RN Life

ER tech passing by: Back in place, hopefully.

Day shift nurse during report: But did you give him a bath?

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.

I was rounding on the newer nurses & one of them asked me to help set up the FloTrac for hemodynamic monitoring. I say sure & as we are setting it up I asked why she needed it. She said the doctor started Dopamine & we need to titrate for cardiac output.

I asked her what the patient came in for because he was a young guy resting in bed. She said he came in for a tree branch falling on his chest. I knew her other patient was here for cardiac reasons. I asked if the same doctor is following & she said yes.

I told her to call the doctor & make sure he didn’t put the order in on the wrong patient. The doctor did & we had to put a safety event in because the patient had gotten about an hour of the drug.

my old therapist derek, from across the reception area, seeing me for the first time after the summer of 2015: HEY DID YOU SEE AGE OF ULTRON?? IT SUCKED, RIGHT???

“You’re bassicly a glorified sad lizard.” (It makes sense with context)

“Damn girl you need to get your shit together.”

“Go home and cry. Stop drinking in bathtubs. Eat something that isn’t bleach or memes.”

You have a patient come in with a stomach ache, nausea, feels tired and sort of generally miserable, no other obvious characteristic symptoms.

Out of 100 patients like this, 90* will be a minor gastroenteritis or whatever, maybe you ate something bad, here’s some nausea medication, go home and eat bland foods and get enough fluid and sleep it off.

And 7 will be appendicitis or gallstones or pancreatitis and need to be admitted to the hospital, 1 will be a heart attack with atypical symptoms, 1 will be the first sign of cancer, and 1 will be some weirdo disorder with a name like “Coleman’s 4268py deletion snydrome, Type II”** that you never heard of.

If I were a doctor, this would make me terrified to ever tell a patient “maybe you ate something bad, go home and sleep it off.”  Even though that’s usually the right answer, and even though it’s a waste of time and money to do an EKG and CT and 4268py test on everyone with a tummy ache–it’s got to be anxiety-provoking to not be certain that you aren’t missing something.  And at some point you will send someone home only to get a call the next day that they collapsed and now they’re in the ICU (or the morgue).  And it’s got to be really hard to go back to work after that and say “go home and sleep it off” to your next patient, even though that’s still usually the right answer.

I’m understanding more these days how tough it is to live with that kind of risk and responsibility.

*not actual statistics

But I have learned to learn from those times. I refine my differential diagnosis, I sharpen my senses. I vow to avenge that death/bad outcome like a father over his murdered son’s grave, while also vowing not to start ordering CT scans for every stomach ache.