Make this page my home page
  1. Drag the home icon in this panel and drop it onto the "house icon" in the tool bar for the browser

  2. Select "Yes" from the popup window and you're done!

Home > Columnists > Tom Bouthillet
All Articles

EMS 12-Lead
by Tom Bouthillet

ECG Challenge: The court's verdict?

How would you treat this patient and why?

By Tom Bouthillet

Editor's note: Check out this month's ECG case study and submit your treatment plan in the comments below. If Tom selects your plan as the best, you could win an EMS1 T-shirt and bottle opener. Good luck!

EMS is called to a local tennis court for a 63-year-old male complaining of chest pain.

At the time of EMS arrival, the patient is found sitting on a bench.

Past medical history: Cataract, erectile dysfunction

Medications: Cialis (tadalifil)

The patient appears acutely ill. He is pale, warm, and diaphoretic.

Vital signs are assessed.

  • RR: 18
  • HR: 74
  • NIBP: 127/65
  • SpO2: 97 on RA

Breath sounds: clear bilaterally

The patient is placed on oxygen via NC mask @ 4 LPM as the cardiac monitor is attached.


A 12-lead ECG is obtained.

What do you think of the 12-lead ECG?

Is the local community hospital appropriate or should the patient be transported straight to a PCI-capable facility?

How would you treat this patient?

About the author

Tom Bouthillet is a Fire Captain/Paramedic with Hilton Head Island Fire & Rescue, Editor-in-Chief of the, Chief Content Architect of, host of the Code STEMI web series at First Responders Network, a member of the Editoral Advisory Board of EMS World Magazine, and developer of the 12-Lead ECG Challenge smartphone app. He has taught nationally in the Critical Care Transport (CCEMT-P) program out of UMBC and his writings have been referenced in the American Heart Journal, the Journal of the American College of Cardiology: Cardiovascular Interventions and the EP Lab Digest. Contact Tom at
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Badshah Khan Badshah Khan Tuesday, June 04, 2013 6:01:55 AM hyperacte T wave in V2....V5 suggest MI also electrical alternance patteran rule out pericardial effusion.
Purujit Thacker Purujit Thacker Tuesday, June 04, 2013 6:46:31 AM I would get an IV line, load him with aspirin, clopidogrel and a statin, hold off on the nitrates because he's on cialis (nitrates could cause severe hypotension) and take him to a center that has PCI facilities. This looks like it's going to turn out to be an anterolateral STEMI. His history and presentation are suggestive of an MI and the ST depressions in 3 and avf look like reciprocal changes and he has poor r wave progression. The T waves in V2,3,4 look like they could be hyperacute.
Nicolas Peschanski Nicolas Peschanski Tuesday, June 11, 2013 6:21:09 AM Anterolateral STEMI with fQRS from V1 to V3 and slight ST depression in inferior leads. I'm going to Cath-Lab with STEMI code right away.
Syke Syrjäläinen Syke Syrjäläinen Monday, May 12, 2014 11:02:22 PM kääntyvien kärkien rytmi kammio extroilla ja infarkti vaara.
Zach Hubbard Zach Hubbard Wednesday, September 10, 2014 7:08:54 AM IV, o2, monitor. I would find out the last time he took cialis, if he has taken it recently i would still give NTG with caution, if he does have a blockage he needs something to open it up. Currently I would not call this a STEMI, He has J-point elevation in V2-V5, but I would treat with with ASA and NTG because it could be a non-STEMI. Fluid bolus after assessing lung sounds. I would perform a R sided and posterior 12 lead, he does have some ST depression in II, AVF with an inverted T wave in lead III indicating ischemia so probably angina after exertion from playing tennis. Could fax this 12 lead to the ER. But I would take this to local hospital.
Ruud Valkenborg Ruud Valkenborg Wednesday, September 10, 2014 8:27:20 AM is not a STEMI or non-stemi. could be ACS using Cialis care for `vt's
Kevin Betz Kevin Betz Wednesday, September 10, 2014 8:46:46 AM Finally, somebody with a brain
Kyle Langlois Kyle Langlois Thursday, September 11, 2014 9:48:46 AM Left Axis deviation
Beau Walsh Beau Walsh Friday, September 12, 2014 1:19:58 PM Looks mildly like De Winter T waves, transport to PCI

EMS1 Offers

Breaking EMS News

Line-Of-Duty Deaths

Featured Columnists

Tactical EMS

Jim Morrissey - Tactical EMS

Active shooter: Rescue task force medics get to victims faster

Rescue task forces and tactical medics offer different, yet more aggressive approaches to active-shooter incidents...


Product Categories