Review: Acadoodle

Acadoodle.comonline

Price: $99/ £66 per annum (approx)

Authors: Dr John Ryan, Dr John Seery

Acadoodle is a subscription-based online resource for ECG training that boasts a large selection of video tutorials which can be viewed individually, or as part of a tested course. The ECG Teacher sections are the primary focus of this review, but other courses such as blood gas analysis are available, however.

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Produced by Drs John Seery and John Ryan, I found these courses to compliment my study, and even when I wasn’t watching them directly, I found myself letting them play in the background as I read a textbook, or went over my lecture notes.

The videos themselves are well produced and make understanding the ECG and its subsequent analysis much easier. The animations are slick and the narration is clear, concise and full of all the pertinent diagnostic information you will require.

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Each area of study is tailored to a specific area of electrocardiogram diagnostics, so each playlist/module flows from one video to the next. In addition, the flow of the modules themselves makes sense, and the learning curve increases in a logical order and as such, each section follows on from the one that precedes it in a manner that doesn’t overload you with information before you’re ready.

A small selection of the videos are available on YouTube, so if you wished to try before you buy, then searching for “Acadoodle” would throw up some of the more basic tutorials for you to have a look at. I noticed that these YouTube videos are also embedded in the Acadoodle site proper, giving rise to a sometimes noticeable drop in picture quality, on occasion.

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It’s nearly impossible to fault the content and structure, as these videos have helped me immeasurably throughout the last six or seven months, but it is an expensive purchase for anyone, let alone students, especially when you consider that almost all of the content is in some way available via lectures or found in other, similar video courses on YouTube. In that respect, despite the quality of the content, I find it hard to recommend Acadoodle to physiology students who are considering purchasing a personal subscription, but for lecturers or professional bodies and universities, it should prove to be a valuable asset when clarifying concepts to a class full of students.

That isn’t to say that a student purchasing a subscription wouldn’t get a lot out of Acadoodle; it’s certainly worth it, it’s just expensive at a time when disposeable income is generally spent on textbooks or… food and shelter. If splitting £66 is something that you and a few peers feel is possible, then I highly recommend it, as the website can be used from multiple PCs with little to no issue.

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Synap: Beta Test Update

Synap is an upcoming revision tool that is driven by students. The platform enables students to create their own multiple choice questions and upload them, then download those created by others. It’s possible to “follow” other users, as you would someone on Twitter or, incidentally, this site (you can do that in the sidebar of this page…), and take any quiz that they have created. Image upload and basic editing is supported, so quizzes for physiology, such as ECG arrhythmia or echocardiography quizzes are more than possible, and are one of the reasons I decided to get involved with the whole thing. In addition, the app tracks your progress and structures your revision for you, based on your course and modules.

I’ve spent the last week or so beta testing the Synap web platform or, more specifically, I’ve been taking tests and creating basic ECG quizzes to help bug test and check functionality.

The platform, as I’ve mentioned, is currently in closed beta and only present on the web, so without having an app and a larger number of users I cannot comment on it fully, but as it stands, the processes involved in creating a profile and quiz are incredibly simple; adding and annotating images is a cinch, and a complete question only requires the user to add a correct answer and a few wrong ones. Whilst I encountered a few bugs initially, the feedback I provided was swiftly taken on board and the problems were remedied overnight. Taking quizzes is incredibly simple, and all you need to do is click “take quiz” (shockingly), then select your answers and have them marked. You can take these as many times as you like, too, and if the creator has provided any, feedback will be available for each individual question.

My only concern is the reliance on the quiz-maker supplying the correct information. I’ve taken a quiz wherein the correct answer was the only one that was possible to be correct (think “What has tusks and a trunk? 1) Elephant 2)Belephant 3)Your hamster”) yet I was still told my answer was wrong. This is a closed beta, though and that’s what these processes are for. I know it hasn’t escaped the attention of the developers, so we shall see how it is dealt with.

To break all of this down and show you what I know for sure so far, have a look at this (incomplete) features list:

  • MCQs:
    • Image/annotation upload
    • Correct answer & up to 5 incorrect
    • Optional feedback for test-taker
    • Optional link to external learning resource
    • Test result calculation
    • Obtainable achievements
    • Personalised revision quizzes sent to you
  • Community links based on:
    • Course/Discipline
    • Cohort
    • Institution

I’ll add to this list the more familiar I become with the platform.

