New intern. How to improve EKG interpretation skills?

[lucid_interval]

Have read the dublin book, but still not very happy with my knowledge or skills really. Hate looking stupid when being quizzed about something.

Is there something interactive and interesting to revise daily to improve skills and knowledge with time? Or is it just sitting down and reading ekg textbooks?

Any advice would be much appreciated.

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[Angry Birds]

Have read the dublin book, but still not very happy with my knowledge or skills really. Hate looking stupid when being quizzed about something.

Is there something interactive and interesting to revise daily to improve skills and knowledge with time? Or is it just sitting down and reading ekg textbooks?

Any advice would be much appreciated.

The dubin book is med school level. You should go through Amal Mattu's ekg book

 

[Zebra Hunter]

Amal Mattu’s book is great for basic ECG understanding for EM docs. Expert emergency ECG analysis is less about understanding vectors and more about pattern recognition, and Amal is phenomenal at providing numerous real life ECG examples. However, most ER docs stop at Amal Mattu’s book and consider that sufficient. What I recommend after getting the basics down is then going to Dr. Smith’s ECG blog, and literally starting from the beginning and reading every post he has submitted. That man is an ECG genius, but can be difficult to follow if you don’t have at least a strong understanding of emergent ECGs. After going through all his posts I guarantee that you will be better at ECG interpretation than most of your attendings as well as most cardiologists.

 

[Rekt]

ECG Weekly is the best resource in my opinion.

 

[SpacemanSpifff]

Amal Mattu’s book is great for basic ECG understanding for EM docs. Expert emergency ECG analysis is less about understanding vectors and more about pattern recognition, and Amal is phenomenal at providing numerous real life ECG examples. However, most ER docs stop at Amal Mattu’s book and consider that sufficient. What I recommend after getting the basics down is then going to Dr. Smith’s ECG blog, and literally starting from the beginning and reading every post he has submitted. That man is an ECG genius, but can be difficult to follow if you don’t have at least a strong understanding of emergent ECGs. After going through all his posts I guarantee that you will be better at ECG interpretation than most of your attendings as well as most cardiologists.

Smith is (hopefully) leading a revolution in the way we classify cardiac ischemia, away from STEMI and towards acute occlusion. Definitely will up your ischemic evaluation game.

 

[DrDrummer]

Smith is (hopefully) leading a revolution in the way we classify cardiac ischemia, away from STEMI and towards acute occlusion. Definitely will up your ischemic evaluation game.

Very much so. Even if every so often he'll post an ECG and it'll essentially be normal and then it's followed by, "I of course immediately recognized 100% LAD occlusion and activated the cath lab without seeing the patient." Followed by a 12x magnification of the T wave in lead aVL and an explanation of how simply plugging some readily available findings from the ECG into the 4-variable formula (0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3) that everyone of course has deeply ingrained into their brain from about Day 2 of intern year quickly yields a lifesaving diagnosis. ;-)

(I am mostly kidding here of course. I rotated with Dr. Smith and he is brilliant and I have learned a ton from his blog, have the app on the phone and have read his generously-freely-available textbook on ECG interpretation. I do think we can learn to be better than cardiologists at recognizing OMI and think the OMI Manifesto is great even if cardiology will be somewhat slow get on-board. But if you read the blog enough, you'll see what I'm talking about.)

 

[betamale]

Amazon product

I like this one. Easy read

 

[thegenius]

Very much so. Even if every so often he'll post an ECG and it'll essentially be normal and then it's followed by, "I of course immediately recognized 100% LAD occlusion and activated the cath lab without seeing the patient." Followed by a 12x magnification of the T wave in lead aVL and an explanation of how simply plugging some readily available findings from the ECG into the 4-variable formula (0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3) that everyone of course has deeply ingrained into their brain from about Day 2 of intern year quickly yields a lifesaving diagnosis. ;-)

(I am mostly kidding here of course. I rotated with Dr. Smith and he is brilliant and I have learned a ton from his blog, have the app on the phone and have read his generously-freely-available textbook on ECG interpretation. I do think we can learn to be better than cardiologists at recognizing OMI and think the OMI Manifesto is great even if cardiology will be somewhat slow get on-board. But if you read the blog enough, you'll see what I'm talking about.)

Yea some of those EKGs where he says there is ST depression in some lead just doesn't exist. Still an excellent blog though.

 

[EM Junkie]

Very much so. Even if every so often he'll post an ECG and it'll essentially be normal and then it's followed by, "I of course immediately recognized 100% LAD occlusion and activated the cath lab without seeing the patient." Followed by a 12x magnification of the T wave in lead aVL and an explanation of how simply plugging some readily available findings from the ECG into the 4-variable formula (0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3) that everyone of course has deeply ingrained into their brain from about Day 2 of intern year quickly yields a lifesaving diagnosis. ;-)

(I am mostly kidding here of course. I rotated with Dr. Smith and he is brilliant and I have learned a ton from his blog, have the app on the phone and have read his generously-freely-available textbook on ECG interpretation. I do think we can learn to be better than cardiologists at recognizing OMI and think the OMI Manifesto is great even if cardiology will be somewhat slow get on-board. But if you read the blog enough, you'll see what I'm talking about.)

probably wouldn’t last 2 months in a busy community ED

 

[Apollyon]

Remember, "3 miles wide, 1 inch deep".

