To Rise From The Ashes, You Must Embrace The Burn.

I’ve had countless sessions and lectures on ECGs. I don’t know how many websites I have bookmarked, or how many times my eyes glazed over reading Dubin. I’m also terrible at cardiology. I was on my way to accepting my fate of being horrible at ECGs forever, until I had a life changing session on ECGs taught by a great ER doc. I want to post it here because it was probably the most useful thing I learned in med school, and it will stick with me for the rest of my career. 

WHEN LOOKING AT ECGs FOR THE FIRST TIME:

1. One ECG is never enough. Always get old ones for comparison. If none available, do another one. Because. One ECG is never enough. 

2. RATE. Look at the number on top of the printed ECG. It’s stupid not to use that number. Yes, you should know the rule, 300-150-100-75-60-50. People say you shouldn’t trust the machine because… well, it’s a machine, and it can make mistakes. This is true. I don’t like to look at their “diagnosis” until I have gone through it myself. But the rate is just a number. Plus you should be able to eyeball it and be able to tell if it’s tachy, brady, etc. If the machine is telling you it’s 200 and if it looks tachy, then it’s probably the right number. 

3. RHYTHM. Is there a p-wave for every QRS and a QRS for every p-wave? Is the p-wave upright in lead II and down in aVR? Good. Done. BOOM. It’s sinus rhythm. ***if you cannot clearly see the p-waves then you cannot call sinus. move on.

4. AXIS. Again, look at the number at the top of the page. If it’s between 0 and +90, then it’s normal axis. If the number isn’t provided, or if your preceptor doesn’t believe in the convenience of machines/technology, look at the QRS complex of lead I and lead II. 

up in lead I, up in lead II: normal axis

up in lead I, down in lead II: left axis deviation (most common causes are left anterior hemi block and left ventricular hypertrophy)

down in lead I, up in lead II: right axis deviation (most common causes are right ventricular hypertrophy…PE)

5. did someone say HYPERTROPHY?

look at V1

is the R wave tall? (greater than 7mm?) right ventricular hypertrophy.

is the S wave tall? (greater than 11mm?) left ventricular hypertrophy.

  6. P-waves

look at lead II

is it wide? left atrial enlargement.

is it tall? right atrial enlargement.

7. PR interval

should be between 0.12 sec and 0.2 sec (3-5 small boxes). I used to always get this interval and QRS complex (less than 0.12 sec) mixed up. Think: atria depolarizing + shit getting to ventricles is gonna take longer than ventricles depolarizing. [2 things happening] versus [1 thing happening]. [0.12 sec-0.2 sec] versus [<0.12 sec].

long PR interval means there’s some sort of block at the AV node. 

1st deg block. PR interval is long. everything else is normal. cool. 

2nd deg block

type I: PR interval progressively gets long. eventually a dropped QRS.

type II: PR interval is constant, but randomly dropped QRS. 

3rd deg block “complete block”

there is no association between P waves and QRS. they run separately. **QRS does NOT have to be wide. Just look for P wave/QRS complex disassociation. I sometimes get this and 2nd deg type II mixed up. The only difference I try to remember is that PR interval is constant in 2nd deg type II, but is variable in 3rd deg. 

8. QRS complex

narrow or wide? 

narrow: good. signal coming from somewhere above ventricles. 

wide: think BBB (bundle branch block)

LOOK AT V1 ONLY.

if the last deflection of QRS is DOWN, then it’s a left BBB

if the last deflection of QRS is UP, then it’s a right BBB. super easy. no more of this bunny ears crap. 

9. ST segment

always look from J point, and compare with the isoelectric line of T-P segment (NOT PR interval). 

elevated/depressed… STEMI… duh. indicates ACUTE ischemic changes. 

look for reciprocal changes of the heart. if ST elevation in lateral leads, could see ST depression in the septal leads. PAILS:

posterior up, anterior down

anterior up, inferior down

inferior up, lateral down

lateral up, septal down.  

LBBB can look like STEMI. How to tell?

disconcordant changes is normal. (QRS and STEMI on opposite sides of the isoelectric line.)

concordant changes is abnormal. 

massive discordance is abnormal. (STEMI is greater than 5mm)

this isn’t that important. Moving on. 

Inferior STEMI. Could right ventricle be involved? 