Omair and James, its creators, and the rest of the Synap team hope that this app will enable students nationwide to help each other and revise together, and it’s a pleasure for me to be involved, even if it’s only in a small way, currently. I’ll continue to post updates as things progress.

For more info, visit @Synap on twitter.

Thanks

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Being A Patient: Part I

(or “what I learned when the tests I have done to others, were done to me”)

The tests presented in this post are intentionally not explained thoroughly here. I have focussed, currently, on patient experience. If you wish to learn more about the things presented here, and the interpretation of the possible results, wait for them to be explained in your lectures, or, perform a quick Google search.

Before the new semester began proper, I was asked to assist with some physiology practicals on my campus. I agreed because I felt (much in the same way a chef will sample his/her food before selling it to the masses) that it would be good for my overall learning to experience the same anxieties and physical exertions -if applicable- that a patient may endure when they undergo physiological testing. When one repeatedly performs tests day in, day out, it’s easy to forget that the patient likely does not have anywhere near the same levels of familiarity with the procedure and proficiency with them as that of you, the practitioner, so to gain an insight into the emotional and physical aspects from the other side would, I felt, be good practice.

Day one was one of a cardio nature, in that I performed lots of exercise tests at a physiologist’s disposal. (Some of these tests are reserved for respiratory physiologists, but if you’re studying and are not yet at the point of choosing which PTP pathway to follow, you’ll experience these, too).

I discovered upon entry, that I would be performing the following:

  • YMCA step test
  • Bleep test
  • Treadmill test: ramp protocol (similar to the Bruce Protocol)

The wait to enter the lab was, (obviously not the same in terms of anxiety levels, but regardless) akin to a patient’s wait to enter a clinic testing room; knowing that I was going to have to perform tests, but not knowing exactly what they were was rather nerve-jangling (especially considering my then-unknown weight gain after the obligatory food-filled, sedentary lifestyle commonly experienced over the festive break).

The real difficulties stemmed from trying to comprehend the techniques required for each test. Explaining, or writing about them is one thing, but actually doing them is another thing entirely.

The YMCA step test itself wasn’t particularly challenging, given that it only involved 3 minutes of steady box steps. The difficulty came in not influencing heart rate on recovery. Knowing that my HR was being documented every minute meant I kept looking at the oximeter, and as has been documented (a quick google search will give you confirmation of this), it is relatively easy to change your HR on command.

For a patient, this last point may not be of particular issue, given that they might not be particularly aware of the potential influence they can have on their HR, but I can easily see how repeatedly stepping onto and off of a box could be difficult task for a patient of advanced age.

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Bonus Clinical Perspective: In this test the Heart Rate Recovery and VO2 max doesn’t appear to be particularly accurate, when using normal values, especially when compared with the VO2 max displayed through the other tests, either. The values are based on age, as oppose to individual physiological characteristics, so assume a physical ideal that doesn’t necessarily transcend to real life.  

The bleep test wasn’t like ones I have previously attempted in the gym, or what have you; rather, it was more about timing, ensuring there were no stops. This involved slowing down so as to reach the end of the designated track in time with the beep, then speeding up to repeat, meaning that pacing yourself was a must. The resulting strain on my legs caused them to become incredibly painful, incredibly quickly..! (I’m aware that bleep test procedure differs between fitness centres, so forgive my whinging if you use this format regularly).

Encouraging a patient to exhaust themselves doing this test would take a great deal of commitment from both parties; I’m not particularly unfit, but I had nothing tangible to aim for, with regards to an end point, so with no time to “beat”, I didn’t have anything to work towards and as a result, I gave up after 10 or so minutes, despite the fact I could have carried on for a while longer.  For the average patient that would frequent clinics to perform this test, achieving maximal exertion may not be something that can be coaxed out of them, especially if they had already endured other tests in the same day.

Already I was beginning to understand the plight of the patient, when it comes to tests that require their full participation, and I still had the hardest one to come… I was not looking forward to the post-lunchbreak activities.

It turns out, the Ramp Protocol test was actually the most enjoyable of the day. Perhaps this was simply because I was growing used to being fatigued/dehydrated, or perhaps it was the setup of the test itself, but I could have happily continued running on the treadmill for a great deal longer than I did, time allowing.

The ramp protocol treadmill test involves the face mask setup presented in the pictures, and a steady speed and incline increase on the treadmill for as long as it takes for the patient to reach their VO2 max, but it is up to the patient when they stop. Unlike the bleep test, which involved travelling at an uncomfortably slow rate at times, the ramp protocol was a fairly rapid journey to a pace similar to that of a distance runner. It was far from comfortable, so would still require a great deal of coaxing and encouragement in order to get the patient to work hard to complete the test, but it was certainly more comfortable than the test that had preceded it.

