A 74-year-old patient was transported to our facility by ambulance from a local nursing home. She had weakness, shortness of breath, and head and neck pain with a sudden change in mental status. The patient had a medical history of hypertension, asthma, chronic obstructive pulmonary disease, and recent hospitalization for deep venous thromboses. Her medications included warfarin (Coumadin), albuterol, prednisone, levothyroxine (Synthroid), methyldopa (Aldomet), potassium (Micro K), hydrochlorothiaz ide (Maxzide), chlordiazepoxide (Librax), ranitidine (Zantac), iron supplement (Niferex), beclomethasone dipropionate (Beconase), and diphenoxylate (Lomotil). During transport the paramedics noticed a wide QRS complex with stable vital signs (Figure 1). On arrival in the emergency department the patient, an obese, white woman, was awake but had difficulty speaking and shortness of breath. The patient managed to report profound weakness with head and neck pain. Vital signs were as follows: blood pressure, 154/90 mm Hg; pulse, 78 beats/min; respirations, 36 breaths/min and shallow; and temperature, 97.5 ~ F rectally. Oxygen was administered at a rate of 6 L/min by mask; pulse oximetry revealed oxygen saturation of 98%. Breath sounds were clear bilaterally. Cardiac monitoring showed a regular heart rate, wide QRS complex, and tall T waves. Pulses were present and palpable. Heart tones were distant with normal first and second heart sounds, no third and fourth heart sounds, and no murmurs, gallops, or rubs. An IV infusion of lactated Ringer's solution was initiated at a keep-open