 

[AlmostAnMD]

The definitive EKG book is Chou's Electrocardiography in Clinical Practice. I flip through a few pages on less busy free standing shifts. 700 pages of EKG theory and well over most of my head. It's not for interns, it's not for residents, it's not even for emergency attendings. I'm just reading it pretending to be a cardiologist.

Though, it does drop bits and pieces of information that have been quite helpful clinically over the last year or so.

 

[Zebra Hunter]

OP, I applaud you for continuing to try to improve. I do think though that many get lost in the weeds of EKG interpretation. We don't need to be better than Cardiologists at interpreting EKGs. If that was the goal, then we should become Cardiologists...Surgeons...Orthopedists...Pediatricians...Obstetricians...Psychiatrists... We are trained in the initial recognition and stabilization of emergent conditions in every field very well, and as well as subspecialty physicians. We aren't trained to be the final authority on other broad fields of medicine. Interpreting a STEMI is often one of the easiest things we do. Paramedics, techs and nurses usually diagnose these patients before we do. High sensitivity troponins x2 make missing a MI very difficult as well. Certainly recognizing a STEMI presentation in progress is important, but just as important is having high suspicion given clinical appearance and repeating EKGs activating the cath lab within a reasonable time. Most STEMIs clinically look like they are having a STEMI from the doorway. Arguing with a Cardiologist over subtle EKG changes leads to more confrontation and also delays care. I don't feel the need to know every nuance of EKG interpretation better than a Cardiologist.

You will do great as long as you can interpret just a few things including ST elevation with reciprocal depression that correlates with certain anatomical locations, De Winter T waves, Wellen's syndrome, LBBB/RBBB, types of AV block, atrial fibrillation/flutter, PSVT, WPW, Brugada syndrome, HCM, and maybe S1Q3T3 pattern (less important). Keep looking at a lot of EKGs. You'll get better over time. I've found its very similar to radiological interpretation. Pattern recognition and experience.

You’d be surprised at the frequency of the things you miss when you have no clue what you’re looking for. I can’t tell you how many times I’ve had colleagues miss obvious (to myself at least) occlusion MIs on ECG, or freak out over a completely benign ECG. The goal isn’t to be better than a cardiologist, it’s to be a better doctor. Having the attitude of “eh, I don’t need to be that good” is a dangerous mindset for a doctor in training to have. I’m not saying OP needs to be able to recognize the precise anatomic location of where the VTach is coming from, but a good emergency physician should have a very strong understanding at interpreting ECGs. There is so much amazing, free, easy to consume ECG education resources online that there really isn’t a good excuse for not being on par with our cardiology colleagues with emergency ECG interpretation.

 

[Zebra Hunter]

I respectfully disagree. I never said you shouldn’t try to be good or shouldn’t try to become a better physician. Your words. I believe in spending the time to become the best physician you can be. There is also life outside of medicine post the world of training which isn’t reflective of most medical practice. You don’t need to get caught up in knowing every detail. I guess you should also do an IM residency and a cardiology fellowship as it will make you better at interpreting EKGs and a better Cardiologist. It probably won’t make you a better EP. I'm all for using free resources as much as you want/need to in order to become proficient. Physicians that get caught up in the weeds though sometimes miss the big picture, are painfully inefficient and introduce harm from over testing and treatment. You aren’t going to miss a MI with two negative high sensitive troponins or a STEMI with serial EKGs. Lead time bias usually won’t affect the outcome. P.S. Vtach comes from the ventricle

I guess we will agree to disagree, but what you state is a false dichotomy. It takes a minimal amount of commitment to become an expert at ECG interpretation. Read a couple blog posts a week from Smith's ECG blog. It's about the same commitment as reading a news article every couple days. An IM residency or cards fellowship will not make me any better at reading ECGs, because the resources are already available without having to do that. Also, those that are proficient at ECG interpretation generally aren't the doctors that get "caught in the weeds" trying to interpret ECGs and overtesting, those tend to be the doctors that believe they didn't need to learn ECGs past AV blocks and obvious STEMIs and then recognize an abnormality on an ECG and have no clue how to interpret it. And you will miss many acute occlusion MIs in your career if you are relying on an obvious STEMI to appear on your serial ECGs. I have an entire lecture filled with ECGs and then some of acute MIs that colleagues missed because of a lack expertise in ECG interpretation.

