The missed STEMI

Here is the history of present illness recorded by the physician at the time of the patient’s arrival in the emergency department.

“This 67-year-old male presents via EMS for evaluation of weakness, dehydration and one episode of nausea/vomiting. The symptoms began after approximately one hour of jogging this morning. The patient did not eat breakfast and he did not take his blood pressure medicine. The patient reports that he drank some Gatorade prior to contacting 9-1-1. He denies any chest pain or shortness of breath and reports he has otherwise been feeling well since a hip replacement three months ago. An IV was established by EMS and the patient is feeling improved at this time.”

Imagine their surprise when they recorded this 12-lead ECG.

The treating paramedic had placed the patient on the monitor, but no 12-lead ECG was captured in the field.

Here is the rhythm strip retrieved from the archives of the LP12.

Here is the exact same rhythm strip retrieved from ePCR with the low frequency / high pass filter set to 0.05 Hz (diagnostic mode).

Fortunately, the interventional cardiologist was at the hospital making rounds. The patient was fast-tracked to the cath lab where angiography revealed 100% occlusion of the distal RCA. The door-to-balloon (D2B) time was excellent.

Before – distal occlusion of the right coronary artery (RCA)

Balloon inflation

After successful stent placement

What is the take-home message for EMS professionals?

See also:

The Bait and Switch

18 Comments

  • casey says:

    wow. that rhythm strip alone would have been enough for me to run a 12 lead, no question about it.i might be a tad overkill, but i know i wouldn't have missed this one. glad the gentleman is ok and had quick D2B time. whew!

  • David says:

    is it really that hard to understand that it was missed? i too, would like to believe that i would have run a 12 lead… but the only reason i would is because of a commitment to run 12 leads on atypical presentations where there is another plausible explanation for the patient's symptoms. that is the tricky part. to me, it reminds of the number one reason healthcare professionals (including cardiologists) are sued for missed MI's–complaints of indigestion, where the patient attributes the discomfort to his/her "indigestion he has had before"when faced with symptoms that are easily attributable to something other than an MI, it takes a true commitment, almost a dogmatic one, to running 12 leads on atypical presentations "no matter what".just my two cents, or perhaps four cents.

  • CBEMT says:

    Take home message: to have a high degree of clinical suspicion.And why tiered systems can be dangerous.

  • Geoff says:

    I agree the take home message is to maintain a high risk of suspicion of atypical symptoms. I don't want to second guess anybody's actions if I wasn't there, but something I always ask myself on a call like this is, "If I am going to put the patient on the monitor (3 lead)…what am I looking for? What do I expect to get out of a 3 lead tracing?" If we are putting somebody on the monitor, we must be looking for something right? What do we expect to get from a 3 lead? I'm probably barking up the wrong tree since this is a cardiology site, but how many times have we seen somebody say, "just put him on the monitor real quick"? Then, I think we need to realize that a single 12 lead really doesn't rule anything out. Would you agree, that we can use it to rule in, but not to rule out?Fortunately this patient had a good outcome. In my opinion, sometimes cases like this almost make a greater educational points than a "success story". If it is presented correctly.Once again, great case.Thank you

  • Christopher says:

    I'm not sure I would call that even atypical presentation. Weakness and n&v; with the patient's age and history (high BP) all point me to 12L. The constructive criticism is pointed at myself as much as that crew; due diligence is required to make sure these don't slip by!

  • Atypical MI still = MIChest pain doesn't = MI

  • Brown Frown says:

    CBEMT, what kind of tiered system are you referring to?

  • Anonymous says:

    Whats do you see on the 3 lead? Hard to see an ischemi in a 3 lead or can an St elivation in a 3 lead tell u something ?Plz explain for a rookie student :). Thx/rookie.

  • Christopher says:

    @Anonymous,The original 3L is not of diagnostic quality, but it definitely does not look "right", more specifically in the ST segment. The second 3L given is the same one but using diagnostic filters (hand-waving over that one for now), which clearly shows ST elevation.It'll take a lot of work to get a feel for what is "normal" and what is not. However, as a recent Paramedic grad, I'd encourage you to stick to your rules and not leap to any conclusions about ST-segments from a non-diagnostic 3L. You'll work yourself into plenty of false positives :)You have enough indications from the physical assessment and patient history to run a 12L for this patient.

  • RobertB says:

    Interesting that the 3L didn't show any sign of the bigeminy. You'd expect that you wouldn't necessarily see indication of ST changes, but you'd definitely see bigeminy.

  • njmedic1485 says:

    The take home message for me on this case is everyone over 40 with a complaint gets a 12 lead environment allowing, it takes seconds to perform and can be most helpful. Great teaching case demonstrating that atypical presentations aren't all that atypical.Bob

  • Anonymous says:

    I'm guessing the bigeminy didn't develop until later.

  • John Fekety, J. D., EMT-P says:

    Way before I got into EMS my father had his first MI. After more than 24 hours of "indigestion" he called me to take him to the doctor. As soon as I saw him I knew he needed more than the family doc. But, like I said, before I was in EMS, I drove him to the local ED. After a while the ED doc came out and told me my dad had a heart attack. In the ensuing years before his death, all of his cardiac events were preceded by "indigestion". Since becoming a paramedic I have been criticized for overtreating patients. Regardless of the criticism, every patient I have that has symptoms of indigestion or other "atypical" MI presentations will get at least a 12 lead, if not a 15 lead.

  • Troy says:

    That’s disgusting to me. Remember, ecg patches for a 12L cost 2 bucks, lawsuit for missed STEMI costs 2 million. Remediational training is definitely needed.

  • Colette says:

    Bob – I wouldn’t be putting an arbitrary age limit on it
    Troy – its not just about the money!

  • Troy says:

    Colette,
    I know its not just about the money. Poor work ethic and laziness causes poor patient care. life is worth more than gold!

  • Gary Denton says:

    The patient complained of weakness. Weakness is an ANGINAL EQUIVALENT.  Most paramedics are not familiar with the term.  If they were, we would miss fewer STEMI's.  The AHA has been using that term for years to describe symptoms people have when they have an ACS without Chest Pain.  Syncope, pre-syncope, weakness, palpitations, N&V, and Dyspnea are the main ANGINAL EQUIVALENTS. I recently took an ACLS recert class and the term was never mentioned.  Paramedics graduating from the local Paramedic program have never heard the term mentioned in class or clinical.  ANGINAL EQUIVALENT.  Learn it, use it, teach it.  (Another sad case of people living in spite of EMS, not because of it.)

  • George Duron says:

    Lead II has no clue!! A very good class for new or refresh is Bob Page's class ….He made an 8 hour  class seem like 2 hours!! Great instrustor!!

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