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I’m on cardiology right now, and yesterday the fellow taught us some basics for interpreting EKGs. The trick is the have a thorough algorithm and do it every time so you don’t miss anything.

Disclaimer: Obviously this is just a cursory intro so folks won’t look like complete fools like me- who, when asked to interpret an EKG, went into a cold sweat and said, “Well, it looks like the heart is beating.” Attendings do NOT like that.

INTRO

This is what a normal lead II EKG one beat reading should look like. TAKE NOTE LITERALLY EVERYONE STOP CALLING YOUR SQUIGGLY LINES HEARTBEATS IT IS WRONG GAAAHHHH.

Normal EKG.

What the various leads are monitoring.

1. Rhythm: Sinus or not- aka, is the SA node talking to the AV node correctly? Check in leads V1 and II- if there is a P wave before every QRS you have sinus rhythm. If this is not the case, you do not have sinus rhythm! A whole discussion on things messing up sinus rhythm will come when I have a better grip on it myself.

2. Rate: How fast is the heart beating- aka, how fast are the ventricles depolarizing? So EKGs are little tiny boxes in bigger boxes, right? There are several methods for calculating rate using the boxes, but the one that works for my brain is to count the big boxes between R’s and divide that by 300. So, 1 big box between R = 300/1 = 300 bpm. 2 big boxes between R= 300/2= 150 bpm. And so on.

In general, any heart rate above 100 is tachycardia, and any heart rate below 60 is bradycardia. These values may vary (ex: SIRS criteria counts heart rate above 90 as tachy). Normal heart rate is around 75 (exceptions include athletes- look up athletic heart syndrome)

3. QRS Complex: Wide or narrow- aka, is the Bundle of His bossing the ventricles around? Basically, a nice narrow QRS complex generally indicates the bundle of His is intact and operating how it is supposed to. A wide QRS complex indicates something is awry with the Bundle of His- could be an organic pathology, could be a medication side effect (ex: antiarrythmics, TCAs, quinidine, to name a few), could be an electrolyte imbalance (ex: hyperkalemia), could be other things.

4. Axis: Is the heart depolarizing the way it should- aka right shoulder to left nipple. I, personally, am still sorting out the axis system, and it’s hard to do in this format. The first, most basic place to start is checking if lead I and aVF are POSITIVE, meaning their QRS complexes go ABOVE the isoelectric line. If that is the case, you are probably ok axis-wise.

Essentially, lead I’s vector goes from left to right, and aVF’s vector goes from head to toe. So the average of those vectors is the general path of depolarization of the heart. You want the axis to be between -30 and +90.  So, if aVF is positive, but lead I is negative (the QRS is below the isoelectric line) that means it is going from left to right instead and would be classified as a right shift. Likewise, if lead I is positive, but aVF is negative, that means it is going down to up and would be classified as a left shift. There is soooo much more to axis interpretation, this is just a starting point.

5. Intervals: Again with the conduction system, it’s, like, totally important that it obeys all the rules every time. PR= <.2 seconds, or one big box QRS= <.12 seconds, or 3 small boxes QT= < ½ the RR interval

6. ST segment changes: checking for CAD- aka, is the myocardium getting enough blood/oxygen?  Since the folks in the South seem to consider butter a food group and know that if it can’t be fried it’s not worth eating, CAD is a huuuuuuuuge issue here. When blood supply to the myocardium is compromised, there will usually be characteristic EKG changes. Note- not every episode of angina/MI will have EKG changes though! - Inferior leads —> right coronary artery. - lateral leads —> circumflex artery - anteroseptal leads —> left anterior descending. Disclaimer: does not apply to everyone all the time, some folks have variant coronary anatomy.

So the EKG changes to look for must be seen in two contiguous leads, aka, two inferior leads or two lateral leads. - Ischemia (low oxygen) = ST depression or T wave inversion (EXCEPT T wave inversions are ok in leads V1 and aVR)

- Injury = ST elevation

- Old infarct/dead myocardium = pathologic Q waves. Basically that first negative vector (aka, the Q of the QRS complex) should never be bigger than one tiny box.

And, that, friends, is a basic algorithm for reading EKGs! There is a lot more, but if you follow these steps every time, you will look like a rock star on wards. Good luck!

