OMI vs STEMI: Understanding Critical EKG Patterns in EMS (Part 1)

In this episode of The Erik and Matt Show, Dr. Erik Axene and Matt Ball break down the vital differences between Occlusive Myocardial Infarction (OMI) and STEMI, two critical conditions that can make the difference between life and death in pre-hospital care. While STEMI recognition has long been the standard, new research shows that focusing solely on STEMI could lead to missing up to 25% of heart attack patients. Tune in as Erik and Matt discuss essential EKG patterns and what every EMS provider needs to know to provide the best care possible.

Explore more EMS resources, training programs, and expert insights on our website: https://axenece.com

Transcript

Erik: [00:00:00] If you're only looking for STEMIs, you're going to miss a large group of people who need the cath lab just as much as an ST elevation. And not just be so focused on the EKG where when I see no ST elevation, I'm like dismissing everything you say. I can't do that.

Narrator: You are listening to EMS with your hosts, Erik Axene and Matt Ball.

Matt: So we've got some exciting, I mean, I say that every time, [00:00:30] exciting topics, but this is something.

Erik: Always exciting, Matt.

Matt: Yeah. They're always good topics. We're talking about the human body.

Erik: There is not a more interesting machine on the planet than our human body, I believe.

Matt: Super complicated. But, uh.

Erik: Wonderful.

Matt: Yeah. It's amazing. Amazing how the human body works. If you like our page, if you like our content, subscribe to our page, hit the like button, make a comment on this video, that helps us out. Um, so, as a firefighter paramedic, You know, one of our big things is STEMI [00:01:00] recognition, right? That's a big deal, is you gotta be able to recognize STEMIs and not miss STEMIs.

Erik: Would you say that, is there a bigger red flag? I mean, when you're going through school, recognizing a STEMI? I mean, maybe cardiac arrest, I mean

Matt: Well, yeah, cardiac arrest would obviously be huge.

Erik: But the STEMI though, the heart attack, that's a big deal.

Matt: So when I think about like activations, right, through my career, like even when I started, we didn't do like stroke activations, right?

But when I started, we did do STEMI activations, right? And, uh, you know, [00:01:30] obviously that science has progressed, and now it's progressed even. There's a new term, catchphrase, and just to be clear, we're still talking about myocardial infarctions, heart attack, whatever word you want to put on it. We're still talking about blockage in the coronary arteries, reducing blood flow to the heart, right?

Erik: right.

Matt: But we're not necessarily, STEMI, that term is kind of going out. Right?

Erik: Well, I think it should. I mean, the term itself is good [00:02:00] because an ST elevation on an EKG is badness.

Matt: Right.

Erik: And we need to recognize that. That's good.

Matt: It is one indicator of a heart attack, but it's not the only one. And we've been taught for so long that, and we say this, you know, I've said it numerous times, like, yeah, you know, 12 lead talking to a patient, like this isn't definitive.

We've got to get you to the hospital. We've got to draw labs, blah, blah. But, I mean, I know obviously there's things like end STEMIs, you know, I've had patients and I've always thought, and been taught, treat your patient, not your monitor. [00:02:30] I've got a patient that's pale, diaphoretic, they look terrible, they're complaining of chest pain, and I do a 12 lead and there's nothing there.

I'm still calling that a STEMI, or I'm still, in my mind, calling that a heart attack, maybe transmitting, but, Now, with this new phrase, there's other things we need to be looking for.

Erik: Well, I'm telling you, we're on the tip of the spear here, Matt, because there's a lot of hospitals. I'm not going to name any names here in the DFW area, fourth largest Metroplex in the country.

I mean, we should be, we should be up to date. [00:03:00] We're missing about a quarter of occlusive pathophysiology by only looking for STEMIs. What that means is, and we talked about this, you know this, but if you're watching this or listening to this and you didn't know this, if you're only looking for STEMIs, you're going to miss a large group of people who need the cath lab just as much as an ST elevation.

Matt: Right.

Erik: I'm going to back up just a moment, Matt, because I think it's a good reminder. You know, when we're talking about sepsis, it's [00:03:30] not all about QSELFA and SERS criteria and trying to identify people. I mean, that's a big part of it, right? Yeah. But the problem with, so with sepsis is that you have somebody with an infection that's affecting their physiology and they can't maintain perfusion.

