education – The Student Physiologist

AF Association Pulse Check Event

Myself and some of my colleagues recently relinquished a Saturday off, and braved the icy cold (read: British) weather to try to meet with the public, and raise awareness of atrial fibrillation through a project spearheaded by the AF Association.

I didn’t organise the event, but was kindly invited along, and jumped at the chance to help some of my amazing Cardiology workmates by checking pulses, and recording rhythm strips using the AliveCor mobile ECG monitor (which I have previously reviewed here).

AF is an atrial arrhythmia, wherein the sinus node does not cause appropriate, rhythmic depolarisation as it normally would. Rather, multiple foci activate, facilitating a motion akin to ‘quivering’, which raises the risk of embolism through the inefficient pushing of the blood into the ventricles. It’s an incredibly dangerous problem if left untreated, so it’s vital that it gets detected, and preferably this would happen early.

I go into detail about AF, it’s mechanisms and ECG presentation in this study guide, so have a look at that if you want to understand it further.

As you may or may not be aware, atrial fibrillation is, globally, the most common clinically significant cardiac arrhythmia, and it is thought that whilst 1.2 million people (a conservative estimate) in the UK are known sufferers of the sinus node disorder, a 500,000 have it, and live undiagnosed. The estimated cost of AF to the NHS was somewhere in region of £2.2 billion, in 2008, and given that the prevalence of the arrhythmia has increased year on year, this number may well be higher now.

Obviously, this is far from an exhaustive exploration of AF, but hopefully it gives some insight into why it’s so important to detect and treat, and why initiatives such as this one are a good idea.

We set up shop in Frome’s Westaway shopping centre at around 10am, where members of the public who’d read about the event in the local newspaper were already queueing. We four clinical scientists proceeded to advise and check 85 people throughout the day. We had a surprise visit from Cardiologist’s Kitchen, too!

IMG_-7mgkhu — Mary, of Cardiologist’s Kitchen fame, showed up to say hello!

Many people we talked to had little-to-no idea what the condition was, its risks, or how it was treated, so we used literature, ECG examples, and a scale model of a heart, to educate, and taught people how to check their own pulse before performing quick rhythm recordings which we analysed on the spot. More than a few people who attended had known AF, and their questions largely involved their current treatment, and the potential impact AF might have on their life. Most, however, visited so they could get checked over, hopefully putting their mind at rest, and learning something in the process.

We didn’t find any new atrial fibrillation (although we did discover two cases of previously undiscovered AV Block), but of equal importance to arrhythmia discovery, was the community engagement, particularly in a public setting. In clinics it’s easy to fall into a cycle with patients, due to schedules and time pressures, and whilst we all try our hardest to make sure everyone is treated individually, seeing the problem before the person is always possible. Interacting with patients on “their turf” meant the ball was in their court, if you like, and the sheer volume of people who expressed an interest meant it couldn’t have been further from a wasted day.

The feedback we received was overwhelmingly positive, and there was a recurring theme in the gratitude people felt for the healthcare environment coming to them, as oppose to the other way around. Many of those to whom we chatted understand the strain that hospitals and GP surgeries are under, and felt that visiting to be checked for AF, and other such things, would be inappropriate. In many ways, I suppose they’re right, too; regardless of the importance of finding these things, especially as they do not always present with obvious symptoms, healthcare centres, unfortunately, cannot cope with the demand a service such as this would present. To this end, I was glad to have ventured out to participate in this, an outdoor clinic of sorts, and educate the public on what to look for, as well as how they can guage their own heart rhythm and take some more control over their own health. I sincerely hope to do it again soon!

The AFA is a fantastic charity, so it’d be great if you were to find out a bit more about them by visiting them here.

I’d like to thank my colleagues for asking me to participate, and generally being fantastic people, those who visited us and asked lots of challenging questions, and the kind souls who bought us ginger ale and flapjacks when the temperature reached what *felt* like sub-zero levels.

The statistics used in this post are taken from the BHF. If you want to take a look for yourself, visit the British Heart Foundation, here.

SCST Diploma Day: A Reflection

Myself and OliGS recently sat the SCST Electrocardiography Diploma and Practical Examination, so I thought I’d jot down some of my experiences in the run up, and my retrospective thoughts on the day itself.

If you’re thinking of doing it, or have your PTP finals looming, then read on, as this will give you an idea of what to expect.

I’ll start by saying this: Oli and I have NEVER been so stressed in our entire lives.

