From Blood, Sweat and Tears to Coronary Artery Disease: A Paramedic’s Journey Through the EMS Trenches
JEMS
APRIL 9, 2025
Mike Doss provides a firsthand account of the long-term health impacts of a career in EMS.
Coronary EMS Paramedic 
SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST Elevations?
The Skeptics' Guide to EM
SEPTEMBER 11, 2021
Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. The TOMAHAWK Investigators.
EMR 
130
130 Join 5,000+
professionals
Sign Up for our Newsletter
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Trending Sources
Distractions
EMS 12-Lead
MARCH 19, 2023
David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (Ret) @DidlakeDW Expert contribution by Dr Robert Herman @RobertHermanMD @PowerfulMedical (Chief Medical Officer) An adult male called 911 for new-onset epigastric burning. Fire/EMS crews found him clammy and uncomfortable. Breath sounds were clear in all lung fields.
Coronary 130
130 
Serial ECGs for chest pain: at what point would you activate the cath lab?
Dr. Smith's ECG Blog
AUGUST 11, 2024
Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. In isolation this ECG does not show OMI, but following the paramedic ECGs this indicates spontaneous LAD reperfusion. It’s unclear if the paramedic ECGs were seen or missed in the ED.
STEMI 100
100 
Something Winter This Way Comes
EMS 12-Lead
AUGUST 14, 2022
David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic @DidlakeDW A 50 y/o Male was taking his dog for a leisurely stroll through the park when he suddenly experienced new onset chest discomfort. EMS personnel found him seated on a bench, uncomfortable, but without gross distress. But the lesion is still active!
MICU 130
130 
50 Shades of T
EMS 12-Lead
APRIL 14, 2022
Madden, Paramedic. He presented to EMS with extreme pallor, Levine sign, diaphoresis, bilateral arm pain, and an apprehensive sense of doom. It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). Let's revisit the deWinter occlusion provided by Paramedic Madden.
ACS 130
130 
Hypertrophic Cardiomyopathy
EMS 12-Lead
MAY 20, 2022
David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review and commentary by Dr. Steve Smith [link] @SmithECGblog It is early-summer, approximately 1330 hours, no cloud cover overhead, and 86 degrees with high humidity. Are these findings consistent with a particular coronary distribution?
Coronary 130
130 
Critical Left Main
EMS 12-Lead
JULY 24, 2023
David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. It’s judicious, then, to arrange for coronary angiogram.
Coronary 130
130 
Formula Utilization
EMS 12-Lead
JUNE 20, 2022
David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith @SmithECGblog I was conducting QA/QI on two very recent cases and was struck by the uniqueness of both. He called 911, and EMS crews subsequently found him diaphoretic and vomiting. A 12 Lead ECG was recorded.
ACS 130
130 
Syncope and Block
EMS 12-Lead
JUNE 1, 2022
David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. EMS finds him supine, alert and oriented, and without any gross distress. Crew members note residual pallor and clammy skin.
Coronary 130
130 
Is OMI an ECG Diagnosis?
Dr. Smith's ECG Blog
APRIL 18, 2024
Paramedics provided another 3 sprays of nitro, and 6mg of morphine, which reduced but did not resolve the pain. Similarly, if a patient with known CAD presents with refractory ischemic chest pain, the ECG barely matters: the pre-test likelihood of acute coronary occlusion is so high that they need an emergent angiogram.
STEMI 121
121 
Dark Side of the Moon
EMS 12-Lead
APRIL 8, 2022
David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review by Dr. Stephen Smith @smithECGblog I was reviewing ECG’s in our LifeNet database and happened upon this one without any knowledge of clinical circumstances. He reported to EMS a medical history of GERD only. However, in this context (i.e.
STEMI 130
130 
Peculiar ST and QT
EMS 12-Lead
JULY 30, 2023
She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease. Pharmacology Review Digoxin is probably one of those medications vaguely recalled from paramedic school. David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath.
EMT 130
130 
Hyperkalemia
EMS 12-Lead
MAY 8, 2022
David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith [link] @SmithECGBlog An adult female called 911 for chest discomfort and difficulty breathing. EMS found her acutely ill, mottled, dry mucous membranes, modestly hypotensive, and lethargic. The serum K returned 8.7,
STEMI 130
130 
What Lies Beneath
EMS 12-Lead
AUGUST 22, 2022
The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Furthermore, pertinent electrolyte values (e.g. potassium) were within normal parameter.
E-9-1-1 130
130 
A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?