That's, that's what's going on. Stroke. You've got an occlusive lesion in the circulation to the brain, and the brain cells are going to die if we don't get that circulation back. Same thing's happening in the heart. You get blockage of the heart, [00:04:00] blood, and the blood cells, I'm sorry, the heart cells die.

If you don't reperfuse them. That's what's going on. That's the pathophysiology. Same thing for trauma. If you damage the hoses.

Matt: It's all related to the distribution of blood.

Erik: It is so that’s what’s killing people. So, we're focused today like you said eloquently and perfectly. You said we're focusing on the STEMIs today.

This is occlusive lesion. So OMI is a better term, an umbrella term for [00:04:30] anything that needs reperfusion. Again, if we are hyper focused like many hospitals are, they only activate the cath lab if there's ST elevation. That hospital, you're going to miss a large portion of people. They, uh, we could be missing as much as a quarter of the people with that pathophysiology of occlusion. That's why we call these occlusive occlusion myocardial infarctions, OMI, which is a better term in my opinion, as a physician. And I know you and I [00:05:00] agree, uh, this is what we need to be looking for. And I think in my opinion, that the term STEMI is hopefully an old term.

Matt: Well I think that it's still a term that's relevant because we're still going to be looking for ST segment elevation. What we have to be aware of is that that's not the only thing that could indicate a possible occlusion.

Erik: Well, I would wager to guess that most people in the back of an ambulance are looking at the EKG. They say, Oh, no STEMI.

Matt: Million [00:05:30] percent.

Erik: We need to focus on those situations where it may not be a STEMI, but it's just as dangerous as a STEMI. Those other five patterns we're going to talk about today that, that you need to know. I think this, this information needs to get out there to everybody. And I, I hope that this gets forwarded, distributed. I mean, if you hear this and you've never heard it before, I think you have an obligation to spread the news on this and that we need to get this out because there are a lot of people missing our [00:06:00] family members potentially, or they're going to miss the EKG pattern and we're talking about minutes that count for those little cardiac milesides that are dying.

Matt: And we're going to do a true one hour long CE on this. But this, this information is very new to us.

Erik: Well, yeah, the term is.

Matt: The term is new to us and we felt so passionate about it that so it was so important that we wanted to get it out in some form. So that's [00:06:30] why we're doing this podcast on it.

Erik: I'm going to, I'm going to defend you and me though, because we covered four of the five pretty thoroughly.

Erik: So if you watched our STEMI lectures, we called them STEMI mimics or STEMI equivalents. But, but again, the problem is our hospital system isn't, isn't activated. We don't activate cath labs on some of these patterns, which we should be.

And we're missing them. And I think some of us in the pre hospital environment aren't even aware of this. The ones I've talked to.

Matt: Yeah.

Erik: [00:07:00] We need to, we need to get the word out on these things.

Matt: It seems like a lot of times and a lot of things like this that have come up, for example, like end-tidal.

The pre hospital providers are usually really quick to change or not change but update their practice as opposed to the hospital system. I'm not sure why that is, but like I've gone in like, you know, in, in my department, we're very well educated on the correlation of end-tidal with sepsis that, you know, end tidal readings of 25 or less typically correlate with fairly high lactate readings in the [00:07:30] hospital.

And I can tell you from my experience. that that is held true when I have had a patient that I'm calling sepsis on because they're meeting the Sears criteria or whatever, I will always throw them on end title just out of curiosity to see what their end title is. And. Almost 100 percent of the time, if their end tidal is low, their lactate has been super high.

Erik: And what does that mean when the lactate's high? They're not perfusing organs. And those organs, to survive, are going through alternate means of metabolism, and they're using things that are inefficient, and that's how organ [00:08:00] systems shut down. So when you get a high lactate, that's kind of like that last ditch effort, we're shutting down if we don't get this fixed.

Matt: We're shunting, we're doing psych trauma, it's the same, yeah, exactly.

Erik: Same thing here, back with the stammies. Yes. Again, it's all about the fact, if you block coronary arteries, you're going to see a patient potentially complaining of chest pressure, of an elephant sitting on the chest, radiating pain down the arms up to the jaw, diaphoresis and nausea.