This exam was a nightmare for which to prepare; I have extensive experience in taking exams, and it is my view that they’re 50% what you know, and 50% what the examiners want you to tell them. Without having met these examiners or seen a previous paper, it was very difficult to know what to really nail, in the revision stage. The syllabus was long, detailed, and contained what seemed like an entire career’s-worth of things to learn, so we already knew it was going to be a slog, but nothing prepared us for the written paper…

Read these. Lots.

We studied, sometimes sleeplessly, for weeks. Tested each other on rare arrhythmias, read textbooks cover-to-cover (repeatedly), and watched each other’s once sunny outlooks and youthful (ahem) features rapidly wither as the examination date draw closer. It consisted of 20 multiple choice questions, 10 arrhythmia analysis and knowledge questions, and 4 full ECG analysis recordings. Some of these were almost instantly recognisable, but others were brutally difficult to analyse. The MCQs (often the most looked-forward to section of any exam) were equally tough. Those 3 hours lasted a lifetime…

We left the exam battered and bruised, but glad it was over.

But it wasn’t over. It was far from over. As well as the written paper that had almost ruined us, we had the practical exam to do as well.

We had made sure that during our post-ECG placements we still got ourselves in the clinic so as to keep everything fresh, as performing a perfect ECG is not like riding a bicycle.

The last attempt before test day

It turns out that this was the correct call, as was practicing on one another in the hotel the evening before the exam; the margin for error in the exam is 2mm(!) Anyone who’s had an informal assessment, or had their Direct Observed Practice scrutinised whilst training knows that it’s very easy to second-guess when it comes to electrode placement, and despite having 20 minutes to complete the whole thing, this timeframe becomes devastatingly short once you’re in there. It’s a clinical assessment, so one needs to complete the necessary ID checks, explain the procedure to the patient AND to the examiners (i.e. in two different ways), perform it whist answering questions, and then complete a verbal examination.

Three hours after we had finished the written paper, we were called to attempt our practical exam. There were ashen faces all around. Some were on those still waiting for their number to be called as ours had just been, others had been told that their 2 attempts had been unsuccessful. Neither of us were looking forward to this. Now, given that I’ve already stated that each electrode is allowed to deviate only 2mm from the precise, gold standard location, the internet-purchased electrodes pictured in the above image would be somewhat unfair, right? It seems that the examination board concur, as they provide some rather cool, transparent electrodes complete with crosshairs. They doesn’t make it easier, per se, but they certainly go some way eliminate that lingering trepidation when it comes to deciding you’re happy with your placement and ready for judgement.

Crosshair emblazoned electrodes(!)

I opted for the “all at once” technique: I explained everything to the patient before I started, gained consent, then explained everything I was doing as I went along. Once was put simply to the patient, then once to the examiners, using correct terminology. I paid extra special attention to V1, V2 and V4, as my patient had a particularly wide sternum, so I wanted to be totally sure that I had the sternal border, especially given the electrodes were rather far apart when placed and looked slightly odd to me. After I took a step back and looked at my work, I was incredibly tempted to move the aforementioned electrodes, but either due to fear, fatigue, or a combination of the two, I decided to leave them as they were, opting to go with my initial judgement. After that, I waited.

I’m not entirely sure how the placements are measured, as candidates are asked to leave the room whilst they are checked by two examiners. I heard someone mentioning special rulers, but I didn’t get a look at them (it’s all very cloak and dagger), in any event, you’re called back into the room and, in my case at least, informed of your passing or failing grade. I’m pleased to report that I passed on the first attempt, which as I’m sure you can imagine, was a tremendous relief; I lost my cool somewhat, and expressed my joy rather loudly, as I was informed I wouldn’t have to do it again. Oli soon found me in the waiting area and, grinning wildly, slapped me on the back and hissed “YESSSSS!” before promptly throwing himself into a chair. It was over, and we were victorious.

We didn’t speak too much about it, on the way home, but in the couple of days that have passed since the exam, we both feel a tremendous sense of pride that we actually did it, and did it successfully. If I were to give you all some advice, it would be the following:

Be prepared for anything and everything, including waiting around for a long while
Practice analysing ECGs until you hate them
Practice performing ECGs until you hate them
Go with your gut as much as you can during the practical exam
Bring lunch
Don’t under ANY circumstances, stay at the Ibis Hotel in Birmingham’s Chinatown district (I can’t stress this enough because it backs onto a nightclub that doesn’t stop playing the most bass-heavy music until the wee hours of the morning)

7 Epic Fails to Avoid During Your Medical Fellowship

by Robin Dale

A cardiology fellowship will give you the opportunity to be fully prepared for the field and can go as long as four years. It will help you to hone your clinical skills and have cutting edge skills in surgery. A mix of research, public lectures, clinical experience, and classroom-based learning all combined enable one to be very well versed in the field at hand. Fellowships in Cardiology range from Cardiac Surgery Training, Cardiac Critical Care and Paediatric Cardiology, Vascular and Interventional Radiology, and Vascular Surgery and Endovascular Therapy Fellowships.

