# Why are we still interpreting cardiac rhythms?



## MMiz (May 8, 2021)

Whenever I see a cardiac strip posted online, in this community or elsewhere, I note how different the interpretations are by so many qualified people.

With AI, deep learning models, and so much technology, why aren't we better leveraging technology to assess cardiac rhythms?  Why in 2021 are paramedics still interpreting cardiac rhythms?


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## NPO (May 8, 2021)

MMiz said:


> Whenever I see a cardiac strip posted online, in this community or elsewhere, I note how different the interpretations are by so many qualified people.
> 
> With AI, deep learning models, and so much technology, why aren't we better leveraging technology to assess cardiac rhythms? Why in 2021 are paramedics still interpreting cardiac rhythms?


Because the algorithms are wrong enough of the time that we can't trust them 100%.


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## EpiEMS (May 8, 2021)

MMiz said:


> With AI, deep learning models, and so much technology, why aren't we better leveraging technology to assess cardiac rhythms? Why in 2021 are paramedics still interpreting cardiac rhythms?


I love this question! I don't know the answer and I am so not qualified to interpret rhythms, but I have been involved in my share of AI and automation work, so I can lend a little insight.

In a financial services context, there is an immense amount of scrutiny that has commenced in recent years around automated decisionmaking tools, such as trading models and credit decision tools. Part of this is because models - particularly without skilled oversight - not infrequently run into issues like overfitting to the training dataset, errors in use (e.g., applying a model to the wrong circumstances), or an inability to adjust to changing conditions (for example, a model designed based on a certain market environment that doesn't "kill" itself when conditions change).

In short, models aren't perfect -- they are best used as a guide or subject to skilled oversight, even if they've been tested and retested.

So, what does this mean for cardiac rhythm analysis? 

Well, I think it's about the general lack of concordance in expert reads of ECGs, for one. Combine that with the problems of technology application,  as well as legal and ethical concerns about machine diagnosis (namely, failure to diagnose & who is accountable) given the tech issues themselves, I am not so surprised that there is a need for an art as well as a technical solution.


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## EpiEMS (May 8, 2021)

NPO said:


> Because the algorithms are wrong enough of the time that we can't trust them 100%.


And to that point, I don't think we can trust them even close enough to 100%, ethically speaking, to make a clinical decision.


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## CALEMT (May 8, 2021)

MMiz said:


> Whenever I see a cardiac strip posted online, in this community or elsewhere, I note how different the interpretations are by so many qualified people.
> 
> With AI, deep learning models, and so much technology, why aren't we better leveraging technology to assess cardiac rhythms?  Why in 2021 are paramedics still interpreting cardiac rhythms?



If you have the knowledge to change your car oil, why pay someone to do it? 

I've seen LP15's interpret a regular sinus rhythm as a STEMI. My X series is pretty consistent but I still interpret every 12 lead I run. Why? Because I have the knowledge to do so.


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## EpiEMS (May 9, 2021)

CALEMT said:


> If you have the knowledge to change your car oil, why pay someone to do it?
> 
> I've seen LP15's interpret a regular sinus rhythm as a STEMI. My X series is pretty consistent but I still interpret every 12 lead I run. Why? Because I have the knowledge to do so.



I agree with your second point, but I am not so convinced about the first. If there is less knowledge required, or at least if there can be cognitive offload to a machine (contingent on it being accurate...), I think that is an advantage system wide.


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## Aprz (May 9, 2021)

I totally thought you were gonna go somewhere different with this. I thought you were gonna ask why do we interpret when so many people say "It doesn't matter. What matters is if it is sloooow or fast? Are they stable or unstable?" Lol.


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## mgr22 (May 9, 2021)

I think there are too many patient and equipment variables to trust machine algorithms more than we do now. In my opinion, human oversight will need to accompany automated rhythm interpretation indefinitely -- sort of like pilots overseeing glass cockpits.


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## CALEMT (May 9, 2021)

EpiEMS said:


> I agree with your second point, but I am not so convinced about the first. If there is less knowledge required, or at least if there can be cognitive offload to a machine (contingent on it being accurate...), I think that is an advantage system wide.



I'm a firefighter/paramedic its a miracle that I know what analogy means, executing a good analogy on the other hand... 

