The Skeptics' Guide to EM

SEPTEMBER 11, 2021

He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP). The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation.

EMR 130

EMR Coronary Defibrillator Life Support 130

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. There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. Who needs the cath lab?

STEMI 52

STEMI Paramedic Coronary ALS 52

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. The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 The serum K returned 8.7,

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. 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 prehospital, ED computer, and final cardiology interpretation was STEMI negative.

STEMI 73

STEMI Paramedic Coronary ED 73

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. Below is the initial ED ECG. Manual of Cardiovascular Medicine (5th ed.).

Coronary 130

Coronary STEMI Firefighter ED 130

EMS 12-Lead

APRIL 14, 2022

Madden, Paramedic. There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI). Let's revisit the deWinter occlusion provided by Paramedic Madden. 4] Surawicz, B.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

JUNE 17, 2016

Jason was very skeptical of STEMI. This also argues against STEMI. 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. He complained of 3 days of diarrhea and abdominal pain. What do you think? Jason, I agree. There is high R-wave voltage.

STEMI 52

STEMI OR Coronary EMS 52

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. 1] Here is the admitting ED ECG after cancellation of Code STEMI. 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

DECEMBER 9, 2023

He has a history of STEMI and heart failure. link] Case continued The conventional algorithm diagnosed STEMI and so did the paramedics. On arrival in the ED, the patient denied any symptoms at all. A 50-something had syncope while driving. He was belted and it was low speed. He had a prehospital ECG.

STEMI 115

STEMI Coronary ED Paramedic 115

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. A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered.

ACS 130

ACS Coronary STEMI CAD 130

ESO

APRIL 19, 2024

Due to this, it’s important for the industry to develop strategies for better supporting psychiatric patients while avoiding unnecessary ED visits and secondary EMS transports. For Eagle County Paramedic Services, turning to MIH was integral to helping them provide services for their underserved population while also saving millions in costs.

MIH 105

MIH EMS Paramedic Firefighter 105

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. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. Attached is the first ECG.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

FEBRUARY 25, 2009

RBBB in acute STEMI has a very high mortality. The paramedics activated the cath lab from the field. But here there is a large degree of ST elevation in V2-V6, I, and aVL.

Defibrillator 52

Defibrillator STEMI Paramedic EMS 52

Dr. Smith's ECG Blog

JUNE 24, 2016

The paramedic recorded a series of ECGs; the initial ECG is representative here: Computer read: “ Normal ECG ” What do you think? He was almost asymptomatic when he arrived in the ED. The paramedic interpreted this as a STEMI. An ECG was obtained in the ED: There is ST elevation in V2-V4. or LAD occlusion?

STEMI 40

STEMI Coronary Paramedic ED 40

Dr. Smith's ECG Blog

JANUARY 8, 2024

She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. Paramedics found her semi-conscious, pale, cool, diaphoretic, tachypneic, very hypotensive. Medics recorded the above ECG and called a STEMI alert. Her troponin I returned at 900 ng/L. Patient was given aspirin, sublingual nitro as well as heparin.

Coronary 71

Coronary STEMI EMS Paramedic 71

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

Jason was very skeptical of STEMI. This also argues against STEMI. 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. Look for old ECGs Do serial ECGs Do echocardiography June 17, 2016 Anterior STEMI? What do you think? Jason, I agree.

STEMI 52

STEMI Coronary EMS Paramedic 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2020

Her initial 12-lead ECG that was obtained by paramedics in the field is shown in Figure-1. Figure-1: The initial ECG in todays case, obtained by paramedics in the field. ( The Case Continues: The initial ECG was transmitted to the ED physician at the hospital. Both tracings were obtained by paramedics in the field. (

STEMI 52

STEMI Paramedic ED OR 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

This was shown to me by a very astute Hennepin paramedic. Although this comes from a Hennepin paramedic, the patient was not brought to Hennepin County Medical Center. It is important for cardiologists to realize that a paramedic may see something they do not. For some reason unknown to me, the interventionalist was in the ED.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The paramedics found the patient with ROSC and a GCS 7, and an ECG showing LBBB with possible lateral ST elevation. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Below is the first ED ECG, labeled LBBB by the machine. Vitals were HR 58 BP 167/70 R20 sat 96%.

EMR 52

EMR STEMI CPR ED 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

This case was sent by Lou B, a paramedic and RN. Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 Pattern looked to be BER.

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

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. Learning Points: 1. Learn to Recognize Hyperacute T-waves 2. From Gue at al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI).

STEMI 40

STEMI EMS Coronary ALS 40

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. The patient was brought directly to the cardiac catheterization lab for PCI, bypassing the ED. 2 The astute paramedic recognized this possibility and announced a CODE STEMI.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

JUNE 8, 2023

Here’s the paramedic ECG (digitized by PMcardio). STEMI negative : the EMS automated interpretation read, “STEMI negative. But the latest ACC consensus on the evaluation of chest pain in the ED warns that “STEMI criteria will miss a significant minority of patients with acute coronary occlusion.”[1]

STEMI 86

STEMI Coronary Paramedic ALS 86

ESO

APRIL 19, 2024

For Eagle County Paramedic Services, turning to mobile integrated healthcare was integral to helping them provide services for their underserved while also saving millions in costs. Supporting and advocating for mental health Mental health calls are increasing.

EMS 105

EMS Paramedic Critical Care STEMI 105

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

This is what the providers in the ED understood on patient arrival: Patient called 911 for syncope, then had witnessed PEA arrest after medics arrived. Here is the written paramedic report available after all the events were over: Patient was seen by witnesses to become unresponsive. Not a shockable rhythm.

STEMI 89

STEMI Paramedic E-9-1-1 Epinephrine 89

Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. He presented to a rural ED at approximately 0630hrs.

STEMI 116

STEMI Coronary ED Paramedic 116

Dr. Smith's ECG Blog

MARCH 3, 2025

She was found by paramedics with an oxygen saturation of 64%, but could not tolerate BiPAP during transport due to claustrophobia. She arrived to the ED with a nonrebreather mask. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. As her pain worsened, so did her dyspnea.

E-9-1-1 74

E-9-1-1 Coronary STEMI Emergency Department 74

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. The paramedic thought it was LAD OMI, but wasn't certain. The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI".

STEMI 121

STEMI ED Coronary EMS 121