These are classic signs, those high, uh, [00:08:30] What we call in medicine likelihood ratios of association with a heart lesion again If you see a patient that's complaining a chest pressure, and they're vomiting. That's a bad sign.

Matt: Red flag, red flag.

Erik: Right, like Adam says you know danger, danger danger!

So that's that's the key that's the key here, so let's let's say should we

Matt: yeah, let's go through yeah There's how many

Erik: There's five, five.

Matt: We hit four of the five, but there's one that was kind of new to us, [00:09:00] too, that we kind of had to do some research on. So don't feel bad if you're a paramedic or even a physician out there like, I've never heard of that before.

Erik: Yeah, there's certain EKG patterns that I kind of said, ah, that's for the cardiologist to worry about. I'm not going to trouble myself with that. Because, you know, in the ER, and I think it's true with paramedics in the prehospital environment, it's like, tell me what I need to know. Oh, man. I don't want to waste time with a bunch of, you know, esoteric little geek outs.

I don't need to prove to anybody I'm smart. You know, I just want to know what I need to know to save my patients. And [00:09:30] so honestly, I thought some of these patterns we're going to talk about today, I didn't need to know. So I kind of blew them off. I learned them in medical school and in residency. But since then, I just, it kind of mothballed them.

Matt: Right.

Erik: But I got to take them out of mothballs and I got to memorize them. So we're going to talk about those today.

Matt: Yeah. Cool. All right. So five different. What, what would we call these? Not STEMI mimics. Because it's, it's, uh, I would say like EKG patterns indicative of an OMI or something.

Erik: Good. Yeah, I think that's a good [00:10:00] description for them.

Matt: I make an acronym for that. I don't know. Yeah, I know.

Erik: Well, again, an OMI is a term that will cover all occlusive lesions, that pathophysiology of blockages in the coronary artery system that are going to kill your heart. Some of those patterns won't show up on a STEMI EKG, so we, to get all of them, we need to learn these five patterns of Occlusive pathophysiology.

I don't know. That's all I'd say. Yeah. That's what you said. [00:10:30] It's probably better, but you've always got good terms.

Matt: Occlusive patho OP. You can just call it OP.

Erik: As long as you understand that these are not STEMIs and if you're not looking for them, you're going to hurt your patients.

Matt: And, and also like we talked about in prepping for this, it's also important to remember that the pathophysiology that we're talking about

Erik: No.

Matt: we're still, again, I said it at the beginning, and I think it's important, especially for our firefighters and our EMTs and paramedics to understand is that we're not talking [00:11:00] about anything different that's happening to the heart.

All that is the same. What we're talking about is new things to look for on your EKG. It's not just about looking for a quote unquote STEMI. There are other things, five other things that you need to look for. If you don't see, ST segment elevation. You need to look for these five other things because they could be just as indicative of a heart attack as a STEMI.

Erik: Do you want me to tell you how smart you are? And if you're listening or watching how smart you are [00:11:30] I don't look at the camera very often, but but But we have all felt this. You and me, Matt and I, we've all felt this. Have you been in a situation where you're like looking at the patient, they're gray, and it's like, Oh, STEMI for sure.

I'll bet money on it. EKG comes out, Oh, there's no STEMI here. Dang it. You right? And you don't activate it, and you go to the ER, and you drop them off, and maybe they go into cardiac arrest, who knows? Or maybe that next subsequent EKG shows STEMI, and you're like, that [00:12:00] didn't pop.

Matt: I knew it.

Erik: Right. Yes. You felt that, right?

Or maybe they're an NSTEMI, and you're like, oh, well.

Matt: That's why I say I always treat, I've had a specific, I had that exact case, a guy that had multiple MIs in the past. Yeah. Called us to his house. Yeah. Guy was diaphoretic. I mean, just crushing chest pain. The whole classic symptoms. And I'm thinking, oh, we're going to run this, have this, nothing.

I still activated. Yeah. Oh, good. And the ER physician walked into the room. Said, where's the [00:12:30] 12 lead? And it wasn't the 12 lead. It was the story. Right? It was the presentation. That 12 lead and said, this isn't a STEMI, literally threw the 12 lead on the bed and walked out of the room.