Interestingly enough to the topic at hand I have a pt today C/O difficulty breathing with associated chest pressure. On my monitor the pt was anywhere from 60-150 on the rate. There was artifact on my monitor (Zoll X series) so I was having trouble finding P waves. Got a brief picture saw that it was in fact a sinus rhythm, just irregular AF. I didn't run a 12 lead becuase the pt was sitting on the tailboard of the engine. In the back of the ambulance on a different monitor (LP15) the 12 lead was reading inferior MI. Lead 2 on the 12 showed depression, on the monitor lead 2 wasn't showing depression. My X series also showed no depression on lead 2. My and the transporting medic's interpretation of the 12 was sinus arrthymia. There was no elevation anywhere. 

I guess what I'm getting at is why solely rely on a technological based algorithm that is wrong more times that it is right? I don't view it as a crutch, more as a last ditch tool for when I get those 12 leads that are littered with FLB's (funny looking beats) where I have no idea what the hell is going on. At least I can look at the top of the 12 and it more than likely gets my train of though going in a different direction.


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## Carlos Danger (May 9, 2021)

CALEMT said:


> Interesting question. As much as the conversation so far has revolved around artifact and examples of poor interpretation by current machines, I have little doubt that software could be developed that far exceeds the ability of most individuals to accurately interpret rhythms or MI criteria.



Like so many other things, it probably just comes down to how much $$ you are willing to spend.

Edit: this isn’t working on my phone. I meant to reply directly to the OP and somehow ended up replacing CALEMT’s text.


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## wtferick (May 9, 2021)

My main concern is why do Paramedics transport elevated trop levels to non cardiac receiving hospitals? Lol


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## DrParasite (May 10, 2021)

NPO said:


> Because the algorithms are wrong enough of the time that we can't trust them 100%.


Why are they wrong?  is not the critera for a stemi the same on the east coast as on the west coast ( as per https://ecgweekly.com/classic-stemi-criteria/ 
Fourth Universal Definition of MI (Thygesen et al., 2018):

*New* *or presumed new, ST-segment elevation (STE) ≥ 1.0 mm (measured at the J-point in 2 contiguous leads) is required in all leads (except* *V2, V3, V3R, V4R, V7-V9)*)?  ditto a LBBB? benign early repolarization?  and a slew of other things?  I mean, all paramedics learn from the same book right?  Afib is afib is afib right?  and it's different from aflutter via objective criteria.

If I give a rhythm strip to 3 cardiologists are they going to have the same diagnoses?  isn't interpreting an ECG an objective activity?  if the monitor says STEMI, what is it triggering off of?  Artifact can screw stuff up, but if you are putting two monitors on a person 5 minutes apart, and they are showing different things, how accurate is the $15,000 monitor (assuming no weird medical conditions)?

And is this really accurate? https://www.tiktok.com/@drglaucomflecken/video/6934839183609433349

While I understand having human oversight (and agree it's needed), and not treating strictly off a machine, shouldn't the machines be able to objectively weird stuff with a heart rhythm?


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## EpiEMS (May 10, 2021)

DrParasite said:


> If I give a rhythm strip to 3 cardiologists are they going to have the same diagnoses? isn't interpreting an ECG an objective activity?


I don't think they will, at least, a significant fraction will be off. For example, in one study from 2013, it was found that:



> One hundred twenty‐four physicians interpreted a total of 4392 ECGs. Among all physicians, interreader agreement (kappa) for ECG interpretation was 0.33, reflecting poor agreement. The sensitivity to identify “true” STEMIs was 65% (95% CI: 63 to 67) and the specificity was 79% (95% CI: 77 to 81).


This is specifically for ECGs without clinical information in the setting of ST-elevation, and these were all real ECGs where a patient was cathed.



DrParasite said:


> While I understand having human oversight (and agree it's needed), and not treating strictly off a machine, shouldn't the machines be able to objectively weird stuff with a heart rhythm?


One would think so, but I have seen enough literature to be convinced that the machine is not 100% trustworthy, at least not yet to the point where it can be relied on blindly.


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## DrParasite (May 10, 2021)

EpiEMS said:


> One would think so, but I have seen enough literature to be convinced that the machine is not 100% trustworthy, at least not yet to the point where it can be relied on blindly.


Is the machine not 100% trustworthy because the objective criteria aren't as objective as we would like them to be, or because the cardiologist who are interpreting can't agree on what constitutes a STEMI (using your examples among MDs that there was poor agreement over what constituted a STEMI)?


