52 y/o M Chest Pain – Conclusion

If you said early re-polarization, you may or may not be right.

Unfortunately, we will never know. This guy refused care even after strong, STRONG advice from me and my partner (who knew the guy through family connections) about that he may be having an AMI even though the computer says “NORMAL.” Even if we transported him, many of the cases I request feedback on get lost in translation, and usually with the hospital withholding records because of a supposed chance of a HIPAA violation.

I captured a second 12 lead before I cut him loose, which was pretty much unchanged from the first.

I will split this into multiple posts, because there are many issues here that came to mind, but first I want to focus on the ECG.

After seeing this, I felt a bit uneasy about this guy, considering his onset time and reason, pain sensation location and type, and just looking at him generally. What prompted me to post was something I found while both looking at Dr Smith’s ECG blog AND the Pre-Hospital EMS 12 Lead blog.

Dr Smith is an excellent resource, and I refer to his blog frequently when I’m seeking an answer. I was mainly interested into his research into identifying NSTEMI or evolving STEMI when the computer throws an early repol analysis. I didn’t agree with the interpretation (as any discerning medic should never trust the computer alone) so when I made it back to the station I began scouring Dr. Smith’s blog for some way for me to tell what the heck was going on. I found an equation he had derived that had a 90% specificity (that is, identifies 9/10 supposedly normal ECG’s showing early repol as being an LAD occlusion). The source video is on his blog here.

[(1.1.96 x STE 60 ms after J point V3 in mm)] + [(.059 x QTc in ms)] – [(0.326 x R wave amplitude in V4 in mm)] with >23.4 = LAD occulsion

So, I quickly scribbled this out, and with the 2nd 12 lead looking much the same as the first, I used the 2nd one for application. Double check my numbers ECG nerds but I got:

STE 60 ms after J point in V3 – 2 mm
QTc – 25.429
R amplitude in V4 – 14 mm

Which when assembled looks like:

[(1.196×2)] + [(0.059×431)] – [(3.26×14])
2.392 + 25.429 – 4.564
=23.257

Based on the numbers alone, we could say this isn’t an evolving STEMI, or could we? The numbers are VERY close, with only a difference in tenths, and of course this would require further investigation.

If this patient HAD went to the hospital, we would have had the lab access to draw his blood and find out within 15 minutes of his arrival if his chest pain was the cause of a STEMI or COPD. I know some places test triponin in the field, and I would have run that diagnostic while waiting if I had it available. If only there were a meter similar to a glucometer or lactate meter, but I digress.

My thoughts on chest pain patients refusing care, that is another story.