Two hours ago I was in a trauma room doing compressions on a toddler. The mother’s screams mixing with the sounds nursesdoctorstechs calling out, the beeping monitors telling us what we already know. Now I’m sipping a raspberry vanilla latte out of a mug with red birds riding snowflakes listening to some 80s music. The baby inside of me is kicking. My hands still smell like gloves and hand sanitizer.

And while we were taking history, the patient beside ours (it’s a government hospital so the beds are literally right next to each other), was surrounded by family.

They were talking. I couldnt see them but judging by the sound of their voice, i was pretty sure they were holding back tears. A few minutes later, there was a long pause and a longer songular beeping sound. The patient had flatlined, as confirmed by the sudden wailing from maybe his wife? daughter? Anyway, all I could see through the little slit between the thin drapes that divide us was a lifeless body.

And it was weird to see someone die up close, right in front of you. I wasn’t disturbed or anything. It was just… the first time I saw someone die. I’ve never even seen an old relative die. After that, I continued with our Hx and PE taking like I had not just witnessed death for the very first time. Like nothing happened. By the time we were finished with hx taking, the body had already been moved.

Basically, she found that people generally fall into four categories based on how they respond to external expectations (like a school or work deadline) and internal expectations (like a New Year’s resolution). Upholders respond readily to both external and internal expectations. Obligers respond to external expectations but struggle with internal ones. Questions respond to internal expectations but struggle with external ones. Rebels, well, they struggle with both.

These tendencies are hard-wired! We’re born with them, and they aren’t something you can really change. What you CAN do is learn your tendency and then change your circumstances to make yourself accomplish the expectations!

I’m an Obliger myself, so that’s where I have the best examples. Plus, that’s kind of what this thread is about! I can’t get myself to go to the gym - but if I’m meeting a friend there, I know they’re counting on me, so I’ll be there. For Obligers, it’s all about taking your internal goals and creating external accountability for them. You want to read more? Join a book club! You want to get up earlier? Find someone else who wants to get up earlier and schedule a morning conversation every day!

For Questioners, they (surprise) question everything. They need to turn external expectations into internal ones, and the key is to know why this is necessary. Questioners can easily get lost in research, so they have to be careful - they may never buy a coffee pot because they’ll spend weeks searching for the perfect one. If something feels arbitrary, they’ll never do it. They have to find the why.

I know a lot less about Upholders, just because it always seems to me like they struggle less with expectations and goals. They want to do something? They will do it! Someone else wants them to do something? They will do that too! It’s important for Upholders to recognize that people around them aren’t always wired the same way, or they can become very frustrated easily.

As for Rebels, they struggle with all expectations. They can do whatever they want - if they want to do it. Accountability, like what an Obliger needs, will NOT work for a Rebel, and in fact will make it more likely that they will not accomplish the goal. Rebels need to make things appeal to their sense of identity. “I want to be known as a smart person, therefore I will write this paper.” Rebels need to do things because they choose to do them.

There’s lots of nuances and variance within each of the Tendencies, strengths and weaknesses and striking patterns as well. The important thing here though is that if you know how you respond to internal or external expectations, you can accomplish what you need to do by changing your circumstances to best suit you!

There’s tons of information on Gretchen Rubin’s website, where there’s a quiz you can take to find out which tendency you are. She also has a book called The Four Tendencies and talks about the framework all the time on the podcast she hosts with her sister, Happier with Gretchen Rubin.

Omar al-Bashir, dictator of Sudan, has been brought crashing down after 30 years of rule. Whilst we’ve been carpeted with wall-to-wall Brexit, the mass of Sudanese people have been engaging in months of protest in the face of police violence and military repression - the President, whose reign saw 300,000 people die amidst state ethnic cleansing in the Darfur, was ousted by his allied military grandees on Thursday.

Yet this is not the Arab Spring of 2011; the working classes of the region have been through a shearing process of fracture and reforging through the dark night of the last decade of social turbulence. The Sudanese people have seen the revolutions in Egypt, Libya and Yemen where removing the hated figurehead of their regimes left the underlying society unchanged, with militaries closing ranks to stultify social change, comprador civilian governments selling out to foreign powers. Sudan’s revolutionaries have vowed to see the end of military rule wholesale, demanding the dissolution of the military junta claiming to be a ‘Transitional Council’. Clearly, the momentum is with the streets, with al-Bashir’s Vice President resigning the chair within a day of the creation of the Council.