Erik: You know what?

He was right. It wasn't a STEMI.

Matt: That's true!

Erik: And that's the problem because hospitals are so focused on STEMIs and that is, and listen, I'm going to defend my cardiologists here and my ER doctor colleagues, is that based on the data, we cannot activate the cath lab [00:13:00] And, and, and if we did that on everybody that showed a potential ACS or acute coronary syndrome or, or potential heart attack, um, we, we are, we are actually causing the system harm by, by inappropriately activating the cath lab on anything but a STEMI, but we've learned more now.

And there are five patterns that we need to know and I hope hospital systems hear this too. Send this podcast to your hospital or nurse leadership or your, whoever you have, maybe your EMS liaison.

because we need to rethink, I believe, some of how we activate our cath labs in the hospital. Support our pre hospital providers who are recognizing these patterns because it's frustrating for us.

When we recognize a pattern, we go to the hospital and the doctor does that, and I'm sorry that happened, but I've been there too. It's like, you know, but I don't think I've ever said that or like, well, yeah,

Matt: I wouldn't see you saying

Erik: that. No.

Matt: Yeah. I got my justice later when they. Dr. [00:14:00] Traponin.

Erik: Here's how I would have handled it.

And again, I'm no holier than anybody else, right? I'm just, this is the way I handle things. So if you're an ER doctor listening, I think you got to hear this because some of your doctors don't understand the prehospital environment like I do, right? And so when you're bringing in an EKG to me and you feel like this is something really wrong, I need to listen.

And not just be so focused on the EKG where when I see no ST elevation, I'm like dismissing everything you say. I can't do that. I have to listen. Um, and, and we cover a lot [00:14:30] of the, the presentations of these OMI's in our other lectures. Uh, but today we're talking about EKG patterns. Right. So. Let's talk about the five EKG patterns that won't show up as STEMI's.

Matt: And the one last thing I'll say before we get to the five is if you're a pre hospital.

Erik: You can say two things if you want.

Matt: Alright, we’lol keep it to one. But if you're, if you're a paramedic, right, because EMTs typically don't do 12 leads. Anyway, if you're a paramedic and you're running a 12 lead and you suspect your patient's having an MI.

Yeah. [00:15:00] And you're seeing one of these five, right? And you want to activate because you just watched this podcast and you're like, I'm cutting edge. This is an OMI, right? Send the, I would recommend that you send the EKG, transmit the EKG to the hospital, call, ask to talk to a physician and say, Hey, this is why I'm basing.

I think we should activate and this is why it's one of the, this patient's meeting one of these criteria.

Erik: Yeah. We do our job. That's all we can do. Yeah. And, and, uh, you know, Hey, I think we should activate the cath lab. It's not [00:15:30] ST elevation, but this is a EKG pattern. There's data to back it up.

That right. You can say what you want. And if it falls on deaf ears, that's on them. You got to be advocates for our patients, right? Don't, don't acquiesce, push hard. Right. And, um, anyway, um, so let's, let's talk about it.

Matt: Let's talk about the five. Okay.

Erik: So I think the first one again, it's subtle. Um, but, but we look carefully at, uh, for an inferior MI at Leeds.

Matt: I'm glad you started there.

Erik: Two, three, and [00:16:00] AVF, right? Yeah. We all know that. That's like two, three, and AVF, inferior MI. Everybody's got that memorized.

Matt: Get the blood pressure. Don't give up nitro. Be careful with the nitrates. Yeah. Be careful with, yeah.

Erik: Yeah. Ask them if they have erectile dysfunction. All this stuff, right?

Yeah. Uh, avoid morphine, just because again, with an inferior MI, you're hitting the right side of the heart and you can really hit the preload. Yeah. So we know that we're not going to go over a lot of that. Watch our lectures if you, if you want to review what an inferior MI does. But the key here is that based on data, [00:16:30] Any elevation in AVF should be highly suggestive of occlusive pathophysiology or a heart attack.

So if you stuck to the guidelines for an inferior STEMI ST elevation, you got to meet criteria of 1mm in those leads, right? Because an EKG that shows maybe half a millimeter, just subtle elevation, kind of hard to even pick up, but you're, you're concerned. It caught your eye because you're a great paramedic [00:17:00] EMT and you know that look weird, right?