 

[Zebra Hunter]

Most ERs to my knowledge don't have high sensitivity trops and you might catch an MI, but miss the fact that a coronary artery is completely occluded. You can doubt this but we have plenty of data that demonstrates this to be true. Patients with delayed PCI for 100% occlusion of major coronary vessels have worse outcomes including increased mortality. About 20-30% of acute occlusion MIs found on delayed PCI will be negative for the STEMI criteria. Those patients have similar mortality to delayed PCI for STEMIs. Many of those MIs had evidence on ECG for acute occlusion of a specific coronary territory. STEMI criteria is an arbitrary cut off of voltage measures that has very little data to back its use. You have undoubtedly missed several acute occlusion MIs in your career, as have I. Luckily the majority won't die, but many will go on to develop significant ischemic cardiomyopathy from delayed recognization of acute occlusions. I continue to learn about ECGs just like I continue to read new literature so that I can be the best doctor for my patients.

I go run and bike on trails, I go drink whenever I want with friends, I (used to) go on plenty of vacations, and I also carve out a tiny amount of time each week to get better at my job. Its really not a huge undertaking, and I just don't think we should be discouraging EM interns from wanting to become experts on ECG interpretation.

 

[Zebra Hunter]

Most eventually will. Please feel free to substitute serial normal sensitivity troponins into my statements above.

Maybe negative for initial STEMI criteria. The inverse of that is that 70-80% of occlusion MIs initially met STEMI criteria. As I said above, lead time bias usually won’t affect the outcome.

You see a STEMI though and both you as well as everyone in the room knows the patient is having a heart attack. We use it because it works. It's like looking at an open fracture.

I'd encourage interns to learn how to interpret EKGs. We just have a different opinion regarding the importance you place on learning every nuance of EKGs, especially for the intern level. Learn to walk before you fly. Cardiologists are experts of the heart. We are experts at initial recognition and stabilization of emergencies. You can't learn everything. If you want to spend your time learning every nuance of an EKG that is your prerogative, but that is time you are taking away from learning about the ocean of medicine that is 3 miles wide. You will have deficiencies in other areas by devoting all of your time to EKGs. I don't think interns need to become EKG experts as I pointed out above. I noted that they need to learn the things I mentioned. Like both of us said, agree to disagree.

You will miss quite a few MIs throughout a career with just a single 2-3 hr delta troponin I ignoring patient risk factors. And STEMI criteria works, when present, however it fails a non-trivial number of patients when it is not present. And not every STEMI presents looking like they are having an MI, that is an obviously false statement for anyone that has been doing this long enough. You also keep throwing out these false dichotomies like asserting that some how it requires some extraordinary amount of time to become an expert on emergent ECG interpretation. It doesn't. You also seem to believe that developing an expertise in something means you cannot develop an expertise in others. It's like claiming because you want to run mountain trails, you can't devote time to becoming a good doctor. It's a nonsensical argument. I read about everything related to EM, not just ECGs.

 

[DeadCactus]

The Mattu books are a solid next step. The Smith website and EKG weekly are a good way to keep advancing.

The reality is you pick and choose what you want to excel at and accept competent in other areas of your practice. Some of the choice will be personal interest, some will be who mentors you, some will be what specialists are available in your practice, and some will be what scares you or a bad outcome that burned you. Talent and determination may let a select few be more skilled in a broader number of topics but you can't be at the top of the game in every area of emergency medicine. There's a reason even subspecialists further specialize. I think La Cumbre Lines provided a reasonable list to be a competent emergency physician delivering the standard of care. You could make similar lists for bedside ultrasounds, advanced airway techniques, laceration repair, ophthalmologic evaluations, etc.

 

[RuralEDDoc]

Interesting Zebra/Cumbre debate. One challenge with identifying occlusion MI that do not meet STEMI criteria is getting anybody to do anything about it. You can give ASA, start heparin, control BP, but getting a cardiologist to see and then cath the patient can be a challenge based on local practice patterns. Plenty of cardiologists will tell you that emergently cathing NSTMI patients leads to worse outcomes. So then what? TNkase?

 

[SpacemanSpifff]

Interesting Zebra/Cumbre debate. One challenge with identifying occlusion MI that do not meet STEMI criteria is getting anybody to do anything about it. You can give ASA, start heparin, control BP, but getting a cardiologist to see and then cath the patient can be a challenge based on local practice patterns. Plenty of cardiologists will tell you that emergently cathing NSTMI patients leads to worse outcomes. So then what? TNkase?

Document your interpretation of the ECG as concerning for an acute occlusion and your conversation with the cardiologist relaying that concern. A bedside TTE with RWMA will probably convince most interventionalists to cath in the light of day. Otherwise we wait until the paradigm shifts from STEMI to OMI.

 

[WheezyBaby]

12 lead EKG - The art of interpretation by garcia is what I read as an intern after I realized Dubin offers basically zero value in interpreting actual EKGs. I thought it was a great book and have recommended it to many. Have not read Mattu's to compare. I think garcia is plenty to get through residency - if I went into a field like EM with frequent high stakes EKG interpretation I likely would have read a more definitive text than garcia at some point late in residency though

 

[Angry Birds]

In his defense, his name is literally Zebra Hunter.