pocket medic

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.

My teacher handed them back the next day with an obvious zero written on mine, and when I started crying in class he told me that’s what I get for cheating, in front of everyone.

My therapist asked me why I saw her as separate from myself. I realized I felt that at some point between then and Adulthood, that girl had died, and I was mourning her death. All the time, I looked at photos of my younger self as if they were memories of a childhood friend I’d lost.

My therapist helped me understand and accept that she never died, she is me, and by surviving, I did save her life. She is alive, and those hopes and dreams she had before she felt pain and loss still exist in me. And every time someone treats me badly and I stand up for myself, I am standing up for her. Every time I try to get better, I am nursing her back to health. Every time I take care of myself, I am taking care of her. I am the adult she needed.

She was saved, because she is me, and I saved myself. I saved her. I saved us both.

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Jade and striped icebergs. “When seawater at depths of more than 1,200 feet freezes to the underside of massive ice shelves like East Antarctica’s Amery Ice Shelf, it forms ‘marine ice.’ Enormous hunks of ice calve—or break off—from the ice shelf, creating icebergs. When one of these icebergs overturns, its jade underside is revealed. The wondrous color of this ‘marine ice’ results from organic matter dissolved in the seawater at those great depths,” explained Audubon Magazine. “Green icebergs are infrequently seen because their verdant bellies are underwater; it’s only when they flip over, a rare event, that their richly colored regions can be seen before they melt. Striped icebergs, perhaps even more scarce than jade bergs, are thought to form in one of two ways: either meltwater refreezes in crevasses formed atop glaciers before they calve icebergs (creating blue stripes), or seawater freezes inside cracks beneath ice shelves (creating green stripes).”

She’s working at the hospital since Rhona came to town,

Hide away, hide away, Miss Rhona’s come to town,

Hide away, hide away, she’s come to take us down.

Miss Rhona’s at the doorstep, I’ll keep 6 feet away,

But Grandma needs the paper, I’ll take her some today,

Hide away, hide away, Miss Rhona’s come to stay,

Hide away, hide away, we can’t come out to play.

But Grandma needs the paper, I’ll take her some today,

And here’s a note from Rhona, she wanted me to say,

Hide away, hide away, keep 6 feet away,

[Image ID: Tumblr user @neanderthyall says in the notes, “I thought that 6 feet was kind of a double meaning. Like six feet away to stop the spread, but when people die they’re six feet underground, and its six feet of the dirt that keeps you apart. Like ‘Hide away, hide away, even though it hurts Hide away, hide away, or the six feet will be dirt’.” End ID.]

I’ve taken the liberty of expanding the lyrics slightly and coming up with a tune:

Daddy’s at the food store, Mummy’s out of town, She’s working at the hospital since Rhona came to town, Hide away, hide away, Miss Rhona’s come to town, Hide away, hide away, she’s come to take us down.

Miss Rhona’s at the doorstep, I’ll keep 6 feet away, But Grandma needs the paper, I’ll take her some today, Hide away, hide away, Miss Rhona’s come to stay, Hide away, hide away, we can’t come out to play.

I need to see the sunlight, I’ve not been out in days And here’s a note from Rhona, she wanted me to say, Hide away, hide away, keep 6 feet away, Hide away, hide away, she took us down today

how to make smores

Like, if you can’t tear yourself away from a video game, even to make it to an important event on time? Addictive tendencies.

If you keep spending your allowance money on those funny collectibles or new shoes even when you promise yourself you’re going to save it? Addictive tendencies.

If you find yourself unable to resist and manage food cravings, or frequently overeating even when it makes you feel bad? Addictive tendencies.