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## ffemt8978 (May 10, 2021)

DrParasite said:


> Is the machine not 100% trustworthy because the objective criteria aren't as objective as we would like them to be, or because the cardiologist who are interpreting can't agree on what constitutes a STEMI (using your examples among MDs that there was poor agreement over what constituted a STEMI)?


Does it really matter in deciding if the machine is capable of being trusted to interpret the rhythms 100% accurately, or is it more of a reflection of our inability to accurately interpret what we see?


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## NPO (May 10, 2021)

DrParasite said:


> Is the machine not 100% trustworthy because the objective criteria aren't as objective as we would like them to be, or because the cardiologist who are interpreting can't agree on what constitutes a STEMI (using your examples among MDs that there was poor agreement over what constituted a STEMI)?


It's several reasons. The largest factor in my experience is artifact. They don't seem to factor artifact at all. 

No Life Pack 15, my patient is not atrial paced irregularly at 300 times per minute. She's just got Parkinson's.


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## Aprz (May 10, 2021)

Have they done any studies with EPs? I feel like cardiologists do not study ECGs as much as EPs and emergency physicians or physicians in general would not be good to study agreement and accuracy of interpreting ECGs. We always bring up cardiologists because it would make sense that a cardiologists would know ECGs well, but I don't think it is actually their specialty. From what I've seen EPs tend to agree with each other, are more specific, and have methods to confirm rhythms.


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## BobBarker (May 10, 2021)

wtferick said:


> My main concern is why do Paramedics transport elevated trop levels to non cardiac receiving hospitals? Lol


I can't tell you the amount of times my father's trops were high from missing dialysis and fluid overload. He never went to a cardiac center to fix it.


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## wtferick (May 10, 2021)

BobBarker said:


> I can't tell you the amount of times my father's trops were high from missing dialysis and fluid overload. He never went to a cardiac center to fix it.


My apologies. I should have been more specific. Turns out many Paramedics have no clue what troponin is. 🤯


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## NPO (May 10, 2021)

wtferick said:


> My apologies. I should have been more specific. Turns out many Paramedics have no clue what troponin is.


Nor do we have the ability to check it in the field (usually).


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## E tank (May 10, 2021)

NPO said:


> Nor do we have the ability to check it in the field (usually).


Wouldn't matter if you could...


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## NPO (May 10, 2021)

E tank said:


> Wouldn't matter if you could...


I disagree. If I could check troponin levels, I could use that to help paint a clinical image in combination with patient presentation and the ECG. Also, it could be used as an intial measurement in delta trops, which doesn't help me, but does help the patient.


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## E tank (May 10, 2021)

NPO said:


> I disagree. If I could check troponin levels, I could use that to help paint a clinical image in combination with patient presentation and the ECG. Also, it could be used as an intial measurement in delta trops, which doesn't help me, but does help the patient.


would you base where you brought the patient if you could measure troponin?


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## NPO (May 10, 2021)

E tank said:


> would you base where you brought the patient if you could measure troponin?


Probably not. That's not the question I was answering. I was answering your point that it doesn't matter if we check trops.


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## CALEMT (May 10, 2021)

NPO said:


> Probably not. That's not the question I was answering. I was answering your point that it doesn't matter if we check trops.



I think he was referring to destination and treatment plans.


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## NPO (May 10, 2021)

CALEMT said:


> I think he was referring to destination and treatment plans.


I think so too, which makes sense since that's where the line of conversation was going. I was just commenting that there isn't no point at all.


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## wtferick (May 11, 2021)

NPO said:


> I think so too, which makes sense since that's where the line of conversation was going. I was just commenting that there isn't no point at all.


No point? In our current County, we have seen an influx in patients being transported to non Cardiac facilities. Transports where paramedics have trop. Results from clinics. For example Kaiser.
Then they have to get transferred out once again to a hospital that has Cath Lab capabilities. Which could have been avoided if Paramedics had basic training on  basic labs.
I don’t see how Trop. Levels would be useless.


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## E tank (May 11, 2021)

NPO said:


> Probably not. That's not the question I was answering. I was answering your point that it doesn't matter if we check trops.


The best determination of what treatment the patient needs (and by extension, where) is the whole purpose of EMS. Nothing else does matter. What do you mean by "helps the patient"? Benefit is a very broad category that requires randomized control trials to determine.