Several institutions offer what are considered the best Cardiology Fellowship Programs. To choose and get accepted into the best cardiology fellowships programs successfully, requires much more than an exceptional personal statement; applying to a residency, especially a cardiology one, is challenging and requires a lot of work. The existing places for such mentorships are extremely limited and contested, so you have an obligation to be unique and to stand out in order to be accepted.

Your cardiology fellowship personal statement is an opportunity whereby you can say why you feel you are the most deserving of being enrolled in the program. Elevating yourself above the bar will determine whether you are accepted or rejected. Here you will find the help to writing a personal statement for fellowship in cardiology, as well as some dos and don’ts.

Fellowship goes above and beyond a good resume. A good resume can only go a long way. You can be the most qualified and have the best CV, but this will not guarantee you a spot in the fellowship program. As a candidate, do research on your options, enhance your exposure on volunteer work, conduct clinical research projects, and get publications. Ensure that you have filled the gaps in your resume and took the time to address all of them practically. Most candidates limit their options depending on where the hospitals are situated. This approach is detrimental, however, and prevents them from having a varied list and therefore options pertaining to the top-notch institutions. As a candidate, you can polish up your resume with a clearly defined and well put together personal statement.

The AMA or the American College of Physicians. Most candidates are not part of any corporate entity that advocates for their medical practice. With the continuous cutting of funds in the national budget, it is getting harder and harder to provide any services. This, in turn, has reduced the number of applicants able to be accepted and therefore numerous candidates find themselves being turned down. Joining the AMA will help you get a fair trial and increase your chances of getting approved.

Application to highly competent residency. Programs in radiology, dermatology and cardiology are highly competitive, and the stakes are high. Some of these students’ performances in their former medical school are usually not up to standard and sometimes place few schools on their ranking list.

Expansion of classification list. Students tend to limit their options and apply to a few residency programs. However, it is encouraged that a student lists down at least five hospitals to increase their chances of getting accepted. These choices can either be within their chosen specialty or even selecting a different specialty.

Transitional slot. A student can contact their medical school and ask for an interim slot or see a research fellowship. With this, the candidate will be able to become more competitive in the field and increase their chances of approval. An additional degree is also a supplement to a candidate’s resume and consideration.

Ill-preparedness. Two or more years of postdoctoral training whereby there is formal coursework in the fundamental sciences pertinent to the investigator’s area of expertise; this increased chances of attaining a fellowship.

Medical residency interview. It’s like a pass mark for all residents. Most programs won’t absorb candidates they have not interviewed. It is crucial that you take this interview seriously as it will not only determine if you will get accepted but also where you will get accepted.

Robin Dale is a junior doctor and her passion is guest post writing. She is fond of writing useful posts for students to make their learning lives easier and more effective. Her own life credo is “Keep calm, study hard, and become a doctor”.

TSP Mobile: ECG

EDIT: The Android version of TSP Mobile: ECG is available for download, but due to the way in which Google Play operates, I have been unable to offer it for free. The iOS version, when available, will be gratis for the promised 14 days however. Still no word from Apple when that will be, but I have been assured that it is being vetted as I type this, so fingers crossed!

Original article follows:

Well, that TSP mobile app I promised…

I’ve been saying I’d do it for months and, despite remaining fairly quiet with information about starting, I actually have been working on it. So much so, in fact, that the bulk of the development is finished! It’s in final stages of testing, after which it will be available on the Google Play and iOS app stores, where it will be free for the first two weeks of release, so please download it and leave some constructive feedback and a review.

The app features tutorials on ECG analysis, exercise and ambulatory ECG, cardiac flow and cycles, action potentials and useful formulae for trace analysis. Each section is laid out in an easy to follow format, with colourful diagrams and both real and illustrated ECG traces.

Heart rate and QTc calculators are included to aid analysis without leaving the app, and also access to the website blog, so you need never miss an update.

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I hate advertisements in apps, so in order to keep TSP mobile ad-free, I will charge £1 to download it after these introductory 14 days are over. In an ideal scenario, I would keep it completely free, but it has been, and continues to be, a rather expensive endeavour from both a chronological and economical standpoint especially for my shallow, student pockets, so I hope you understand why I have decided to charge.