Well, it doesn't meet criteria for STEMI because it's not a millimeter, so it's not a STEMI.

Matt: Just run them code one to the hospital.

Erik: It's not a STEMI. Well, it's true, dang it, it's not a STEMI.

Matt: Yeah.

Erik: By that criteria. But what we're saying though.

Matt: Doesn't mean it's not an MI.

Erik: Right. The data shows that even subtle elevation, and the reason for that is, as we've talked about.

Matt: Yes, this is a great, your explanation is awesome.

Erik: Yeah, but we both know, we've talked about this in our lectures, what causes the deflection for ST [00:17:30] elevation, the movement. of the, the line on an EKG above baseline that we're looking at. It's all about the amount of heart muscle, the amount of electrical activity, and how close it is to the lead.

Those are variables, right? Well, the right side of the heart doesn't have a lot of muscle. So if it's deflecting a lead, that's pretty significant. And I think that's why we need to be more careful with the inferior MIs because we're dealing with minimal heart muscle.

Erik: The left side of the heart, big, [00:18:00] thick, muscular heart.

Easier to move those EKG, uh, blips on the paper.

Matt: It's, if you think about it, and, and I'm gonna, you're gonna laugh when I say this. I'm not. But it's kind of like, think about me as the right side and you as the left side. No! But I'm going to be able to, I'm going to probably generate less energy because I am a smaller framed guy than you.

You're a big strong football player, dude. You're going so

Erik: You’re so good at calling me fat. You know, you're like

Matt: I said you're a big strong football player.

Erik: I know, I know. I'm big boned, [00:18:30] right? No, I'm kidding. You're right. It's a good note.

Matt: But I mean, if you think about it in that, I'm going to generate less energy than you are, right? But that doesn't mean that our output isn't the same. We're both trying equally as hard, but I simply can't do it as much because I don't have as much muscle mass as you do.

Erik: Now, uh, the other thing is we could have the same muscle mass and I could be more fluffy. And have more fat outside of my muscle, like a fat between the lead and the heart.

And I will have a smaller deflection than you if you're more fit [00:19:00] because the lead's closer to the heart. So, a lot of factors can affect the deflection. Lead placement. Lead placement, all these things. So, back to the, so this is the first pattern we're talking about. Uh, an inferior MI with any elevation at all.

Matt: Does it mean reciprocal changes?

Erik: Well, reciprocal changes also should increase our suspicion. But I'm just talking about the leads. Any sort of elevation in 2 3 and AVF. is highly suggestive of blockage in the coronary arteries on the right side of the [00:19:30] heart.

Matt: So use that maybe in conjunction with your patient presentation.

And be highly suspicious. Transmit your EKG. Talk to the physician.

Erik: So in this case, you've got an inferior elevation. I would, I would follow your protocols, but I would recommend you activate the Cath Lab.

Matt: Well, we don't

Erik: let the EKG say, right. Well, I mean, we could activate

Matt: a STEMI,

Erik: but I'm saying when you call a STEMI, they will activate the cath lab if they're smart and if they follow their rules.

And I, and I would stand by that EKG if it's inferior [00:20:00] and you see any elevation at all, I would activate the heck out of it. Talk to your medical director, talk to your FTO, talk to your leadership within your EMS training division, and talk about these things. Be on the same page. Yeah. Do your own research. I'm just telling you I'd activate.

If I was on a ride out with you, Matt, and you and I saw this EKG, you and I would be lock, stop, and barrel. Isn't that the right term?

Matt: Sure. Sounds good.

Erik: We'd be together. Unified.

Matt: Yeah, we'd be unified.

Erik: Holding hands. Alright, that's the first one.

Matt: So, any elevation, 2 3 AVF?

Be highly [00:20:30] suspicious.

Activate. Transmit all that stuff.

Erik: Okay, let's go right to the weird one.

Matt: Yes, this one's odd.

Erik: Well, it's not weird. I mean, we all learn this. It's just that, it's just not one of those things we see a lot or look for a lot. So let's, let's learn something.

Matt: Yes.

Erik: And we'll spend more time on this maybe than the other ones.

Matt: And I think this is probably going to be a two part podcast.

