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First let me complement you on your thorough and diligent assessment. A lot of people never realize that the "paramedic assessment" is *much* more about diligence than it is about diagnosis. As far as your questions: No. ST elevation means the condition is acute. With rare exception (like in the days following a CABG), there is no such thing as "old ST elevation." Keep your STEMI mimickers in mind (LBBB, BER, LVH, pacers, etc etc etc), but real ST elevation is something to be considered as cardiac injury. Depression can be a number of things, but "cardiac depression" is caused by ischemia or is a reflective change from injury. Consider it an acute problem. Whats the difference? What does a "cardiac" patient get that a GI patient does not? If you are worried about a AAA or some sort of GI bleed I would imagine you might be concerned about ASA (and I would too), but it seems you did the right thing by passing that decision on to on-line medical control. NTG as well. Other than that, both GI and cardiac patients get IV/Monitor/O2 and continued reassessment. Don't forget that this patient may have both a GI problem and a cardiac problem. It is not necessarily one or the other. You can't rule out cardiac because he has problems in his belly. Take heart, though. Our job is largely the same. Prepare for something worse to happen, consult on any meds you might want to give (if any), and reassess, reassess, reassess.

This sounds like a complicated case, and to be honest I would have stayed on the safe side and gone down the cardiac route as well, and I'll tell you why. To my knowledge, the most common chronic EKG changes following an MI is chronic Q waves. Now cardiology is one of those subjects where you can go as deep as you want into it, and I'm sure there are some real cardio wizards out there who could probably tear that simplistic argument apart, but that's my understanding. Secondly, it's true that an MI is NOT the most common cause for ST elevation, but there's some factors that we in the prehospital arena have to consider. First, what is this guy's baseline EKG? We don't know. We don't know if this is what his EKG always looks like or if this is truly new ST elevation; because of that, in the absence of the patient saying he always has that on his EKG, we have to assume it's new onset until proven otherwise. The second thing you ought to think about is his age, and how that can alter the presentation of an MI. To be honest, you make a better case for this being an atypical MI than for it to be a GI issue. When was his last BM? Has he had GI issues before? Any dark, tarry stool or bloody vomit? Recent fever, cough, nausea/vomiting, diarrhea? Are those PVCs a known issue? If not, you'd better assume they're acute, even despite his age, and the most common cause of PVCs is myocardial irritability, which is more consistent with an MI than a GI issue. Did they go away with O2? Now, am I convinced that this is definitely an MI over anything else? No. With a recent history of pneumonia, there's a ton of possible diagnoses and you're unlikely to make a definitive diagnosis in the field; he could have developed pericarditis (though to my understanding the EKG generally presents with a different morphology of the ST segment than in MI and the elevation is diffuse except for V1 and also I believe AVL). You said his rhythm was irregular? History of a-fib? You also say his abdomen was distended, was that per the patient's own assessment? And you mentioned you palpated for any pulsatile masses, did you also have a listen? I've heard from a physician that the more effective way of assessing for an abdominal aorta is to actually listen for audible bruits over the aorta. Is the dark colored urine new for him? Anyway, I'm not trying to knock you, but as you can see this is a complicated patient. I don't know if you can make a definitive diagnosis in the field, but I wouldn't feel comfortable ruling out an MI in the presence of ST changes, dyspnea, and abdominal pain. Great case, let us know if you find out any more about it.