The whole day not only reminded me of tests and theory that I had almost forgotten, but it really helped me to understand what a patient has to go through when they visit a hospital. The feelings and tests that I personally experienced were, on the whole, not pleasant, but I wanted to be there. For a patient, this will most likely not be the case. When your clinic list is seemingly never-ending and you don’t have time for restarts, it’s easy for the fact that patients don’t know the requirements and procedures as well as you might, to slip your mind, but thanks to this experience, it’s something that I’ll never forget, and I feel it solidifies a vital skill that students require to be able to operate efficiently and fairly: empathy.

Tomorrow brings a different kind of discomfort, in that I will be having my first echocardiogram. I’ll add that experience to part II

The ramp protocol will also get the full write up treatment, as it was by far the most complex and in addition, I have a detailed set of results.

Thanks for reading.

Christopher.

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Interview With A Distance Learner

The fact that this specialist degree exists primarily in universities is a relatively new event; before the shakeup by Modernising Scientific Careers, the majority of training was completed in-house with an element of distance learning thrown in to assist with the theory behind the practical concepts.

As physiological science makes the transition to a 100% university- led discipline, there remain students that are still learning the “old way”. Sarah is one of those people, and I had the pleasure of working with her this year during my rotations between respiratory medicine and cardiology. In order to get a bit of insight into exactly how the course differs between bases, she kindly agreed to be interviewed for TSP.

Hux-Ham

Hello Sarah! Could you outline the structure of your week, with regards to working in your department and studying the degree simultaneously?

I’m employed by the hospital, so have to work my set hours which are Monday – Friday 08.30-16.30. Although I’m studying, I am not employed as a student, rather, I am an Assistant Technical Officer, which basically means I help around the department doing admin, portering and some clinical work. I have certain responsibilities with regards to admin that I have to keep on top of regardless of what clinical work I need to be learning.

Monday is my main admin day, so I spend the entire day sorting through referrals, checking messages & booking appointments for certain procedures that only I book. I need to keep on top of this as some of the procedures have extremely long waiting lists, so if a patient cancels last minute I need to try my best to fill that slot. Once my admin is complete I normally help out my colleague in the office with some of her work load. If there is no porter to bring inpatients up & back for echocardiograms then it is part of my job to do this as well, which means I can’t get my necessary admin work completed.

Tuesday is the start of my clinical week, unless I have been portering the previous day. At the moment I am spending all day Tuesday in analysis, analysing 24 hour and 48 hour tapes. I am able to analyse a tape independently, but as I am still learning they all need to be checked after, just in case I’ve missed something or worded my report incorrectly.

Wednesday is a half day in the department for me as I have a collaborate session starting at 12.00 so I need to be set up in the library ready to start. After my collaborate session I catch up on any studying I need to do, such as looking over lectures that have been released for the following week, researching/ writing an assignment or revising for upcoming exams. On a Wednesday morning I will either be fitting ambulatory blood pressure monitors (supervised, as I am not confident to do them alone yet) or analysing.

Thursday mornings I am in Electrocardiography, either in the department or going down to the ward, and in the afternoon I analyse.

Friday mornings I do tape clinic which occupies the entire morning and keeps me very busy, especially if I have patients returning that have had symptoms of dizziness & I need to get the tapes checked before I can let them go. I spend Friday afternoons in analysis.

That is my current working week, but I will start going on the rota soon to sit in on exercise treadmill tests as well. Most mornings I get into work at around 07.30 so I can get some studying done before work and I try to do an hour or so in the evening as well. Most weekends I keep to myself, but if I have an assignment due or exams I will do a couple of hours each day.

That’s a hectic week. This might now be a silly question, but do you feel that this is this enough?

In terms of clinical exposure … yes! But it is very hard to keep up with the academic work load when there is very little time to fit things in. I commute for over 2 hours a day so this eats into my potential study time, but I try to keep a balance of work, study and actually having a life!

Do you feel that working in the same department as you study helps you to learn more and keep you motivated?

I feel that second year especially has helped me learn, but most of the academic work in our first year wasn’t particularly relevant to cardiology. I feel like I learnt more in the last 2 months from analysing tapes than I have in the whole 2 years that I’ve worked in the department. I definitely think it has helped to keep me motivated as I’m constantly surrounded by people that are doing the job I am training for, so I’ve got a clear goal at the end of it.

