Mom brings in her 24 year old daughter and says that she is not sure what happens, but the daughter suddenly goes into convulsions and starts shaking and having a seizure. You attach the EKG machine for fun, then you capture the following over the next 10 seconds. Is this artifact and shaking or something very bad?

A 20 year old patient comes in to the ER complaining that he was playing soccer, and the ball hit him in his chest. He feels like "I got the wind knocked out of me" and is doing well otherwise. He has no medical history, vitals are stable. One of the brightest ER interns decides to get an EKG, and you see the following:

What is this?

Every once in a while you wonder if people actually understand what they are dealing with and whether or not they really understand what's going on. A recent encounter with another physician perplexed me.

A patient is brought to the ER because he or she is found unconscious by a family member. It turns out the EKG looks "scary" and they call cardiology. What the ER thought they saw on the EKG was an entity called "ST Elevations" which typically means someone is having an acute heart attack and needs to go to the cath lab to get the artery opened up.

We arrive. It turns out the patient is in acute renal failure, with a creatinine of 3.5, the potassium is over 8 (which gives you a similarly bizarre EKG pattern), and has a blood sugar of over 1300, and a bicarbonate of 5. The ER also ordered a troponin which was indeterminant and a BNP which was 1300.

The patient on paper looks like he is in Diabetic Ketoacidosis, dehydrated as hell, and has gone into acute renal failure from the severe dehydration. Yes, the elevated potassium is very high and at such high levels you get EKG changes which look very abnormal. A potassium over 7.5 gives you wide QRS complexes, wide T waves (the QRSs and Ts look similar), lack of P waves (or very blunted), bradycardia. 

We rehydrate the patient, his potassium quickly comes down (as is expected, because they are really potassium deficient), treat his DKA, and over the next few days his kidneys resume normal function.

A few days later one of the physicians from the ER saw me in the hallway and asked me, "Hey, how do you explain the CHF in that guy?"

I asked, "CHF? Why do you think he was congested? You think he is volume overloaded?"

"His BNP was like 1300"

"He was in acute renal failure."

"So, why was he volume overloaded?"

"He wasn't. He was about as dry as they come. You coulda given him 10 Liters and he'd be fine."

"And the BNP?"

"You can't really evaluate a BNP with renal failure. Nor troponin for that matter. Just toss those two out the window."

Sometimes you just think to yourself, "Wow!" Sometimes things that you think are common knowledge may not always be. We can't rely on merely tests and numbers. We can't be robots. We have to understand what happens behind the numbers.

Medicine humbles you every day! There isn't a day that goes by that I don't learn something new.

I found a really nice chart to help elucidate the diffeent types of tall, peaked T waves. A lot of people look at tall T waves and aren't sure if the patient has hyperkalemia or is having an acute myocardial infarction (heart attack). The first finding when someone is having a heart attack is "hyperacute" T waves. Then you see the ST elevations. These hyperacute T waves, are wider, rounder at the top, and symmetrical as opposed to the hyperkalemia T waves which are narrow and sharp. Of course, some tall T waves are normal, but they are usually uneven and asymmetrical.

Take a look at this nice chart!

I love teaching!

A new batch of students, Melissa and Suzanne, are now on EKG week with me and are loving every second of it!

As physicians, we will always be teachers and will always be students! We have to remember this for the rest of our lives. We will never know everything, and we will always know more than someone. We have to teach and learn!

Teaching is a passion and it takes time to hone your teachng skills. I highly recommend teaching. It is extremely satisfying and you feel like you have imparted something important on to someone. It is especially gratifying to know that you are good at explaining complicated concepts in a way that simplifies them and allows them to enjoy being taught.

You should never teach because you feel obligated or because you "have to". You should teach because you love it. It should come from within. You shouldn't teach for a pat on the back or a "thank you" from someone. You should do it because you enjoy it, regardless of reward. Teach for the sake of teaching!

I am especially competitive. My entire life I spent competing with my brothers and friends at everything! Football, basketball, jobs, reporting, business projects, politics, just about anything! We have an inner drive, and we never settle for second. I am the same way about teaching and being the best damn doctor I could possibly be!

One reason I love to teach is because I want to be the absolute best teacher there is. It's a competition for me. When I hear that one physician is a "great teacher", I will attend all their lectures and try to find out what makes them so good, so I can emulate their techniques. If a freind wins a teaching award, I want to win more awards than them. If one person finds a great way to explain something, I will use that same technique to explain other concepts. 