Dr. Smith's ECG Blog
MAY 23, 2023
EMS arrived and recorded this ECG: What do you think? But the paramedic and the ED physician in this case did not subscribe to this idea. It is far too premature to say that paramedics and physicians should not be bothered to interpret ECGs labelled as "normal" or "otherwise normal" by the computer algorithm.
STEMI 98
98 
Two patients with chest pain and RBBB: do either have occlusion MI?
Dr. Smith's ECG Blog
OCTOBER 17, 2024
Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Coronaries were normal, as was serial troponin. Vitals were normal.
STEMI 73
73 
60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?
Dr. Smith's ECG Blog
JULY 7, 2024
Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain with diaphoresis, and called EMS. Here’s the EMS ECG, digitized with PM cardio. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. Take home 1.
STEMI 66
66 
What do you suspect from this ECG in this 40-something with SOB and Chest pain?
Dr. Smith's ECG Blog
JANUARY 8, 2024
She went to angio and had normal coronaries. Paramedics found her semi-conscious, pale, cool, diaphoretic, tachypneic, very hypotensive. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed the case with Cardiology will admit to their service."
Coronary 71
71 
Syncope While Driving. Activate the Cath Lab?
Dr. Smith's ECG Blog
DECEMBER 9, 2023
link] Case continued The conventional algorithm diagnosed STEMI and so did the paramedics. A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA. Figure-1: The initial ECG in today's case — obtained by the EMS team. (
STEMI 115
115 
I'm so sorry when medics get abused for activating the cath lab
Dr. Smith's ECG Blog
OCTOBER 28, 2022
Cortland Ashbrook from Spokane County, Washington, sent this message: Hey doctor Smith, I wondered if you’d give me your opinion on these ECG tracings I took as a paramedic in the field? Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria.
Coronary 52
52 
When Acute Anterior STEMI Does Not Meet Guidelines
ECG Medical Training
SEPTEMBER 4, 2016
EMS was called to evaluate a male patient in his 60s with a chief complaint of chest pain. Onset: Gradual while walking Provoke: Initially the pain felt better with rest Quality: Described as a dull ache Radiate: The pain radiates to the back Severity: 7/10 Time: 3 hours He states that he feels nauseated and vomited x2 prior to EMS arrival.
STEMI 52
52 
Target Acquired
EMS 12-Lead
APRIL 2, 2022
David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Expert commentary provided by Dr. Ken Grauer CASE 1 An 82 y/o Male called 911 for sudden onset dizziness while at rest. Upon arrival he was found alert and oriented, and without gross distress. He denied difficulty breathing, epigastric pain, or chest discomfort.
ALS 130
130 
Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."
Dr. Smith's ECG Blog
NOVEMBER 30, 2022
This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!!
Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm
Dr. Smith's ECG Blog
FEBRUARY 13, 2023
Written by Jesse McLaren Two 70 year olds had acute chest pain with nausea and shortness of breath, and called paramedics. But these ECGs were from the same patient: #1 on paramedic arrival and #2 thirty minutes later. Thankfully this patient’s second ECG met STEMI criteria, so paramedics brought them as a code STEMI.
STEMI 52
52 
An Elderly Male with "Indigestion"
Dr. Smith's ECG Blog
JUNE 24, 2016
This case was contributed by Brooks Walsh, an ECG enthusiast who has contributed frequently , and edited by Smith Case An elderly male called EMS after he developed “indigestion.” The paramedic recorded a series of ECGs; the initial ECG is representative here: Computer read: “ Normal ECG ” What do you think? or LAD occlusion?
STEMI 40
40 
Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!
Dr. Smith's ECG Blog
NOVEMBER 19, 2016
It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. The paramedic’s initial impression of the patient was that he was critically ill. 2 The astute paramedic recognized this possibility and announced a CODE STEMI.
Coronary 40
40 
A 58 year old with Weakness and more than 4 mm ST Elevation in V3
Dr. Smith's ECG Blog
AUGUST 9, 2018
This case was sent by Lou B, a paramedic and RN. The coronaries were clean (this is not the gold standard, however, as some patients with ischemic ST elevation may have clean coronaries). ACTUAL CORONARY ANATOMY: Dominance: Right LM: A 5 mm vessel which bifurcates into the LAD and LCx coronary artery.
E-9-1-1 52
52 
Anterior STEMI? Or Benign Early Repolarization?
Dr. Smith's ECG Blog
JUNE 17, 2016
Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them.