Stay tuned to TSP via site, Twitter or email for a release date. It’s very soon!

The Power of Social Media Influence

Like it or loathe it, social media is pretty much inescapable. It’s used by your family, friends, and increasingly by institutions and corporate entities to connect and share ideas, market and promote. Statista puts worldwide social media usage at 2.22 billion people, so it’s no surprise that it has been utilised, and continues to be, to the extent to which we are now accustomed.

It’s been proved that it’s possible to connect with all kinds of people using social platforms, so why should the resource fall solely into the hands of multi-million dollar companies like Coca-Cola and McDonalds, for whom advertising is merely a formality, as oppose to a make-or-break necessity?

Perhaps it needn’t.

Due to the fairly self-regulating nature of some of healthcare’s more specialised areas, the burden falls predominantly on us to showcase innovations and engage with patients, prospective students and fellow professionals. Networking tools like LinkedIn are already being used to connect professionals, even from physiology backgrounds. This platform is relatively self-serving, being a predominantly business to business niche, but according to current statistics it has seen a rise in use to over 60 million views per month in 2016, so is undeniably a great tool to use for quick networking with other like-minded individuals.

Of course, social media can be used to network with everyone, not just our own, so, in the same way that we utilise more than one test to make a diagnosis, we should be using the whole spectrum of tools in this instance, shouldn’t we? Facebook (1.6 billion users worldwide) and Twitter (325 million) usage polls would suggest that users are logging on for a surprisingly narrow selection of reasons. 68% (Twitter) and 65% (Facebook) of users state that they log on to keep abreast of the latest news relevant to themselves, and 63% and 48% of Twitter and Facebook users respectively, use the platforms to receive information relevant to their personal interests. These present huge, potentially untapped resources for healthcare professionals, that can be used to promote transparency and trust, gain feedback and keep colleagues and patients informed.

I’ve mentioned before, the relatively unknown nature of physiology as a profession, so I think that taking hold of the opportunities available on Twitter, and other forms of social media could be something that could benefit physiological science. One of my favourite online healthcare personalities is Mr Olivier Branford, a plastic surgeon in London. He advocates education as a resource that should be available to all, and public engagement as a high priority. Olivier has over 62.1k followers and uses Twitter to provide news relevant to his specialism, and to wider healthcare in general. I conversed with him about the use of social media as a free platform to provide evidence, studies, inspiration and information to students, prospective students and patients everywhere, and we both agreed that it was the perfect resource to utilise. We aren’t alone, however; Olivier ran a telling informal poll, the results of which I have displayed below, enquiring as to what other users believed was the best way for plastic surgeons to use social media, and I feel that the words “plastic surgeon” can be substituted for any within the health service with a similar outcome. As you can no doubt see; despite the unscientific nature of the evidence, the percentages speak for themselves.

Whilst it would be incorrect to state that healthcare organisations have no presence on social media, they don’t dominate in the same way that more commercial entities do, at least not in the UK. That doesn’t necessarily mean that it is a lost cause, however. Mr Branford has provided a personal touch that corporate entities cannot emulate; his approach of “evidence not opinion” when dealing with healthcare information, is complimented by his willingness to offer an opinion when it’s relevant, on top of the facts. This transparency is refreshing, and, in conjunction with his professional accolades, is surely something that has aided him in gaining over 62.1k people who want to listen to what he has to say. The cardiac physiology profession is notoriously under-staffed, and whilst the numbers of applicants is on the increase, a quick visit to various college forums shows that the ins and outs of the career are still lost on many students (if you can find a discussion at all). The general career pathways and the salaries seem to be known to these confused individuals, but the actual job is what nobody has much of an idea about. How are we to persuade these potential cardiac scientists to sign up if they don’t know what they’ll be doing for the rest of their professional lives? Asking someone to commit their future to a career and saddle themselves with increasing debt when they don’t really have a great deal of information readily available to them is a far cry from the informed consent we strive to gain from our patients. Taking responsibility, and putting some research into one’s own future is obviously something everyone has to get used to, but I’m sure most people remember how overwhelming that was, so the shortage of new staff members must be more complicated than students simply not looking hard enough. Besides which, it SHOULDN’T be so difficult to find this career..! I’ve got a year to go until I qualify, and I’ve met some truly inspiring people whom, if I wasn’t already on my way, I know could easily convince me to start. We find what we do fascinating, so surely some of these young minds will be just as invested if they have the chance to see it for themselves.

