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Fiznat, First off I applaud you for going the extra mile for your patient. Most medics would stop with the initial 12 Leads and scratch their heads. Any chance you have to look at additional heart muscle is good in the context of understanding what may or may not be happening. The initial ECG does show inverted T Waves, which is a sign of ischemia. Now this may very well be caused by the bradycardia. I would lean this way due to the additional T Wave Inversion in the Anterior Leads ..... This is not from an old event, T Waves are not typically inverted. It may be fixed with simple oxygen administration. Maybe not .... As far as the Right Sided debate, I would like to offer my thoughts. First off, the Right Ventricle is viewed in the original 12 Lead ECG with V1-V2. In this ECG we have RBBB, so we cannot get a good look at the RV .... Also - V4r is a much better view of the RV, and this is the Lead of Choice for Diagnostic purposes. It is totally appropriate to look at the RV to Rule Out RVI. Typically I teach Medics to look at the RV in the setting of Inferior AMI, but there is a small population whose Inferior Wall is fed by the LCX. In this case a person with a proximal occlusion of the RCA would have RVI with no signs on the initial 12 Lead. These are the ones that you are looking for in this case. It may truly be Life Saving...because as you found out - Most ED Docs aren't interested in looking for this. It just ain't high on the priority list. If we don't find it Pre-Hospital, time will be lost. My crews have found 2 Posterior AMI's in the field which led to Rapid Triage to a Cath Lab .... On a personal note I have a good friend who went to the same ED with a Posterior AMI and sat in the ED for 4 hours until his enzymes bumped. Muscle was lost .... One last note - The RBBB is typically fed from the LAD, but it may receive its blood supply from the PDA. In the setting of Proximal RCA Occlusion you could have this Tri-Fasicular Block presentation. I think it was a good thought to take a look .... Keep up the good work, and keep asking WHY ... I still learn something new every day .... Jason Kinley Xania,Ohio

Dust Devil .... There is ST Elevation in all 3 examples above. Please share whay you thought #2 was a Slam Dunk .... You may understand Sgarbossa's Criteria better than you thought ... And I'm glad to participate in good discussion .... Jason Kinley

There is some literature that supports the Glass Bottle theory for both Nitro and Amiodarone. We put 150 mg of Amiodarone in a 250 bag of NaCl and run it over 10 minutes. You are not going to see any degradation of the drug in this short of time. For the Nitro infusion we also use a 250 bag of NaCl ....... The hospital switches them over to a glass bottle. Jason Kinley Xenia, ohio

ECG #2 has Concordance in the Lateral Leads .... This is the AMI Patient. I once had the opportunity to spend a day with Dr. Tomas Garcia (Author of 12 Lead ECG: The Art of Interpretation) and he spoke the next day at an all day 12 Lead Class. He has alot of great information ...but he stressed that Concordance is BAD .... He did not give any example of Good Concordance ..... It is always in the Company of AMI .... That has always stuck with me. I have attached another example of Concordance ..... This time in a patient with an Implanted Pacemaker. Obviously if the QRS is >.12 we teach the Paramedics that they cannot distinguish STEMI .... but when there is Concordance it is a different story. This particular patient was lucky enough that the ED Doc liked the report and did activate the Cath Lab ...The patient did get their intervention and had a great outcome. EEP Online - Pacer ECG Jason Kinley

I'm not sure you are interpreting the study properly ..... Concordant ST Elevation in V1-V3 is very Specific ....... in the setting of LBBB. Just because it is not as sensitive does not make it a benign finding. If they have it ... it's an AMI ... The second study posted describes the low number of LBBB Pt's who properly get their PCI or Intervention ....leading to high Mortality. More reason to try to identify these patients early and get them the proper intervention. To say that ED Docs would just ignore this seems like No Faith in the EMS Provider .... Thats why it seems like we want to dumb down the EMT ... If the Docs dont have faith in the skills of the EMS folks they should invest in helping to educate them. It will equal better patient care .... Not trying to argue with you ...but in systems with AMI Alert Protocols ....These patients should get the benefit of an Alert ... Jason Kinley Xenia,Ohio

Why do we keep trying to Dumb Down EMS .... If a Paramedic wants to better understand ECG Changes that occur in the setting of LBBB that will better predict STEMI why would we want to discourage this ? Concordant ST Elevation in the setting of LBBB is highly predictive of STEMI and should be an indicator of a patient who will need to be taken to the Cath Lab emergently. If your system has STEMI Alert Protocols for EMS this is definitely a Patient who is both High Risk and would benefit greatly from the EMS Activation of the Cath Lab. Far too often I have seen ED Physicians shrug off a LBBB Patient and defer to Cardiology ....The delay has proven Deadly in at least 2 patients I have seen. Had the Paramedic recognized any of the Sgarbossa's criteria the patients may have had a better outcome. I applaud you for asking the question...and trying to better understand those ECG Findings that may indicate STEMI in this patient population. Jason Kinley Xenia, Ohio

We have been using the Bone Injection Gun for 2 years with great success. There are no extra start up costs, and we are paying about $60.00 per device. I believe this is half the cost of the other options. We recently used the BIG on a Trauma Victim for RSI .... The Flight Crew was preparing for Central Line until we stuck a BIG in the Proximal Tibia. Airway captured, Patient on the way to Trauma Center. I would recommend that you explore all options. we have found Adult I/O to be very valuable. Jason Kinley Xenia, Ohio