STEMI 52
52 
Severe Chest Pain on ED Arrival, after Wellens' waves Seen on Prehospital ECG
Dr. Smith's ECG Blog
MARCH 13, 2023
Smith — in the setting of a patient with new chest pain — the initial ECG in today's case ( = ECG #1 — obtained by the EMS team prior to ED arrival ) — is diagnostic of ACS ( A cute C oronary S yndrome ) until proven otherwise.
ED 52
52 
This patient did not present with chest pain
Dr. Smith's ECG Blog
FEBRUARY 4, 2023
Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them.
STEMI 52
52 
The computer calls this a “normal ECG”. We'll just keep making this point.
Dr. Smith's ECG Blog
DECEMBER 19, 2018
The symptoms improved somewhat after the paramedic gave her nitroglycerin. In combination with the subtle ST depression in aVL , these changes are diagnostic for, or at least nearly so, for acute occlusion of a coronary artery, probably with some reperfusion, as inferior T-waves are inverted and the T-wave in aVL is reciprocally upright.
ED 52
52 
A 40-Something male with a "Seizure," Hypotension, and Bradycardia
Dr. Smith's ECG Blog
OCTOBER 7, 2019
This is by one of our outstanding 3rd year residents , Aaron Robinson, with some edits and comments by Smith EMS responded to a reported seizure in a 42 year old male. One of our EMS Fellows along with a Senior EM Resident were on duty that evening, and arrived on the scene with the Fire Department.
STEMI 40
40 
The Cardiovascular System for EMTs: Interventions and Heart Conditions
EMT Training Station
JUNE 18, 2023
Oxygen Administration Oxygen is crucial for patients suffering from a heart attack as it can help increase the amount of oxygen available to the heart muscle, which may be deprived due to blocked coronary arteries. Nitroglycerin can help to dilate coronary arteries and improve blood flow to the heart muscle.
EMT 52
52 
75 year old with 24 hours of chest pain, STEMI negative
Dr. Smith's ECG Blog
JUNE 8, 2023
Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. Here’s the paramedic ECG (digitized by PMcardio). STEMI negative : the EMS automated interpretation read, “STEMI negative. paramedic transportation to the ED as “chest pain, STEMI negative” 2. What do you think?
STEMI 86
86 
Acute coma, then Sudden PEA arrest in front of paramedics, with STEMI?
Dr. Smith's ECG Blog
FEBRUARY 20, 2025
Here is the written paramedic report available after all the events were over: Patient was seen by witnesses to become unresponsive. Moreover, when someone has immediate resuscitation of an arrest witnessed by paramedics, they rarely have a GCS of 3 (deep coma). Moreover, it does not follow a coronary distribution very well.
STEMI 89
89 
What is Wellens' syndrome? And what conditions mimic it?
Dr. Smith's ECG Blog
APRIL 2, 2025
A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. He awoke from sleep with crushing central chest pain and called ems. EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain. Penn, Hein J.J.
STEMI 76
76 
Fueling the Failing Heart: A Guide to Cardiogenic Shock
FOAMfrat
DECEMBER 4, 2024
You’re me, and you’re in paramedic school, in the thick of the cardiology section. In the EMS setting, the most common cardiogenic shock patient is most likely a STEMI. The ultimate goal is to optimize coronary perfusion pressure (CPP)—in other words, the amount of blood flow into the coronary arteries.
Coronary 64
64 
Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?
Dr. Smith's ECG Blog
MARCH 3, 2025
A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. She was found by paramedics with an oxygen saturation of 64%, but could not tolerate BiPAP during transport due to claustrophobia. As her pain worsened, so did her dyspnea.
E-9-1-1 74
74 
Anterior OMI with RBBB has VF x 3: how to prevent further episodes of VF?
Dr. Smith's ECG Blog
APRIL 9, 2025
The paramedics diagnosis was "Possible Anterolateral STEMI." Lidocaine had been used for the prevention of VF since the 1960s after coronary care units became a standard setting for the treatment of AMI. Results: After application of exclusion criteria, 23,263 patients from 1,707 EMS agencies were eligible for analysis.
Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"
Dr. Smith's ECG Blog
OCTOBER 27, 2024
This was submitted by a paramedic, Hailey Kennedy A late 50s male called 911 following 2 hours of chest pain that started while working at his desk. Here is his EMS ECG: What do you think? The paramedic thought it was LAD OMI, but wasn't certain. Cath lab was activated by EMS and transported emergent."
STEMI 121
121 
Let's personalize your content