, get their vitals, put in two large bore IVs, open up the fluids wide, and do it all on the go, as well as getting name, date of birth and social security number on your race to the trauma room.

After the initial rush, they were unsatisfying because the calls were over almost before they even started, and there wasn’t a real sense that what you did for them made any real difference. Their injuries were their injuries. It is hard to fix a bullet to the head, a broken spine or a torn aorta. And eventually we learned that the fluids wide open and even the c-spine were bad for the patient.

Today, my favorite call is the STEMI. It is also a clock and task call, but there are so many more tasks. Plus your recognition abilities are tested and the outcomes are much better. Do your job well and can make a huge difference. Screw up, either missing the recognition or not calling soon enough and the patient will suffer harm.

Here’s my vision of the perfect STEMI:

I get called for an unusual complaint, toe pain or vomiting or something not quite so obvious as “Man clutching chest, says he’s having the big one!”

My sixth sense tells me to do a quick ECG. Within two minutes of arrival, I have the patient’s chest exposed, and am running my 12-lead. It is not a huge honking STEMI with tombstone T-waves. No, it is subtle. Let’s say an isolated posterior, where I spot the inverted T waves in V1-V3. No hesitating a moment, I am on my cellphone simultaneous with tossing four baby aspirin in the patient’s mouth (after of course asking is he has any allergies.) On the phone, I call CMED, and request a phone patch with medical control for the STEMI Alert to my favorite cath lab hospital. As they connect me, I orchestrate getting the patient on the stretcher, after first having him stripped naked and have applied the defib patches, and then of course recovered him with the sheet. We are already moving down the hall when the doctor picks up. “This is Ace paramedic with a STEMI Alert requesting cath lab activation, ” I tell him. “I have a 55 year old male with toe pain and a diagnostic 12-lead that shows a posterior STEMI with isolated T wave inversion in V1-V3. He says his father and seven uncles all died of MIs at the same age after experiencing the same symptoms. We’re twenty minutes from your door. I’ll transmit when I get down to the ambulance, but trust me on this one…”

En route, I bang in two large bore IVs, give the patient Zofran and Fentanyl (He’s vomiting now and in 10 of 10 pain that has now moved from his toe to his chest). His ECG has now popped an inferior with elevation in II, III, and aVF. I withhold the nitro to not risk knocking his pressure down. I get all his demographics while explaining to him what will happen at the hospital, how we will go right up to the cath lab and they will put him on the table and run a wire into his heart to clear the blockage. I stop the explanation only long enough to defibrillate him as he goes into sudden v-fib, but because I have the pads on already, I just shock him back to our conversation, missing only the slightest beat.

At the hospital, I hand the demos to the registrar and she chases after us with the bracelet. The ED staff bows as they signal for us to go right up to the cath lab. We are upstairs in a flash, and on to the table, where after the patient signs the consent with the pen I have already strategically put in his hand, cap off, ready to sign. Before we even have our stretcher out of the room, the interventionist (using the radial artery approach) has the wire across the lesion and the patient sighs and says, “Wow, I feel so much better,” and the cath lab doc says, you owe your life to these wonderful public servants. Door to Balloon 9 minutes, beating your old record of 10 minutes. Hats off gentleman!”

That’s how its supposed to go.

Here’s how my last one went.

Dispatched to MD’s office for “Confirmed STEMI.”

Now, keep in mind, I have been to many doctor’s offices for ECG changes that the doctor thought was a STEMI, but clearly were not. “Interesting, doc,” I say looking at the ECG he has handed me. “How long has the patient had a pacemaker?” But in this case, the doctor’s office is actually a cardiologists’s office so “Confirmed STEMI” sounds much more likely.

Mentally, I psych myself up for the call. Got to make this qood and quick.

The Fire Department first responders are already there. There are in fact so many of them, I can barely make it the room. Someone hands me a 12-lead ECG and sure enough it looks like an inferior STEMI. ST elevation in II, III, and aVF, slightly less than 1 mm, but with a distinct cove shape as well as slight reciprocal depression in I and aVL.

I look for the patient now, and after clearing the room somewhat I find a fairly athletic looking man in his 50’s sitting comfortably in his chair. I introduce myself and ask how he is doing. “Fine,” he says. “I feel great.”

He does not look like a man having a STEMI. I ask him if he is having any pain, nausea, shortness of breath? Nothing. How did you come to be here today? He says he saw his own doctor earlier in the day, and the doctor was concerned with his ECG so he set up the appointment this afternoon with the cardiologist. I ask why he saw his own doctor this morning. He says he wasn’t feeling well yesterday. He says he felt like he had the flu.

I have him strip down and get him in a gown, then attach him to my monitor and start taking him down to the ambulance. I did not get a chance to speak to the doctor directly, but the staff tells us to take him to the cath lab at their affiliated hospital. They will be expecting him.