You’re one of the last sets of the distance intake. Do you think, if you had the choice, you’d still do the degree in the manner you currently are, or would you choose to be based at the university?

I’ve already done a previous degree so I’ve experienced the whole student life thing, so I’m not missing out by doing it this way. At the moment I am essentially being paid to learn, which is ideal. I wouldn’t be able to afford to do this degree if I was based at the university, as I’ve already had a student loan so I’m not entitled to another. I think I get a good amount of exposure in the clinical setting, but I just have to do some of the boring admin jobs to make up for it. At the end of my degree I will have a job and I know 100% that this is the career I want for myself. I wasn’t passionate about my previous degree subject so I lost interest and didn’t want to spend the rest of my life doing it, whereas I know from working in this department and from studying the way I am, that this is what I want to do. I don’t think I’d have that level of clarity if I was based more at the university than the hospital.

That’s fair. When we worked together during my placement, I was aware of the fact that you were much more comfortable in the clinic environment than I was (obviously), so what do you feel we at the university have by way of an advantage?

I definitely think that as I’m exposed to patients and the environment all day every day that I am more confident and comfortable than yourself, but I would say that full time students based at the university have a lot more academic knowledge. We have 1/2 hours a week of contact time with our lecturers so we need to go out and research ourselves, whereas it is clear that you guys have a lot more academic time although you miss out a lot with the lack of placement.

Thanks, Sarah!

As you can probably tell, despite the fact that Sarah and myself are in the same cohort, our academic years have a vastly different focus. As I (rightly) assumed just from working with her on the department, both routes present their pros and cons, and seeing as this is a vastly understaffed form of diagnostic science, it does, in my opinion, open the career up to a greater number of people now it will be university- led.

If you’ve got an opinion, or a question regarding anything you’ve read, sound off in the comments below.

Photo courtesy of Facebook

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I Have LVH, Should I Be Worried? Normal Variants Of An ECG

As part of our course we often perform ECG’s on one another to enhance and refine our practical ECG skills. During a practical recently I volunteered to be the patient so that my fellow students could practice their electrode placement skills; whilst being filmed and critiqued by others. The group universally agreed in the value of this experience, despite the fact it felt strange performing an ECG to an audience of your friends whilst being filmed in an artificial clinical environment. After everyone had practiced we printed of a recording of my ECG. Our lecturer, whom is a senior physiologist, explained that we would as a class analyse the ECG in our following lecture.

Upon the analysis of my ECG, my lecturer broke the news to me that I had left ventricular hypertrophy (LVH) with sinus bradycardia. Considering the previous lectures we’d had on LVH and its clinical significance I was pretty scared few a seconds or so. He then thankfully reassured me that in my case this was completely normal. My lecturer emphasised the importance of always combining your ECG analysis and findings within the context of your patient.

My ECG LVH sinus brady

He explained my athletic physique (his words) and my age were enough to convince him that my development of LVH was not due to pathological reasons but that of heart remodeling as a result of prolonged physical conditioning. If presented with a 30 stone, 60 year old male, with LVH, or a 70 year old sinus bradycardic female ticking a long at 50 bpm and suffers occasional syncope; this would not fit as a normal finding in the context of these patients.

This practical highlighted the importance of always putting your ECG findings in the context of your patient and the normal ECG variants that may be encountered. The patients we see will be varied. They will be of different genders, ethnicities, ages, physical condition, possibly even pregnant. All these groups will produce significant normal variants in their ECG’s. These factors must always be taken into consideration when assessing the significance of your findings. Is your patient bradycardic and symptomatic suffering frequent dizzy spells or are they a young physically conditioned adult. We will be posting articles shortly on the normal variants expected in some of these patient demographics.

What is LVH

LVH is an increase in size and proportion of ventricular myocardium (in this case specifically the left ventricular myocardium). This can occur in any chamber of the heart but is most commonly found in the LV.

How is LVH diagnosed on an ECG

Most trained operators will spot signs of LVH relatively quickly on a ECG recording as it will be common that precordial ventricular tracings will overlap one another requiring a reduction in gain settings.

However, the Sokolow Lyon criteria is correct method of choice. This involves measuring the amplitude of the S wave in V1 and adding it to the R wave amplitude in V5 OR 6 (whichever bigger). If the sum amplitude is greater than 3.5mV LVH is suspected.

