Subtle Signs


At some point in EMT or paramedic school, actually both, students are taught the classic signs and symptoms of Myocardial Infarction. They include dull, sub sternal chest pain (or pressure), often with radiation of the pain to the left jaw and arm. Often this is accompanied by Dysnpea, Disphoresis, Nausea and Vomiting, as well as other symptoms.

The problem is that this description is based on a theoretical mid 40s male. The illustrations often show a drawing of said non existent male.

Some mention is made, or was in the past at least, of the “Silent MI”, but few instructors ever really try to teach what that really means. A “Silent MI” means that the patient is not having chest pain, not that they are completely symptomless. That’s an important distinction, but I rarely see it mentioned.

The problem is that patients come in all shapes and sizes. As an instructor once told my paramedic class, “If you don’t like elderly people, you’d best find a new line of work”. The truth is that many of our medical patients are elderly and elderly people often don’t present the “classic” picture of a sick person. This is especially so if we add in Diabetes, Hypertension, the aging process, and other factors that can skew the presentation.

What we often see or hear are subtle clues that our patient (or family member) is having a medical problem. It’s easy to miss them, but often devastating to do so.

So, if some patients, elderly or diabetic or women, don’t have chest pain, what do they have?

Often the chief complaint, the only complaint, is Dyspnea. This is important to note because being short of breath can and often is attributed to other causes. Dyspnea on Exertion (DOE) is particularly insidious because often the patient will minimize the symptom, especially if it resolves with rest or nitroglycerin. This also tends to progress gradually until the problem becomes acute.

General Malaise or weakness and lethargy are also common and frequently missed. Stoic patients will often dismiss this as part of getting older and fail to mention it to their families or physicians. If this happens during or shortly after activities that used to be routine and easy, it’s a warning sign that should be heeded.

Dizzyness, syncope, or near syncope when standing up are also common and although not always signs of MI, can also be caused by other things. Persistent or frequent episodes should be considered warning signs and require further investigation. Any of these when the patient is sitting or lying down are more serious and should be treated as such.

All of which means that when we are examining and interviewing a patient we need to look for the not obvious. Just because someone doesn’t complain of chest pain doesn’t mean that they are not having a cardiac event.

As paramedics and EMTs we often won’t see these things because we generally only meet the patient once, and for a limited time at that. For that reason, it’s important to carefully interview the patient (or family) to ferret out pertinent information. It’s the subtle hints that will give you your diagnosis, be careful not to miss them.


  1. I had an acute myocardial infarction last August and thankfully, I had classic symptoms (chest pain, acute pain in my arms, sweating, nausea and retching). I thought I was having a panic attack (although I had never had one in the past!) Fortunately the ambulance & fire personnel who attended me correctly assumed that I was suffering something cardiac. I had a stent put in within 2 hours of suffering the heart attack, and am fine now. I was told that women don't usually have the same symptoms as men but in this case, I am glad that I did.

  2. Grace, I’m glad that you did well and recovered from your MI. It sounds as if the system worked the way it should every time. By being typical, you were actually being atypical. I don’t know how old you are, and since you aren’t a patient, I won’t presume to ask. My experience has been that women as young as their early 40s have a different presentation than men in the same age range. We are slowly learning that the differences between women and men go beyond the obvious (and pleasant) ones. This whole thing of anatomy and physiology is a lot more difficult than it looks.

  3. I was 50 years old at the time of my heart attack and quite overweight. I had quit smoking 2 1/2 years previously. However, heart disease has been passed down through my mother’s family and I believe it is hereditary. My mother, while never having had a heart attack, had a quadruple bypass several years ago. My cholesterol is now under control and I hope I never have another heart attack.

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