The Pew Research Centre provides data that places 16-24 year olds as the most avid users of social media (above), and displays a steady growth of users across all age groups year-on-year since 2005, so with a collective effort, it surely wouldn’t be too difficult to a) entice some of these users who are in the middle of their A-Levels, and unsure of which healthcare profession is for them, and b) come together as a profession in a more open and approachable manner to showcase our science and how much of an impact we have on medical diagnostics.

Olivier Branford is a plastic surgeon and associate editor of PRS Global Open journal, and can be found on Twitter under his eponymous handle @OlivierBranford.

Social media statistics obtained from The Pew Research Centre, Statista & Visually

Review: Epicardio Simulation v1.5 (Full Version)

Download for Windows/OSX:

Trial (Free)
Paid (£149-£215)
60% discount for full-time students

Developer: Epicardio.Ltd

After my review of the temporary access trial of Epicardio Simulation (which offered a great deal of praise, I might add) I couldn’t wait to have a look at the full version’s features. I still can’t afford it yet even with the 60% discount offered to full-time students, but thankfully, the good people at Epicardio.Ltd allowed me to access the complete package so that I could review it. As I’ve already covered some of the functions of the program, I won’t re-tread old ground, but you can check out what I thought of the trial version here, and consider this a continuation of those original opinions.

So, what functionality is offered by the full version? Let’s go over it now.

The previously-unavailable tutorial section has some marvellous interactive elements; a view of the electrical action and a live ECG accompany the written tutorial pages, allowing the user to view the very thing they’re reading about in real-time. The procedurally generated ECGs are very accurate (I’ve measured them), but if you want to see a genuine patient-obtained trace recording, then one is included with each arrhythmia, too, which really helps with comparisons to the actual recordings one is likely to find in practice.

Almost everything you can think of is covered in some capacity, both on its own, and linked with other, relevant arrhythmias, so you really get a feel for just how interwoven some conduction and rhythm abnormalities can be.

A marvellous inclusion is the level of interactivity within the tutorials; degradation from VT to VF, for instance, is displayed live on the ECG strip and the defibrillator (that I didn’t really have cause to use in the trial version) can be charged, and a shock administered, altering the rhythm strip as it would a real patient.

The pacing tutorials are easy to use and easy to follow; they walk you through the physics of single and dual chamber, as well as biventricular pacing. In using them to learn the basics of pacing, I can appreciate how effective the arrhythmia sections are and how useful they would have been during the early days of my studies. The interactivity of the aformentioned tutorials remains, too. Placing a pacing wire in different sites allows the user to view live rhythm changes, and sensitivity, HR and pacing rate can be toyed with so as to identify intrinsic rates and pre-pacemaker abnormalities such as 3rd° AV Block on the real-time trace.

The test area throws generated ECGs at the student, and offers multiple answers from which to choose. Much like any degree-worthy multiple choice test, they range from incredibly easy to downright tricky, but a review section allows you to view the areas that might require further learning before each future run-through. As with the main bulk of the software, measurement calipers are useable during the test, allowing for some precise questions to be given. Importantly, this software allows and encourages repetition; fundamental to successful learning. It may seem obvious, but I noticed that my understanding of unfamiliar areas increased the more I explored them. What won’t be obvious, is just how quickly this occurred. With the addition of the test function, the user can consolidate what they have learned at their own pace, and not have to exit the program find a different testing app.

My time with the trial version of Epicardio only threw up a couple of minor issues. Whilst these are still present, they detract from the simulator even less than before, due to the myriad of extra content present in the full release. My only new problem came in the single chamber pacing tutorial, wherein I was instructed to reduce the pacing rate to 45bpm, yet I couldn’t lower it past 50bpm. This made it impossible to view the intrinsic rhythm of the digital patient (the point of the page in question’s existence), but only in this instance. It’s worth pointing out that regular updates exist to iron out glitches such as this, so errors needn’t remain for long.

If, like me, your learing speed is increased by doing, as oppose to just reading or seeing, then you’ll find this tool invaluable. To be able to safely induce life-threatening ventricular rhythm is, understandably, an uncommon occurrence, so a method to facilitate this, and things like it, is always going to be welcome for students. In Epicardio, however, you get so much more than that. Pacing of all types is covered in depth, real and digitally created ECGs, and an effective test facility really do set this above any of the other programs that I’ve used. It’s also incredibly simple to get the hang of, too. The things it does well far outweigh its minor issues, so I can wholeheartedly recommend this program to everyone who wants learn about cardiac arrhythmia and interventions. Whilst the implementation of a 60% student discount brings the price down to the £59-£89 mark, it is still expensive, but you really do get what you pay for.