I always love attending Dr. Matthew Kamin's EKG lectures. I know EKGs pretty well, and his lectures are very elementary and usually at the level of a third year medical student. However, I always manage to gleen a nugget or two from his lectures. All those nuggets add up over the course of a year and Dr. Kamin is a great teacher. He has amazing ways of explaining complicated issues. I can never get enough of him!

These are people who we should model ourselves after and emulate! Teach on!

It's especially exciting when your students' eyes light up and they start to "get it". They suddenly are excited about the material and want even more! That is the ultimate satisfaction, the ultimate high! Nothing is more rewarding than when someone says, "Hey, can you teach us again tomorrow?"

One component of life that goes with teaching and being knowledgable is staying humble. It's very easy to mistreat people, be condescending or to think highly of one's self when you think you have achieved something. Humans should never think highly of themselves nor mistreat anyone. We are one and the same.

We should treat everyone exactly as we would treat the person who we have the most respect for. Treat everyone as you would want to be treated! Treat everyone as you would treat your parents, or a famous celebrity, or a role model that you have a ton of respect for. There is no excuse for not respecting people or being kind and generous.

I hope to continue many more years of teaching and learning!

One of the marvels of modern technology is the ability to view faxes on your phone. Having a Palm Pre makes that very convenient, if you are on a football field or at a restaurant!

If the emergency department calls and says, "Hey, can you take a look at this EKG for us?" You can say, "Sure, fax it to me." You give them your fax number (provided through www.MyFax.com) and they fax it to your number, and it promptly pushed through my gmail account to my Palm Pre as an image or pdf file. I can quickly view it on my phone and tell them what to do with the patient (or what not to do)!

That is pretty amazing!

To the right is an example of an EKG that was faxed to my phone. It may look blurry and unclear to all of you, but there is enough information for me to give them a useful answer. If you right click and save the image, you will get the full sized image. On my Palm Pre, I can zoom in to view various parts of the EKG and that is awesome!

Thank you Palm, Google, and MyFax for providing us with the latest and greatest technology! This certainly makes life easier for all of us, and keeps patients safer!

One of the most important weeks in a medical student's life is EKG week with me! During EKG week, students learn the art and science of reading EKGs.

I know that EKGs are "taught" in medical school. We all "learn" about EKGs. Unfortunately, the way EKGs are taught leaves a lot to be desired. It's taught in a very boring, isoteric way. And it's nearly impossible to really use that information practically.

So students never end up really applying that basic information to real life EKGs and real life patients.

I want my students to be able to look at an EKG and in 2-4 seconds be able to give you a diagnosis and know what to do with it.

I usually start off by giving them a quick EKG pretest to see how they do. They usually struggle and no one gets all the answers correct. Most haven't even gotten over 60%. That's bad.

The next step involves printing out over 200 EKGs and cutting off the tops. We start going through them in a systematic way.

First, I want the rate. Count up the QRS complexes and multiply by 6.

Then the rhythm. Is it sinus or not? P waves or not? P before very QRS?

Then axis. Left? Right? Normal?

Then PR interval. Long?

Then QRS duration looking for blocks.

Then evaluate the ST segments. Early repol? STEMI? Pericarditis?

Then evaluate QT duration.

Then look for abnormal Q waves.

Then everything else?

More...

One of the most important things to learn about medicine is how to know when someone is really having a heart attack. Especially, a STEMI (ST Elevation Myocardial Infarction). Those are the deadliest and heart muscle has died and is dying as we speak.

If you learn anything in all of medicine, please learn to recognize a STEMI. Why? STEMIs have to go to the cath lab and the artery needs to be opened up within 90 minutes. That saves heart muscle and saves lives!

 Below is a quick review of all the various parts of an EKG. We are mainly looking at the ST segment.

So what is a STEMI?

STEMI criteria:
The ST segment of an EKG will be elevated by more than 3 mm in the precordial leads and by more than 1 mm in the limb leads. Further, in the precordial leads, the shape should be convex up (like a tombstone). The shape matters more than the amount of elevation in some cases. You may have minimal elevation, but the shape is convex up, that could be considered a STEMI.

In the limb leads, the shape does not matter, just the elevation. Anything more than one small box, and you have a STEMI! Pretty straight forward. Unless, of course, it is an early repol!

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