ECG Challenge: The missed match

EMS is called to residence of 67-year-old male complaining of shortness of breath; what's happening with this patient?

EMS is called to the residence of a 67-year-old male complaining of shortness of breath.

At the time of EMS arrival, the patient walks out of the bedroom into the living room and slumps over onto the gurney in obvious distress.

Past medical history: Hypertension, prostate CA
Medications: Lisinopril, Norvasc
Breath sounds: Diminished bilaterally

The patient appears anxious. His skin is dusky and diaphoretic.

He states that he was short of breath "on and off" all night and had planned on playing tennis in the morning but "felt way too bad."

Vital signs are assessed.

  • RR: 40
  • HR: 74
  • NIBP: 154/89
  • SpO2: 93

The patient states that he became "much worse" after ambulating from the bedroom to the living room. As he calms down, his respiratory rate comes down to about 28.

The patient is placed on oxygen via NRB mask at 15 LPM as the cardiac monitor is attached.

A 12-lead ECG is obtained.

The electrodes were not sticking well to the patient's skin, so lead V3 was held down manually, and another 12-lead ECG was taken.

Upon questioning, the patient admits to some chest discomfort. The treating paramedic decided to assess leads V4R, V8 and V9 (sometimes referred to as a "15-lead ECG").

The patient states that he recently got back from a business trip to the West Coast.

What do you think is happening with 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

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