DO NOT GIVE NITRO DO NOT GIVE NITRO DO NOT GIVE NITRO.

order a 15 lead

is STE in lead III > lead II? likely RV involvement

INFERIOR MI? 15 LEAD NO NITRO

INFERIOR MI? 15 LEAD NO NITRO

INFERIOR MI? 15 LEAD NO NITRO

10. T waves

is it inverted? indicates recent ischemic changes. 

11. Q waves

is it significant? indicates old ischemic changes. will likely be present if followed rule number 1 of reading ECGs. (1 ECG is never enough= look at old ECGs). 

I literally go through this list of 11 points in my head when I’m reading an ECG, regardless of whether or not I have an atrial flutter jumping at my face or if I see a massive anterolateral STEMI. Obviously I needed background knowledge on ECGs and the physiology of the heart before constructing this list, but this basic checklist has been very, very useful to me so far. It might look lengthy, but it doesn’t take a lot of time at all- a patient is not likely going to have all these issues with their heart. 

  Anyway. I still don’t love ECGs, but it feels pretty wonderful to be able to be able to evaluate it in a systematic manner, and get the theory behind interpreting the scribbles of an ECG reading. I don’t get these moments as much as I would like to, but it’s that crosspoint where my classroom learning actually meets real-life applications that gives me happy brain-gasms for days. I love knowing things and more importantly, knowing why.

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To those of us in EMS that respect the EMS Gods and would never utter the words, “it’s been a pretty quiet shift”, ten minutes before our shift ends, I have named the EMS Gods. I think there are two of them and I will explain why.

The first is who I call Chaos.

He’s a sneaky one, but we have probably all danced with him in the back of our ambulance. Who among us hasn’t dealt with him as our ECG monitor suddenly becomes a magnet for all artifact in a quarter mile radius? How many of us have not seen our perfectly established IV ripped out by an unsuspecting partner? Come to think of it Chaos probably employs many of our partners, this theory would explain so much.

Chaos doesn’t just work in our ambulance, he also works against us prior to us arriving at the emergency. Sometimes he works by making a person suddenly allergic to something he’s eaten his entire life. A peanut butter sandwich suddenly sends a patient into anaphylactic shock, even though he has worked at a deli for the past 5 years and eats it on a regular basis. Oh and just for a few extra giggles the call is actually dispatched as a seizure, on the third floor of an apartment (did you catch that? I started by telling you it’s in a deli). I can’t totally blame Chaos for messing up my dispatcher on that call, the police were involved also. (You see what I did there, Chaos works through police just as much as he works through dispatchers).

Chaos can be evil though, don’t ever give him an inch. (I’m using “him” for Chaos very loosely, as you will see the other God is much more feminine).

I have seen Chaos kill random pedestrians and bicyclists. I have seen Chaos poison people and cause a simple stumble by a person walking down their stairs turn into an open femur fracture (yeah that call came in as “fall injury” with no indication I was about to walk in on a trapped, bleeding and very angry patient).

Chaos is the whimsical and occasionally sadistic God of EMS.

Consequence, now here is a God that takes very little pity on any of us. Consequence walks among us and spares us of many things, but he remembers. Consequence makes us need that one item, in a list of a couple hundred, that we didn’t make sure of during our unit check off. And of course it’s no where to be found during the emergency where it’s needed the most. Consequence watches us eat the food we eat and skip the exercise we shouldn’t skip and then hits us with diseases we shouldn’t have.

Consequence is the “I told you so” God of EMS (remember what I said about this God being more feminine? Who’s better at the “I told you so’s” than women? Ask any married guy and he’ll tell you no guy can stand a chance against a woman who has just proven you wrong. Which is why I rarely let it happen. :)

Consequence works through our patient’s and many times will give us a glimpse of what we can try to avoid. Too many times we ignore it. (I’m looking at all you heavy drinkers who transport someone with cirrhosis of the liver and don’t stop to think where they might have gotten it, smokers who transport COPD patients in respiratory failure, diabetics who eat two burgers for lunch after transporting a patient with BKA home, hypertensives who forget their pills after running with lights and siren to the nearest stroke center with a patient who can’t move their right side….I could go on forever.)

Chaos and Consequence. Can any call not be placed in one or the other’s ballpark?

Chaos and Consequence. When we make a mistake is it not one or the other? Most of the time when we have a complication on a call isn’t it a Consequence for an action we did or didn’t do? Can’t remember the dosage? Shouldn’t we have looked at that protocol instead of playing that game on our phone during our downtime?