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## E tank (May 11, 2021)

wtferick said:


> No point? In our current County, we have seen an influx in patients being transported to non Cardiac facilities. Transports where paramedics have trop. Results from clinics. For example Kaiser.
> Then they have to get transferred out once again to a hospital that has Cath Lab capabilities. Which could have been avoided if Paramedics had basic training on  basic labs.
> I don’t see how Trop. Levels would be useless.


Ok, fine. You run a POC troponin and it comes back normal. Now what?


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## wtferick (May 11, 2021)

E tank said:


> Ok, fine. You run a POC troponin and it comes back normal. Now what?


Then you run your show as you please. 
What if it comes back high/abnormal? Seems to me that many disregard the result, and get hospital staff annoyed/ticked.


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## NPO (May 11, 2021)

E tank said:


> What do you mean by "helps the patient"? Benefit is a very broad category that requires randomized control trials to determine.



They're going to run delta trops in the ER. The sooner that is complete, the sooner they can get a useable clinical result, reduce LOS, and speed up the process. No randomized controlled trials needed to know that the less time a patient has to spend waiting in the ER, the better.


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## E tank (May 11, 2021)

wtferick said:


> Then you run your show as you please.
> What if it comes back high/abnormal? Seems to me that many disregard the result, and get hospital staff annoyed/ticked.


You'll have to tell me....can NSTEMI's go to any hospital where you are?  Because you could be home from your shift before your patient's troponin bumped. There is a  long list of non-cardiac causes of troponin elevation too. As far as hospital staff getting ticked off...at the ambulance crews? For misinterpreting a hospital based biomarker test? I'm definitely missing something there.


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## E tank (May 11, 2021)

NPO said:


> They're going to run delta trops in the ER. The sooner that is complete, the sooner they can get a useable clinical result, reduce LOS, and speed up the process. No randomized controlled trials needed to know that the less time a patient has to spend waiting in the ER, the better.


So how do you determine a "useable" clinical result (as opposed to an un-useable?) Are they going to use your POC instrument? Is it a high sensitivity test? Does the hospital use a different assay? Way more to the issue than good intentions and what may seem like common sense. You get normal levels and transport accordingly.  The non-PCI capable hospital you bring them to follows the cTn for the next 8-16 hours then transfers for NSTEMI. What have you accomplished?


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## wtferick (May 11, 2021)

E tank said:


> You'll have to tell me....can NSTEMI's go to any hospital where you are?  Because you could be home from your shift before your patient's troponin bumped. There is a  long list of non-cardiac causes of troponin elevation too. As far as hospital staff getting ticked off...at the ambulance crews? For misinterpreting a hospital based biomarker test? I'm definitely missing something there.


I think you missed the point at the first post.


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## johnrsemt (May 18, 2021)

to go back to the OP, monitors have issues:  They need people to remind them that the patient isn't isn't dead when it thinks they are.


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## BobBarker (May 19, 2021)

wtferick said:


> My apologies. I should have been more specific. Turns out many Paramedics have no clue what troponin is. 🤯


Troponin leak from kidney issues, fluid overload or missed dialysis. Yeah bud, never required a stemi/heart center/cath lab to fix those for my dad.


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## MMiz (May 20, 2021)

johnrsemt said:


> to go back to the OP, monitors have issues:  They need people to remind them that the patient isn't isn't dead when it thinks they are.



I get it, but why is this the case in 2021?  Is reliably interpreting cardiac rhythms really that difficult with all of the technology we have?


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## EpiEMS (May 25, 2021)

This is less a tech question than a risk management question, I think. For example, taking Physio-Control's 2009 documentation as a reference point...do we think it is OK that the algorithm misses nearly 20% of AMI? Is that an appropriate level of risk to take? I don't know - I would say no, but that's a gut response. On a system level, is that right? Do you need a clinician to interpret? Probably.

I have to keep digging on recent research though.

I will say, it looks like even EPs don't have great accuracy at reading ECGs, but it seems close to paramedic read quality.


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## NomadicMedic (May 25, 2021)

I'd think within the next decade as AI and machine learning continue to improve, we'll see all computer/AI interpertation.


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## Aprz (May 26, 2021)

EpiEMS said:


> Is that an appropriate I will say, it looks like even EPs don't have great accuracy at reading ECGs, but it seems close to paramedic read quality.