To calculate right ventricular hypertrophy (RVH): Amplitude of R wave in V1 + S wave V5 or 6. If the sum amplitude is greater than or equal to 1.1mV RVH is suspected.

However, an ECG alone cannot determine the extent of hypertrophy and its clinical consequence. An echo-cardiogram would be required to ascertain this.

Causes of LVH

LVH is a result of increased demand put on the LV to increase cardiac output. Over prolonged periods of time this increases cardiomyocyte size. As discussed earlier, this increased CO demand could be the result of exercise, and therefore sustained activity levels could lead to LVH. The upshot of this is that for every heart contraction the ventricles can force out a greater volume of blood for every beat (stroke vol) reducing the demand on the heart to supply cardiac output at rest. For this reason athletes with LVH will have a lower resting HR (sinus bradycardia).

However, there are also many pathological reasons for developing LVH, all of which result in pressure overload in the LV increasing its resting workload.

Some of the most common pathologies associated with LVH are as follows:

• Hypertension (most common cause)

• Aortic stenosis

• Aortic regurgitation

• Mitral regurgitation

• Coarctation of the aorta

• Hypertrophic cardiomyopathy

As LV hypertrophy develops, the myocardium can become so thickened that it begins to inhibit the filling of the LV reducing cardiac output leading to increased risk of mortality.

In my next article I will be looking further into some of the pathological causes of LVH and their clinical significance.

Ref:

http://lifeinthefastlane.com/ecg-library/basics/left-ventricular-hypertrophy/

Have You Ever Tested A Robot? Pt II

I still haven’t.

Bear with me, though, as this is going somewhere, I swear.

After the last session, in which I provided the robot’s voice and controlled its HR and ECG, it dawned on me that as a result, everyone had the opportunity to be filmed performing the test and gain valuable group feedback, except me.

I wasn’t the only one to notice this, as it transpired.

During a subsequent lab session, wherein we practiced manual BP, honed bedside manner, discussed contraindications and compared different methods of BP measurement, it was revealed that the remainder of our ECG feedback period would be completed in the lab. We no longer had immediate access to the simulation mannequin, so thanks to a willing volunteer, another of my colleagues was able to complete the procedure and again receive feedback in a partitioned area of the lab.

Then it was my turn to step up to the plate.

I was the last to ‘go’, as it were. The difference between my assessment and the other’s lies in that everyone else enjoyed an element of seclusion: the curtains around the bed-space being pulled in the first session and the high walls that separated one section of the lab from the other, in the second. The rest of the group stayed outside of these boundaries in everyone else’s case. Not for me, though. I stood away from the couch, preparing to make my entrance to the imaginary treatment room I could see in front of me and just before I could open the invisible door, the consultant physiologist taking the session said “Wait, I’m just going to call everyone else in, if that’s ok?”

“…If that’s ok”, as if I had a choice.

Everyone else filed in. They kept filing in for what felt like an age. My lecturer, the rest of my class and the head of physiology. Then, they all looked at me, waiting.

I’m not sure how I’d have fared if I’d known this was going to be the format for my peer assessment, but I feel no shame in admitting that I don’t remember ever being as scared as I was before I started moving. I didn’t know how to begin, so I just went for it. I walked into the ‘room’ (after, somewhat embarrassingly, opening the invisible door) and performed the test as I would out on placement.

I asked all the required questions and added one or two patient identifiers to account for the fact that I didn’t call my patient from any waiting room and gained a consented, accurate trace.

Not only did I do it all with the eyes of more than a couple of people scrutinising my every move, I did it with a piece of equipment I have never used before and the most tentacle-like cable configuration I’ve ever seen in my life- if you’ve tried to untangle the wires behind your television when you’re moving house, you’ll know what I mean but, trust me, this was worse. In addition, I managed to ignore a completely new experience: the fact that I was so scared that the back of my neck was sweating..!

Fear is natural. It’s normal to be scared of doing something that’s relatively new to you, especially when you know you’ll be watched and judged doing it. Whatever ‘it’ is, it wouldn’t feel like a real achievement if we didn’t feel fear beforehand. I’m glad it was sprung on me, if I’m honest. My final assessments and various practical examinations for the rest of my career will follow this format so it’s good to have a grasp on some of the emotions I’ll be feeling before them. If you’re just beginning the PTP programme, you’ve got things like this to look forward to, so just try to enjoy it. Realise that the fear of these things is normal and, most importantly, the sooner you take a deep breath and swallow the lump in your throat, the sooner they’ll be over!

Thanks!

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