Mr. Schultz is a 64-year-old accountant with a past medical history of high blood pressure and high cholesterol. He has been a smoker for the past 35 years and despite his wife and his doctor “gently nagging” him about it and him trying to quit multiple times, he still has not been able to kick the habit. His work as an accountant keeps him mostly seated at a computer and, while he tried to walk a couple of days per week over the summer, it is winter now and the chilly weather has kept him inside and safely on the couch.

Mr. and Mrs. Schultz are very excited because for the first time in many years, all four of their children and their families will be coming to stay at their house for the Christmas season. The house has been cleaned and decorated but, unfortunately, a heavy snow has been blanketing the area for the last several hours and has delayed everyone’s arrival. Mr. Schultz had at first meant to clear the snow as it came down but then decided just to wait until it stopped so that he would only need to go out in the cold once. His wife had different ideas and, after several hours of “gentle nagging” he finally went out. He had insisted on eating a big meal of steak and potatoes and several cups of coffee before starting the job to “keep his strength up” while he worked. He opted for a sweatshirt instead of his winter jacket, hat, and scarf thinking that the effort of shoveling snow would soon warm him up. He used the bigger of his snow shovels and tried to load it as much as possible with the hope that this would make the work go faster.

The temperature was bitterly cold, and the driveway was large and at first, he moved slowly, making sure to take frequent smoke breaks. But, when his wife came out and told him the first of the kids would be arriving in less than 40 minutes, he knew that he needed to hurry or there would be no place for them to park. She offered to help and had even brought out a second shovel, but he worried about her bad back and so asked her to let him finish the driveway alone. He really started to push himself, loading the shovel even more and not stopping to rest even when he started to become short of breath.

As he worked he noticed some chest discomfort that felt like a heavy pressure and some lightheadedness, but dismissed them as signs of him being out of shape. He mentally promised to take time that night to look through the various gym membership offers he had received in the mail with special New Year’s promotional deals to get more fit.

He continued to try and push himself but his shortness of breath and the pressure in his chest was getting worse and now he was feeling nauseous and the pain and numbness in his left arm was radiating up into his jaw. He slumped down onto one the snow piles he created while shoveling hoping that a rest would relieve his symptoms, but they only continued to get worse. With great difficulty, he got up and stumbled back to his house where he collapsed just inside the door.

Shoveling snow is a known trigger for a heart attack and the story of Mr. Schultz, unfortunately, is not very uncommon. When snow begins to fall and accumulate, Emergency Departments, especially in the nation’s snowbelt, begin to prepare to receive additional patients who ventured out to clear their driveways, vehicles, steps, and walkways.

In our discussion of snow shoveling and a heart attack, we will examine the pathophysiology of how these two events are connected, who is at greatest risk, signs and symptoms to watch for, and tips for preventing a heart attack before and during shoveling snow. Finally, we will examine four ways that Emergency Medical Services (EMS) can achieve higher survival rates for those who suffer a heart attack outside of the hospital setting.