Whelp, that surprised me. I always thought EPs were good at it.


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## DrParasite (May 26, 2021)

EpiEMS said:


> do we think it is OK that the algorithm misses nearly 20% of AMI? Is that an appropriate level of risk to take? I don't know - I would say no, but that's a gut response. On a system level, is that right? Do you need a clinician to interpret? Probably.


That's interesting... and yet, we trust the algorithm/machine to identify vfib/vtach on 100% of the AEDs... I wonder what the failure rate is for those?


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## Knuckles (May 26, 2021)

DrParasite said:


> Why are they wrong?  is not the critera for a stemi the same on the east coast as on the west coast ( as per https://ecgweekly.com/classic-stemi-criteria/[/URL ...{snip}... While I understand having human oversight (and agree it's needed), and not treating strictly off a machine, shouldn't the machines be able to objectively weird stuff with a heart rhythm?


[/QUOTE]

Curious, have you heard of STEMI mimics?

“The mnemonic “ELEVATION”, can help you remember STEMI mimics


*E*lectrolytes (Hyperkalemia)
*L*eft Bundle Branch Block
*E*arly Repolarization
*V*entricular Hypertrophy (Left)
*A*neurysm (Ventricular)
*T*hailand (Brugada Syndrome)
*I*nflammation (Pericarditis)
*O*sborne (J) Waves (hypothermia)
*N*on-Ischemic Vasospasm”

There are some rhythms that act and seem to be STEMI but aren’t. The algorithm the monitor uses may see the traditional STEMI rhythm but no other artifacts or artifacts that aren’t programmed into the algorithm. As such, a working knowledge of cardiac rhythms could prevent a disaster.

Using a mechanical analogy, I actually own a $6k troubleshooting computer from a high end tool company. Computer says misfire on cylinder 1, solution is new plugs, new wires and possibly a new coil. Replace all that, still have a cylinder 1 misfire. Why? Because it didn’t detect the carbon build up on the intake valve causing severely reduced compression thus not creating the environment in the cylinder The engine needs to properly fire cylinder 1. (Yes, this is an actual issue with the Chevy 5.3L).

No matter what anyone does in life, remember, machines can be fallible as its creator is fallible. If any medic relies solely on the monitor, regardless of how much it costs, I worry for the safety of their pt.


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## DrParasite (May 26, 2021)

Knuckles said:


> Curious, have you heard of STEMI mimics?


no need to medicsplain, we are all mature adults here (although some more than others)



Knuckles said:


> There are some rhythms that act and seem to be STEMI but aren’t. The algorithm the monitor uses may see the traditional STEMI rhythm but no other artifacts or artifacts that aren’t programmed into the algorithm. As such, a working knowledge of cardiac rhythms could prevent a disaster.


so, if you are just looking for the ST elevation, I would agree with you.  but why not just program in the stemi mimics into the algorithm?  if it's objective criteria, I'm sure some programmer would be able to add it to the cardiac monitors.


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## Knuckles (May 26, 2021)

DrParasite said:


> no need to medicsplain, we are all mature adults here (although some more than others)
> 
> 
> so, if you are just looking for the ST elevation, I would agree with you.  but why not just program in the stemi mimics into the algorithm?  if it's objective criteria, I'm sure some programmer would be able to add it to the cardiac monitors.



Chaos theory. Doctors call medicine a “science” but there is still so much that can happen within the human body that, when multiple issues arise at once, can throw even the best doctor off.

Eat too much, get gas, but it presents as a cardiac issue. And then there’s the fact that everyone is different. Take me. Just about every textbook will tell you I have to be diabetic with high blood pressure and a cardiac issue as I have quite a few candles on my cake, enjoy Tim Horton’s and don’t belong to a gym. However, my BP is typically 110-120 systolic (114 at my last FF physical), my body processes sugars like nuts and my EKG at my last physical is normal sinus (by machine AND cardiologist interpretation). My PCPs constantly tell me my numbers can’t be right even though they took my BP, EKG, etc., but they are.

Algorithms cannot be programmed for the infinite number of variables, but they can guide us. It’s up to the medic to put the puzzle pieces together. And any EMS instructor worth their salt will teach to “treat the patient, not the numbers.”