Tetralogy of Fallot

Recently, in a Holter clinic, I dealt with an 8 year old patient who was on the road to recovery after a diagnosis of congenital defect, Tetralogy of Fallot. As a result, I got hold of the most interesting ECG I have recorded to date.

Background

ToF is a rare congential defect affecting the heart, that results in an insufficiency of oxygenated blood leaving the heart through the systemic circulation. Thus, it is considered a cyanotic disorder.

The disorder affects roughly 5 in 10,000 infants, and has an equal gender distribution.

Generally, four pathologies comprise ToF. Whilst all four are not always present, three can consistently be found. ToF is a progressive disorder, in that each pathology gives rise to the others.

The four principal defects are:

Right Ventricular Hypertrophy

PVSTEN — ***L-R:*** Normal and stenotic PV

Pulmonary Stenosis

Ventricular Septal Defect
- Hole in septum, due to malformation, causing oxygenated and deoxygenated blood to mix within cardiac structure
Overriding Aorta
- Aorta is placed over VSD, transporting blood with low O2 content to wider systemic circulation

Cyanotic episodes require immediate correction, before surgical intervention.

High flow O₂ administration
Physical positioning
- Knees to chest
- Parent cradling the child will illicit this effect naturally
NaCl fluid bolus
Vasopressor therapy
- Increases systemic vascular resistance, shunting blood through pulmonary system.
Continuous ECG and SpO₂ monitoring

Surgical intervention usually repairs the VSD and addresses pulmonary pathology, often at the same time.

Prognosis for ToF patients is generally very good.

Overall outcome improved since surgical treatment has improved
- Survival of surgery is currently 95-99%
36 year post-surgical survival is currently 96%

Patients who undergo surgical treatment are at greater lifelong risk of ventricular arrhythmia
Complications can arise as a result of a transannular patch repair, specifically;
- RV dysfunction
- Heart block (risk of HB has dropped to around 1%, in recent studies)
- Heart failure
- Recurrent or residual VSD

Hx:

8 y/o
Previous diagnosis of ToF
- VSD
- PV Stenosis
- Mild RVH
Treatment:
Transannular patch repair
PV Replacement

Medication:

Daily:
- Atenolol
- Aspirin

This patient was having a 24hr Holter recording to assess cardiac recovery after their most recent procedure; the PV replacement. Physical examination showed a RVOT murmur, whilst echocadiography displayed a mild RVH and PV regurgitation. Left heart functionality has been classed as excellent.

Previous ambulatory study has shown no arrhythmic action, save for that considered normal in a child of this age. No previous ECG recordings were available.

Upon monitor removal, a 12-Lead ECG was performed, the resulting trace was as follows:

Sinus rhythm with BBB morphology
Sokolow-Lyon value of 36mV for RVH
QRS & ST segment abnormalities in all leads

Ambulatory analysis relating to the most recent study did not differ greatly from previous monitoring, showing occasional sinus arrhythmia and bradycardia, five non-conducted P waves were found, and two of these gave rise to periods of sinus bradycardia. All other instances were gradual onset/offset.

Nocturnal bradycardia reached rates as low as 34bpm.

What does everyone think of this ECG and brief ambulatory report? Let us know by leaving a comment below!

Review: Epicardio Simulation v1.5 (Trial)

EDIT:

After writing this review, I got my hands on the full version. So this review continues here.

Epicardio offer a 60% discount to full-time students

Download for Windows/OSX:

Trial (Free)
Paid (£149-£215)

Developer: Epicardio.ltd

Studying ECG can be one hell of a mountain to climb, especially when you’re at the novice level of cardiac education. Due to how vital it is, it’s imperative that you can not only make the distinction between Mobitz II AV Block and sinus arrhythmia, but also understand the intricacies of the cardiac conduction behind them, and all of the other rhythm abnormalities. Learning these things like the back of your hand is one thing, but combining all that knowledge is, at times, overwhelming. So after 12 months of scouring the internet, trying to find a decent cardiac anatomy and 12-lead ECG simulation tool, I was over the moon to stumble upon Epicardio Simulation; a cardiac electrophysiology tutorial application, developed by Epicardio ltd.

The program is available in 3 main forms; Epicardio ECG, ECG and Pacing, and 3-day trial. As I don’t have £149 kicking around (the price of the basic ECGcentric offering), I can’t review the full version and all of its features, but the 3 day trial version (which is £0), is well within my price range. Thus, I shall only be commenting on the features with which I have been able to sample.