In the ambulance, I do my own 12-lead so I can transmit it to the hospital. Not certain that I have to, since the patient is apparently already scheduled to go there, but it is protocol, and you never know. I do my 12-lead and it looks like this:

New Picture (31)

I look in the lower left at my inferior leads and I only see elevation in one lead, and the corresponding lateral depression is gone. I re-check my placement. It is pristine. I ask the man again about how he feels and he says he is fine. No symptoms. I ask about family history. None. I start to wonder if maybe the 12-lead placement in the doctor’s office was screwed up. I transmit the 12-lead calling in a STEMI alert, telling them we are en route to the cath lab. I mention that the patient is asymptomatic and my 12-lead is no longer showing the clear STEMI the doctor’s office ECG was. They tell me they are familiar with the patient and I should continue to the cath lab.

Meanwhile, I am trying to get an IV, and having difficulty. The first blows. On the second, the catheter bends on the patient’s tough skin. On my third shot I have dropped from an 18 to a 20 to a 22 which is all I can fit in the one vein I can find in the wrist. At least this one is good.

I ask the patient again how he feels and he assures me he has never felt better. I open my mouth then and say, well, maybe his arteries will come out clean and this all just a better safe than sorry deal. I feel great, he said again, putting conviction into it.

When we arrive at the ED, their first question is did we patch? Most certainly. I have the name and social security and DOB all set for the registrar, but they are training a new registrar and tell us to wait. When I tell them we are supposed to be going right up the cath lab, I am able to leave my piece of paper with them so they can enter it.

Up in the cath lab, the team is waiting for us. They ask if we have registered the patient and we say yes, we left the information with the registrar. They demand to know why the patient doesn’t have a bracelet on. We repeat that we registered them. More argument until someone announces the patient’s name is in fact in their system now so they can begin their procedure. The doctor comes over and I hand him the ECG and tell him the patient is asymptomatic. He stares at the ECG as well, then begins the questioning. At first the patient denies the symptoms, then under grilling he confesses that it feels like someone is sitting on his chest, and that he was sweaty earlier and also felt nauseous. My partner and I just shake our heads and remain silent. It never ends. The man has a hairy chest and the leads are coming off. One of the nurses plucks at them so my partner goes ahead and takes the man off the monitor as we prepare to move him to the table. Another nurse looks at me and demands to know why I took him off the monitor before they hooked him up to theirs. Again, I just shake my head, thinking why are you yelling at us?

We get him over then sure enough, as they look for what kind of access I obtained, they see the 22 and the harassment starts anew. “A 22! That’s all? A 22!” We don’t bother to stay to watch the procedure. We just pack up our stretcher. On the way down in the elevator, I say to my partner, “10 times I asked him if he felt anything but fine.” “What are you going to do?” my partner says.

The call is completely unsatisfying. Last time we went up that lab we were heroes, treated like honored guests. Today we are just bumbling delivery workers. I sit in the ambulance and stare at the ECG. I still can’t figure it out. There is elevation where there should be depression and no elevation where there once was. It takes me 10 minutes of starring at it to figure it out.

New Picture (31)

The first six leads are completely scrambled.

Lead I is where Lead II should be, lead II is where aVR should be, lead aVR is where III should be, lead aVR is where III should be, aVL is where I should be, and aVF is where aVL should be.

F-me, I say. Can you believe this?

I think what would have happened is I had this guy on the street, presenting like he was, denying any problem and this was his ECG. I would never have called it a STEMI. Good thing he was already booked for the cath lab.

Back at the base, I report my monitor malfunction and have the monitor reprogrammed. I go into archives and I am able to retrieve the 12-lead now in the proper order.

New Picture (32)

In 20 years, I have never seen anything like this. I find an ECG from earlier in the day and see it too was scrambled. I find one from two weeks before with the same monitor and it was proper.

I can only think of 2 explanations. 1. There was a computer glitch or 2. Someone went in and reprogrammed it.

You get so used to seeing things a certain way, you don’t notice the lead labels anymore.


  • Christopher says:

    That’s Cabrera format, popular in some places overseas. Reorders the leads according to their cardinal directions (and turns aVR into -aVR).

    It’s a setting on pretty much all cardiac monitors so option #2 is the choice I’d take.

  • Steve says:

    Ha, I didn’t even notice the incorrect lead positions (yes, incorrect, we’re in ‘Merica damnit!) until near the end!

    Guess that will make me more watchful in the future!

  • Alex says:

    Fantastic case for education. Would you mind if I shared with some colleagues at med school (will give credit of course)?

  • Ezio says:

    Someone has rearranged the position of the leads for a quicker reading, personally I would use that format because I read the leads in groups (II III AvF, I AvL, AvR)

  • Don says:

    Thank you for a good honest post. I think those classic or “typical” presentations we learn in school are the exceptions really.

  • Dan says:

    Initially I thought my eyes were deceiving me while reading the ECG until I figured it out. I’ve run similar atypical STEMIs. Good job! Interesting blog!

  • Karim says:

    Patients make liars out of paramedics!
    And yeah, sometimes the cath lab nurses are so mean.

  • EMS Artifact says:

    Medical calls are just far more interesting and challenging than trauma calls.

    I’ve heard of, but never seen anyone use Cabrera format. It certainly can throw you off if you’re not looking very carefully.

    As to the rest of the call, sometimes nothing seems to go right. You did your job, you’re not responsible for other people not doing theirs.

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