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## mgr22 (May 26, 2021)

Knuckles said:


> Chaos theory. Doctors call medicine a “science” but there is still so much that can happen within the human body that, when multiple issues arise at once, can throw even the best doctor off.
> 
> Eat too much, get gas, but it presents as a cardiac issue. And then there’s the fact that everyone is different. Take me. Just about every textbook will tell you I have to be diabetic with high blood pressure and a cardiac issue as I have quite a few candles on my cake, enjoy Tim Horton’s and don’t belong to a gym. However, my BP is typically 110-120 systolic (114 at my last FF physical), my body processes sugars like nuts and my EKG at my last physical is normal sinus (by machine AND cardiologist interpretation). My PCPs constantly tell me my numbers can’t be right even though they took my BP, EKG, etc., but they are.
> 
> Algorithms cannot be programmed for the infinite number of variables, but they can guide us. It’s up to the medic to put the puzzle pieces together. And any EMS instructor worth their salt will teach to “treat the patient, not the numbers.”


I don't get the part about your history and why it signals DM.


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## DrParasite (May 26, 2021)

Knuckles said:


> Algorithms cannot be programmed for the infinite number of variables, but they can guide us. It’s up to the medic to put the puzzle pieces together. And any EMS instructor worth their salt will teach to “treat the patient, not the numbers.”









No one is saying treat solely off the monitor.  and I already agree with you that there are plenty of stemi mimics, but since you have already identified several of them, shouldn't you be able to incorporate them into the monitor's analysis?

Your example of gas being a cardiac issue is a great one... if someone has gas, are you activating the cath lab?  or should you be using the monitor (which is an objective way to evaluate the heart electrical activity) to determine if it's a stemi or not?  I mean if it's normal sinus, nice easy side, but if it's ST elevation (without chest pain), let's have the cardiologist double check and go to the lab?

I mean, we (EMS) have all these fancy and expensive pieces of equipment on the ambulance, shouldn't we use them to accurately identify what is going on with the patient?  or would you consider that treating the numbers, not the patient?


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## Knuckles (May 26, 2021)

mgr22 said:


> I don't get the part about your history and why it signals DM.


I work In an area that has a high turnover of brand new “doctors”, nurses and PAs. They finish school, come here for quick and easy residency and then bail. But the book says...” mentality has tainted patients and, once that med pro disappears, the pt gets a new doctor. Many of the new med pros go strictly by the book that fat=diabetic=hypertension=etc. Every newbie I’ve seen immediately send me for glucose tolerance tests,  bloodwork aimed mainly to determine hyper/hypoglycemia and ignores previous testing because ”the book says...”

When they finish their testing for DM, hypertension, cardiac issues, etc. and come up empty, they scratch their heads and tell me the tests must be tainted. Putting full faith in a monitor to tell you exactly what’s wrong with your patient is the same, it’s programmed by the book and you end up treating numbers, not the patient.


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## mgr22 (May 26, 2021)

Knuckles said:


> I work In an area that has a high turnover of brand new “doctors”, nurses and PAs. They finish school, come here for quick and easy residency and then bail. But the book says...” mentality has tainted patients and, once that med pro disappears, the pt gets a new doctor. Many of the new med pros go strictly by the book that fat=diabetic=hypertension=etc. Every newbie I’ve seen immediately send me for glucose tolerance tests,  bloodwork aimed mainly to determine hyper/hypoglycemia and ignores previous testing because ”the book says...”
> 
> When they finish their testing for DM, hypertension, cardiac issues, etc. and come up empty, they scratch their heads and tell me the tests must be tainted. Putting full faith in a monitor to tell you exactly what’s wrong with your patient is the same, it’s programmed by the book and you end up treating numbers, not the patient.


Your experiences with doctors, books, and medicine are much different from mine.


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## Knuckles (May 26, 2021)

DrParasite said:


> I mean, we (EMS) have all these fancy and expensive pieces of equipment on the ambulance, shouldn't we use them to accurately identify what is going on with the patient?  or would you consider that treating the numbers, not the patient?



I’m not saying not to use the monitor, I’m saying there are too many things they would have to program in that the monitor will become worse at diagnosis. Learning the rhythms is part of “treating the patient” as, like I said, everyone is different. Being able to verify what the monitor says is a necessity. Going strictly on what the monitor tells you? That’s “treating the numbers, not the patient.” We need to know rhythms to, as you said, accurately identify what is going on with the patient. There are signs and symptoms monitors cannot see. Any chimp that can read can do what a monitor tells them. What if there’s more going on that the monitor doesn’t know and cannot be programmed for?


