A recent graduate of our hospitalâ€™s paramedic program brought this case to me. Leigh works for Stratford EMS, an excellent local service in Southwestern Connecticut.

(A quick note on the specific details of the case: This patient did not necessarily come to my hospital. Additionally, several features of the case have been altered; some to preserve anonymity, others to simplify the case. The ECGs and other essential aspects are unchanged.)

The Case:

EMS was dispatched for a 68-year-old male with altered mental status. On arrival, however, they found the gentlemen to be alert but disoriented. Per the patient, his legs just â€œgave way,â€ and he fell onto the floor. His family found him 30 minutes later, still on the floor, too weak to stand. They called 911.

PMHx: Atrial fibrillation, COPD, CHF, DM2

Meds: Carvedilol, HCTZ, furosemide, metolazone, spironolactone, warfarin, Januvia, Advair, Spiriva

Vital Signs:

HR â€“ 91

BP â€“ 134/78

RR – 24

SaO2 â€“ 93% RA

BG â€“ 74 mg/dL (4.1 mmol/L)

Exam:

Gen: Appears ill

Skin: No bruises/abrasions

Lungs: Diminished bilaterally

Cardiac: No gross murmurs

Neuro: Weakness bilateral legs

Electrocardiography:

A rhythm strip was obtained:

A 12-lead was obtained:

The *** MEETS ST ELEVATION MI CRITERIA *** notification catches your eye, of course!

Discussion:

The nearest 24/7 PCI center is 20 minutes away, while a smaller community hospital (fibrinolysis only, but has an ICU, etc.) is â€œjust around the corner.â€ What is your transport destination?

Update: The conclusion, with the diagnosis, is now available. Click to go there!