Here is a great case submitted by faithful reader Niels, a Paramedic in Germany. As always, some minor information may have been changed to preserve patient confidentiality.
Our case today takes us overseas, to the German countryside. It's a clear blue Monday morning, 11:40 am, when you and your partner are called to a 51 year old male complaining of chest pain. You are dispatched parallel to an Emergency Physician (in Germany, every ALS call is dispatched with an ALS ambulance and a doctor).
On arrival, you find a male patient lying in bed. He appears to be very diaphoretic an pale. He tells you he is very athletic and fit, but today is "feeling horrible". He says his "chest is killing him", and he admits to being nauseous, with several bouts of vomiting.
O,P,Q,R,S,T: He tells you he woke up with the pain, and it seemingly came out of the blue–he was feeling fine the night before. Nothing seems to make the pain, which he describes as "crushing', feel better. In fact he can find no position of comfort. You seem to be compiling "red flags" as he tells you that the substernal pain also radiates to his left arm. He rates it a 4 or 5 out of 10, and says it began about 15 minutes before EMS was called. You ask if he's ever had this happen before and he says no.
As your partner starts to apply the electrodes, you continue your HPI and vitals. He has no real medical history, although he did smoke but quit ten years ago. He takes no meds. He does tell you that he saw his general physician last week for becoming "short of breath" during his workouts. Pneumonia was ruled out.
- HR: 67 and regular
- BP: 92/57
- RR: 28, a bit labored
- Skin: cool and moist
- Lungs Clear, SpO2 99% on room air
You give him 4 baby ASA, and acquire the following 12 lead ECG:
Ok, this is not what you are used to seeing. In addition, the speed is 50mm/sec. Thanks to the studio magic of Christopher Watford, here is the same ECG "stitched" together in the familiar format, speed adjusted to 25mm/sec:
A few moments later, the Physician arrives. He wants to know the status of the patient, and what you see on the ECG.
What do you tell him?