Thankfully, the collection of features available to trial version users is still extensive, so I have lots to cover, and perhaps I’ll spring for the full version when funds allow. The question is: does the trial impress enough to warrant the large expense? Let’s investigate further:

Almost as soon as you open Epicardio, the vibrant display hits you; a large, anatomically accurate heart fills most of the screen as colourful depolarisation waves travel across the atria, and down through the ventricles. The live single lead ECG tracks with concordance, and the right hand menu buttons are nicely presented and clearly display exactly what they do.

Depolarisation mechanics can be viewed through the heart as a whole, or each section on its own. Atria, ventricles, bundle branches and coronaries, can all be viewed independently whilst depolarisation occurs, so it’s possible to learn how the various components of the cardiac system operate during each cycle.

Further structural overlays can be added, in the form of the vena cava, thoracic cage and a translucent torso, further adding to the ability to understand the heart’s positioning in humans.

The electrical readout on the lower region of the screen comes with the option of cycling through all 12 leads on the standard ECG, individually, but as well the real time single lead ECG, users can also activate a live 12-lead, which again updates in real time with each cardiac cycle. This mode itself allows for different viewing styles, including the layout presented on most standard ECG printouts, which is perfect for students. It also features all the subtle morphology differences and minor, unavoidable muscle tremors that one would find on a real ECG recording. Calipers are a welcome feature, too, and they work well in Epicardio, allowing for measurements that students will definitely have to become proficient in throughout training.

Further customisation options are numerous; the colours of the depolarisation waves are changeable, as is the colour of the backdrop. Rather than simply offering pre-set rhythms, Epicardio allows you to manually alter heart rate, and, possibly more importantly, AV delay, so it’s possible to visibly alter the depolarisation wave on the beating heart in the centre of the screen, and see the live trace display a prolonged PR interval.

A most welcome feature is the electrode view option. A click on this button brings up a moving image of the heart within the thorax, and the standard precordial electrode sites. These electrodes can be moved anywhere and the real-time result displayed on the recorded trace, so it’s rather nice to be able to explore the difference in the voltage/time graph that occurs with electrode misplacement.

A defibrillator option allows you to shock the heart, although this was of limited use to me, as I did not have access to the fibrillatory rhythms that come with the paid version, but the artificial pacemaker below it allows the user to alter pacing pulses and observe the changes on the ECG.

My issues with Epicardio range from those that exist simply because the version I tried is restricted, to those that are nought but minor niggles, so I shall focus on those minor niggles, as oppose to content I simply have not paid to access.

The ECG trace, whilst being incredibly customisable, would feel much more authentic if it were set against a proportional image of standard ECG paper; being able to view the trace against the background most students will see throughout studies would be a great primer in the early days of study, and considering the trace speed is adjustable, I was disappointed it wasn’t a feature.

The option buttons look lovely, offer genuine function and, once you’ve been through the tutorial and played around with them, make perfect sense. It would perhaps be helpful if a brief explanation appeared when the mouse pointer was placed over each one, however, as it was a struggle remembering what the more vague options actually did, especially for the first few hours of using the program.

However, as I stated, these are only minor gripes. Epicardio is a wonderful and genuinely fun bit of software to use. I’ve got a feel for how beneficial having this in the beginning of my studies would have been. The layout, options, functionality and simplicity of using Epicardio are all near-perfect, so I can’t wait to get a hold of the full version, complete with pacemaker-specific options. If you have a spare weekend, then follow the link at the top of the page, and download the free trial. If you have a spare £149/£215, then follow the same link and download the full version, as if it’s provides even 50% more features than the demo, I can be certain it’s worth it.

I will review the full version as soon as I can.

Ajmaline Provocation in Suspected Brugada

Today, I was present during a Brugada provocation test using ajmaline, a class 1a antiarrhythmic drug much like class 1c drug, flecainide, in that it acts as a Na channel blocker. As its action lengthens the action potential phase 0, in non-pacemaker myocytes, it induces bradycardia, and encourages the transient Brugada rhythm to present itself.

Indications for the test are outlined here, and the procedure itself, is a relatively simple one;

Ajmaline is prepared at a total dose of 1mg/kg^-1
12 lead ECG is applied to the patient
- V1 and V2 should be positioned on IC3 or IC2
- The ECG should be viewable in real time, as well as be printable
Intravenous Ajmaline is administered in a 10mg bolus, every 2 minutes
- Fractions should be administered slowly over 1 minute
ECG should be printed after each dose

Indications for terminating the test are as follows:

Ajmaline dosage is completely administered
Typical Brugada criteria present on the ECG
- ST coving present in more than 1 right precordial lead
- J point elevation greater than 2mm
Incidence of:
- PVCs
- AV Block (2nd° or 3rd°)
- VT
- Sinus arrest

During the test, the patient indicated that the initial 10mg was very unpleasant, and caused “a horrible feeling” at the back of her throat. She did say that this initial bolus was the worst, however, and that subsequent injections were bearable, by comparison. Towards the end of the test, i.e., one injection from termination, the patient indicated that her lips had become almost completely numb.