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## Knuckles (May 26, 2021)

mgr22 said:


> Your experiences with doctors, books, and medicine are much different from mine.



I’m not trying to say it’s like that everywhere, but there’s 4 hospitals in my area and several medical groups where new doctors show up, do their time and disappear. My wife has lived with low K levels most of her life. Her body has negative side effects when they push the med and, because the new doctor was taught “this is the range the level must be at”, they push it. Even after her explaining the issue. I’ve personally been told by several new doctors that, since I’m overweight, I must have hypertension and borderline diabetic before even running tests. When the tests come back negative, they doubt the tests. Several others I know personally has had similar experiences. But again, I’m not saying this occurs everywhere, but old school doctors that actually practice medicine are getting harder to find near me.


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## mgr22 (May 26, 2021)

Knuckles said:


> I’m not trying to say it’s like that everywhere, but there’s 4 hospitals in my area and several medical groups where new doctors show up, do their time and disappear. My wife has lived with low K levels most of her life. Her body has negative side effects when they push the med and, because the new doctor was taught “this is the range the level must be at”, they push it. Even after her explaining the issue. I’ve personally been told by several new doctors that, since I’m overweight, I must have hypertension and borderline diabetic before even running tests. When the tests come back negative, they doubt the tests. Several others I know personally has had similar experiences. But again, I’m not saying this occurs everywhere, but old school doctors that actually practice medicine are getting harder to find near me.


I can certainly understand how your personal experiences would shape your views. I sympathize with what you and your wife have been through. I hope you find doctors you're comfortable with.


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## EpiEMS (May 27, 2021)

DrParasite said:


> That's interesting... and yet, we trust the algorithm/machine to identify vfib/vtach on 100% of the AEDs... I wonder what the failure rate is for those?



Fair point - and not sure. That said, and I haven’t done a comprehensive review of literature, seems like they are quite good. For example: http://hqmeded-ecg.blogspot.com/2015/04/pulseless-ventricular-tachycardia-why.html?m=1 and even as of 20 years ago, they were very very good:  https://pubmed.ncbi.nlm.nih.gov/11524645/


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## HunterTMars (May 27, 2021)

Didn't have a chance to read all the replies so I apologize if I'm mentioning something that has already been said:

My experience with Cardiac Monitor's is exclusive to LP12 and LP15 but here's my experience: They are pretty darn good at the vertical access, but not so good at the horizontal axis.  I'm more likely to trust it's diagnostics of STE than I am of rhythm.  

Of interest years ago - 2007 or so, the service I worked for participated in a study by Tufts Medical Center regarding the use of a GIK (Glucose, Insulin, Potassium) in the setting of ACS. The idea was that an early administration of the "Metabolic Myocardial Enhancement" preparation could slow the progression of ACS. The study was double blind, placebo controlled but was reliant on ECG findings. Our LPs were programmed to interpret the percentage of likelihood that the patient was experiencing cardiac ischemia by the use of an acute cardiac ischemia time insensitive predictive instrument (ACI-TIPI). So basically, when your 12 lead would print out it would look pretty much like it always did, with one exception, it included a percentage of likelihood that the 12 lead demonstrated ischemic abnormalities. This aided in paramedic's ability to determine whether or not the patient met inclusion criteria. What was amazing to me was that I would have a patient with an ACS like presentation, obtain my 12 lead but refuse to look at the percentage without first performing my own assessment. The number of times I looked at what appeared to be a completely normal 12 ECG that also had a high percentage indicator was shocking (totally possible that my ECG skills weren't so good back then but I don't remember, ha!).  Several times, subsequent 12 leads demonstrated clear criteria for STEMI.  I always wondered, "what was the computer seeing that I missed".  Some studies of the use of ACI-TIPI conclude that this can be helpful in ECG diagnosis.  

For me, AI in ECG interpretation is helpful or supplementary at best but is no exception for clinical judgement.  There is also the garden variety of patient's experiencing NSTEMI that may not demonstrate significant ischemic changes on 12 lead.  Robots and AI could be invented to perform all sorts of tasks, but I'll end with one of my favorite quotes - "Scientists were so preoccupied with whether or not they could, they didn't stop to think if they should" - Ian Malcom/Jeff Goldblum Jurassic Park.


