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