The test, in this case, was negative, and the patient’s ECG showed no changes to suggest Brugada at any point throughout the procedure.

Ajmaline is unlicensed in the UK, but this is not indicative of its level of safety, rather it is because it is manufactured in Germany, and imported to trusts in this country. Curious as to why ajmaline was being used, I asked the nurse practitioner who was on hand to implement the test, who informed me why the trust opted to use ajmaline as oppose to flecainide, when both seemingly do the same thing. She cited the time taken for each pharmaceutical agent to leave the patient after the test; in the event of a negative outcome, ajmaline allows a patient to be discharged safely in around 3 hours, whereas flecainide takes a great deal longer to be removed.

Not knowing the costs associated with each drug, I decided to look for other reasons as to why an imported medication is used in this provocative study, and discovered research by Wolpert et al published in 2005, that tested ajmaline and flecainide against each other in a blind trial.

22 patients for whom a diagnosis of Brugada was already known, underwent IV flecainide and ajmaline testing, and the results were then studied by 3 physicians who were unaware of the drug being used in provocation.

The results for flecainide showed

Significant ST changes in 15/22 of the patients tested (68%)
Mean V1 amplitude of 0.19mV
Mean V2 amplitude of 0.31mV
Mean V3 amplitude of 0.1mV

The results for ajmaline showed

Significant ST changes in 22/22 of the patients tested
Mean V1 amplitude of 0.22mV
Mean V2 amplitude of 0.39mV
Mean V3 amplitude of 0.1mV

It is important to note, that whilst these results show a more favourable outcome when using ajmaline over flecainide, in provocative studies, this research is limited in that, despite being a blinded study, it was not a randomised trial and was not repeated. Nevertheless, it does suggest that provocative studies using flecainide may not successfully unmask Brugada syndrome in patients, and its longer life within the patient may favour the use of ajmaline in investigations.

Teaching

I’m not sure how many students know this, but once you’re qualified and working within a trust, a part of your job description denotes the expectation that you teach those who come after you, regardless of your job title or profession. Those mentors and staff that answer your questions whilst you’re on placement don’t get paid more for doing so and, for the most part, they don’t have special teaching roles. They do it to help and inspire you, and others, into being the best healthcare professionals that you can be, and one day, you’ll do that too.

I had my first taste of this, last week, when myself, fellow TSP writer OliGS and another student, along with two qualified physiologists, gave tech demonstrations, took Q&A’s and generally outlined the profession to a large group of medically-inclined 6th Form students. Oli had the joy of lying still and having successive Echo exams performed on him, but myself and the third student gave some ECG and BP demonstrations to small, rotating groups of young adults. They engaged a lot more than I initially thought they would, given that it was a hot day and the session was scheduled directly after lunch, but with a bit of cajoling, they performed simple 3-lead exams on one another, and took each other’s blood pressure. We answered all of the usual questions…

“Will this hurt?”

“Are you allowed to tell me if this shows I’m going to die”

“Will this electrocute me?”

…which aren’t entirely dissimilar to those put to us by patients, so it actually meant giving the same spiel, in response.

It was nerve-wracking, speaking candidly about your studies to strangers, especially when you don’t know at what level they are, with regards to cardiovascular anatomy, and when boring them is the last thing you want to do, so ensuring we spoke with enthusiasm was paramount. Perhaps unsurprisingly, only a couple of the students actually knew that HCS existed, so that added more of an incline to the mountain it felt we had to climb, but I’d happily do it again, as even one converted student feels like a victory, considering it was the first time I’d done anything like this. They seemed genuinely intrigued by diagnostics, and, after the aforementioned questions, asked some really challenging things about our role in wider healthcare, as well as about the equipment and techniques themselves. It’s odd to know that young students aren’t informed of all of the opportunities available them when they enter higher education, and it highlights the need for more publicity surrounding the scientific careers present in the process of patient care.

It’s difficult to know how to publicise this vein of science and healthcare, but there has to be a way; the disciplines and specialisms within it are at the forefront of diagnostic medicine and research, and are a truly rewarding endeavour for those willing to persevere through the sometimes unforgiving education pathways. If I’m invited back next year, I hope to convey some of that sentiment to the next batch of hopefuls, as, like me, they won’t look back once they start.

Thanks.

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