Paramedic: I call it a wandering arterial pacer with variable conduction and bundle branch block.
Another Paramedic: Nah, it’s a Mobitz type II below the AV junction with occasional PACs encased in a left ventricle that’s obviously hypertrophied.
Another Paramedic on Scene: No way. It’s an AV dissociation with a tattering of atrial escape beats.
(Sigh) Yet Another Paramedic: Fugitaboudit. It’s a 2:1 Wenckeback with a few aberrantly conducted PJCs added in for flavor.
EMT-B: I call it pulseless and apneic!
ECG interpretation is an integral part of being an ALS provider. A paramedic needs to acquire this skill—specifically 12-lead ECG acquisition—if they are to ever turf off the exhausting procedural process of CPR to EMSers unqualified to just stand there on scene like them, staring at tracings of asystole.
On my first day as a raw EMT—back when LIFEPAK 5 cardiac monitors, limited to three leads, were the standard—my paramedic partner, during the obligatory phase of shaking hands, threw a book at me.
“Memorize this book on basic ECG interpretation by the end of the week.”
“No problem,” I squeaked meekly.
Thus began my journey into ECG interpretation. From day one, squiggly, burned tracings were thrust into my face with the thrustee demanding to know what each PQRSTU wave was communicating. PQRSTU, by the way, is also my acronym for Paramedic Quantum Renal Seepage Tracking Utensil. Lasix’s got nothing when it comes to creating incontinence like that of misinterpreting an ECG strip in front of your peers or an ED doc—much less the patient.
Just when I was starting to feel good about my three-lead interpretation skills, a radical paramedic instructor by the name of Mike Taigman came down from Denver and told us at an EMS in-service, “Behold, my children of cardiology, for I bring you tidings of great joy. For unto you, this day is born an electrode. Tis MCL1.”
“Shut the front door,” I bemoaned to myself. OK, those weren’t the exact words. But I gotta tell ya, I wasn’t happy. Selfishly I thought, “Hold your Ps and Qs there big guy. You’re talking about more accountability for the same pay?”
You know who was even more perturbed? ED docs. “These medics are getting out of control,” they’d say. “Before you know it, they’re going to want to paralyze combative patients prior to intubation.”
“Ha! Ha! Ha!” we would say. “Like that would ever … Hmmm that’s not such a bad idea.”
A medic can always date themselves by the LIFEPAK monitor’s model number around at the time. As the number increased from LP-3 to LP-10, to LP-12, to LP-15, more electrodes began to appear on the patient. I can’t wait until the LP-350 comes along. Regrettably, by then, medics will be using it on me.
What I still find irritating is that no matter how well our ECG decoding skills have developed over the years, some patients out there still fail to agree with my diagnostic ECG findings as to whether their cardiac event is indeed cardiac in nature.
“Mr. Smith, I don’t find any significant findings on your 12-lead, so stop your whini … What’s that you said Mr. Smith? I can’t hear you between your agonal respirations.”
We, as paramedics, tend to look for zebras more often than horses when we hear hoof beats. This is the standard line used on those clairvoyant ECG types who always believe the worst possible catastrophic cardiac event is about to unfold every time they encircle a patient’s chest with self-entangled electrical wiring.
It’s no wonder, seeing as how every cardiology instructor savors the opportunity to trick their students by always having a serious cardiac event hidden in ECG strips that flashes across the PowerPoint screen.
From a self-esteem point of view, I can appreciate how medics take pleasure in the prestige their ECG interpretation skills have given them. There’s something about commanding a scene where everyone on your squad gives dramatic pause during their patient care as they anxiously wait for you to divulge the secret hidden within those squiggly lines. Unless, of course, the EMT suddenly takes the 12-lead from your analyzing hands and turns it right side up for you to read.
On a serious note, I want to take this opportunity to give tribute to all those paramedics, docs and nurses who have advocated the need for advanced electrocardiography in the prehospital setting.
For that, I sing your praises from the top of my R wave to the bottom of my Q wave … Wait, scratch the Q wave and make that an S wave.
Until next time, keep a poker face while reading ECGs—unless you see zebras. Then play stripe poker. JEMS
This article originally appeared in January 2012 JEMS as “Rite of P-Wave Passage: The art of interpreting the ECG.”