Erik: Yeah.

Matt: Because we don't want to rush this. We want to make sure that we get this information all in. So, go ahead.

Erik: So, um, so this is called a bifascicular block.

Matt: Okay.

Erik: So you got fascicles. [00:21:00] Basically, these are the conductive conduits of electricity through the heart, right?

And when you break one of these or damage one of them, it creates EKG patterns. So bifascicular block means you're blocking the right and the left. And when you block them both highly suggestive, acutely, sorry, if you, what that means is like, this is the old EKGs never looked like this. You obviously can't compare old EKGs here.

But [00:21:30] if you see somebody that looks gray, like it's a STEMI and you see the EKG pop up and it's not a STEMI, you're like, Oh, I guess it's not. Oh, wait, hold on. I remember Matt and Erik talking about this. Oh my gosh, here it is. This looks like it could be a bifascicular block. This is highly suggestive of a left anterior descending lesion.

Remember the Widowmaker? This pattern, highly suggestive of a Widowmaker.

Listen to this, please. If you're watching or listening, here [00:22:00] it is. If you see somebody looking sick and you see a pattern on that EKG of a bifascicular block, highly suggestive of occlusive lesions in that coronary system of that left anterior descending artery. So here's the bifascicular block. So let's talk about, uh, first of all, uh, you need to have left axis deviation. There's three things we're going to talk about here. So,

Matt: and everybody loves access deviation,

Erik: right? We'll talk about that. And then, uh, and so this is the, this is, this is part of the fascicular [00:22:30] block.

So this is part of the left anterior fascicular block. This is half of what we're looking for here. This is honestly, I had to go look this up because I don't look for this anymore, but I do now.

Matt: Yeah.

Erik: Um, we need to have this memorized. So here, just a quick lecture on this. And again, we're going to cover this in some of our OMI lectures later, but a left anterior fascicular block is going to be characterized by these three things.

And again, generalities here, there are some subtleties we're not going to cover, but. This is the basics. [00:23:00] So, good first step. So, um, left anterior fascicular block, you're going to need left axis deviation. So, uh, left axis is a quick review. I look at leads 1 and AVF. There are other ways to look at it too, but Just looking at one in AVF.

So, if they're both up, we're good. Normal axis. Normal. Now, if you're up going in one, which is good, but you're down in AVF, that's bad. So, we're pointing down, [00:23:30] right? So, if I push down on the turn signal, what way am I going to turn? Left. It's a left Blockage. Deviation. Deviation. Left axis deviation.

Thank you, Matt. Now, again, normal.

Matt: Yep.

Erik: Left axis deviation. Now, if this is normal, right, but the 1 is down, now I'm pushing the, uh, turn signal to the right on AVF. So now I'm going to turn right. So that's right axis deviation. Okay, so, so if you [00:24:00] are up going in one, down going in AVF, that's left axis deviation, quick and dirty.

Matt: Yep. I like it.

Erik: That's one of the three for left interior vesicular block. The other things that we talked about, which again, we have to review these. If you look at leads two, three, and AVF, and you see QR complexes, that means you've got a Q wave.

Matt: Which is the first negative deflection for, like a little Q wave. Not everybody has Q waves, that's important to remember. Typically you won't see those. [00:24:30]

Erik: And again, this is 2 3 AVF, highly associated with the left anterior sacral block. You got the left axis deviation plus a QR complex in 2 3 AVF. So 2 3 AVF QR. And then, uh, and then, uh, if you look at one in AVL, you have QS.

Complexes. That means you've got that Q. Positive and negative. Yes, correct. Uh, sorry, does that make sense? We good? Yep. Okay.

Matt: Makes [00:25:00] sense to me.

Erik: All right. So, this is, this is key for the left anterior fascicular block. Now, the other half of this that, that gives us that STEMI or that occlusive MI pathophysiology is, we have that left anterior fascicular block that we just talked about.

Left axis deviation plus, uh, QR complexes and 2, 3 AVF. QS complexes, 1 AVL. Left anterior fascicular block plus a right bundle. All right. A right bundle.

Matt: Acute right bundle.

Erik: Acute right bundle. Uh, [00:25:30] and whether or not it's acute, that's, those are things.

Matt: And that's going to be hard. It is. You know, you can ask, have you ever had a right bundle block?

And they look at you like you're speaking.

Erik: But if I saw this with a sick looking gray patient. Right. And, uh, I'm in the ambulance. I'm telling you what I would do, follow your protocols, but I would transmit this and I would talk to that ER doctor, whoever receives that call, and I would say, I want to act, I would activate this.

I think it's a STEMI equivalent.

Matt: It's our job to look for patterns. It's not our job to [00:26:00] diagnose MIs. It's not my job. My job is to look for patterns of illness processes. And if I see any of those patterns to tell you, this is what I'm seeing, but you went to school for a whole lot longer than I did. I tell people this all the time.

I went to paramedic school. My paramedic school is six months. You went to school for a decade. I think you probably studied a little bit more depth than I did. So. I'm going to refer to your expertise.

Matt: And then you're going to do what?

Erik: Well, I'm going to do the right thing, I hope.

Matt: Right, but I mean a lot of times you're going to consult [00:26:30] with a cardiologist.

Who that's all they do. So, I tell paramedics this all the time. Don't get so confident in your EKG skills that you're not willing to go, Something looks off here, but I know everything about EKGs and this isn't anything.

Erik: I call that hubris. That is not a good place to be. We want to stay humble.

Matt: Absolutely.

Erik: And always want to learn things. You say, Hey Axine, you've had 10 years of education. Yeah. Well, I have, right? But I have to realize that I can learn new things. I'm going to be honest with you. Maybe I'm an idiot for saying this, but I [00:27:00] didn't, I had to go look up a left anterior fascicular block.

I forgot. And now I, gosh, and again, uh, Diaries from an ER doctor. Confessions from an ER doctor.

Matt: That could be another one.

Erik: This is really actually scary to think about. How many STEMI patterns have I overlooked?

Matt: Oh, I mean, there's no doubt. But again, that's the beauty of Always learning, right? It's the beauty of if you graduate medical school or you graduate paramedic school and you think, okay, I'm done [00:27:30] now.

I'm a paramedic. No, bro. Like you just passed the test. Now you got to learn how to be a paramedic.

Erik: Well, let's, let's, let's put the cap on this before we finish part one here, Matt. So for this second pattern, we're talking about that won't show up as a STEMI, but it is indicative.

Matt: It's a STEMI equivalent.

Erik: Yeah, STEMI equivalent. That's a good way to call it, but this is one of those patterns of occlusion of a coronary artery that won't show up as a STEMI, this bifascicular block. So we talked about the left anterior fascicular block. Again, to [00:28:00] review, we've got left axis deviation, up in 1, down in AVF. We got the QR complexes in 2 3 AVF, the QS complexes in 1 in AVL.

I think I did that right. Did I do that right? Or did I slip it up?

Matt: It's QR and 23AVF and then it's QS and 1AVL

Erik: Boy, I may have flipped that. We may want to review that. I think I did it right. Didn't I do that right?

Matt: You got your thing there. Let's double check it.

Erik: I think I did that right. Yeah, I [00:28:30] think, uh, I hope I did it right.

Matt: This is because this is super complicated. This is not, I mean, there's a lot of factors to this, uh, left anterior or the anterior fascicula. I can't even talk. Yeah. Block. So it's important that we get it right.

Erik: I think so. So we have

Matt: looking at the EKG

Erik: I'm looking at it and it is, um, I'm looking at, this is one and AVL

Matt: should have RS.

Erik: Yeah, we have. R, S, and one in AVL, [00:29:00] and then we have

Matt: Q,

Erik: Q, R. Good, we did it correct. Okay, good. So we'll make sure.

Matt: Yeah, no, absolutely.

Erik: And as, as we close this out, a right bundle, you're looking for those rabbit ears. Rabbit ears and

Matt: V1. And V1. Work backwards, look for that term signal method. Yep.

Erik: Good.

Matt: If it goes up.

That is a right monobranch that's left.

Erik: If you're not looking for these patterns, you're missing people that are very sick, and that's not good. So hopefully this will change your practice. Spread the word, forward this to people. And

Matt: stay tuned for part two.

Erik: Yep. And that was good talk. [00:29:30] Good, good, good content.

See you in part two. Be safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.