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## johnrsemt (May 28, 2021)

Dr Parasite:  Yes we allow the AED to make the decision on V-Tach and V-Fib, but we don't allow them to make the decision to shock the patient we still have to push the shock button.  
Which I reminded my medical director of during a HCP CPR class about 15 years ago when he told me they were fool proof, and he allowed me to put a regular AED on him, not the trainer; and then shake the pads that were on his chest:  when the AED analyzed and announced "shock advised, charging" he sat up, yelling NO when I announced Clear, shocking, while reaching for the shock button, stating "the AED is correct you 'Must be in V-Fib".  I tried that again about 3 years ago with a co-worker and got the same results.

On LP-15's and Zoll's we get the same results on dirt roads (and we have 100's of miles of dirt roads in both my FT and PT jobs coverage areas) when they are on patients, they will alarm and tell us that the patient is in a bad rhythm, but I try hard to resist the urge to de-fibrillate the patient that is awake and talking to me, even though he may be clinically dead and his body just hasn't caught up to the monitor.

So I fall back on the teaching from paramedic (and EMT-Basic) School from 17 and 25 years ago:  Treat the patient, not the monitor.


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## johnrsemt (May 28, 2021)

Plus as a paramedic co-worker found from 20 years ago that tried to get his new EMT partner fired because she refused to start CPR on a patient because the rhythm strip he printed out looked so much like a bad rhythm, until it was pointed out that it was upside down.  She refused because the patient was talking.  Treat the patient


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## Aprz (May 28, 2021)

I feel like "treat the patient, not the monitor" is an abused aphorism we use. It makes sense, but from what I've seen, this is applied incorrectly more often than not. Of course we should be questioning the AED, monitor, or whatever, when it contradicts our assessment, or question our assessment. That being said, we are not using these tools for fun. They serve a purpose beyond being required by our companies or protocols. As much as we'd like to think out assessment is good enough for identifying STEMI, it is not. Quite often, we'll get cool, pale, diaphoretic patients with epigastric patient, elderly, nauseous, and you think this is the big one. GERD. You get patients feel anxious, nothing else really, STEMI. Some rhythms you can probably guess eg irregular pulse is probably atrial fibrillation, otherwise probably a sinus rhythm. You guys are intentionally creating artifacts or there is clearly something wrong, maybe loose electrodes, and these machines can be fooled. At the same time, we can be fooled too. Use the machines to augment your assessment and provide the best care for the patient. @JPINFV once wrote about this aphorism, treat the patient and not the monitor. If there is a contradiction, question yourself and the machine. Find out why. Awake and talking patient? Probably don't need CPR. Probably have time before making a decision on giving a drug or shocking. Is there artifact? Did you miss something? If the machine got a blood pressure different than you, did you hear it right? Are you certain about your blood pressure or heart rate you got?


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## NysEms2117 (Jun 2, 2021)

So 1. I'm late to the conversation and 2. I'm going to speak out of ignorance of being a EMT-B, and a lightly 'seasoned' one at that.
As for Computers, AI, and ML thats more my language. After reading the thread I do agree with a fair bit of what @EpiEMS states. But, the original merit shouldn't be lost, AI is never *meant* to be like in the movies where robots control themselves. One major use is to catch patterns humans can't (lets say in binary for computers, human eyes can't look at X million bits of "1's and 0's" and assert "thats random"), but large data sets w/ sufficient AI/ML can.

It seems to me that for this particular use case it shouldn't be "AI can determine cardiac rhythms", but it should be confirming "we got that rhythm right". The "tech" should also be able to interpret things that may alter any diagnosis and alert on it. This quickly turns into an ethics discussion very quickly though. I can assert as far as cyber goes, if AI (lets say on a dynamic/stateful firewall) detects a large pattern associated w/ a specific nefarious actor it instantly takes action before warning for user intervention to stop.

As a personal observation (sorry Epi, no statistics here) there seems to be a much shorter tolerance for computers to fail vs a human. Simple example of: Computer reads rhythm wrong vs *insert medical provider here* reads rhythm wrong. 

This Mayo clinlic article seems to be fairly representative of the capabilities IMO


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## mrhunt (Jun 7, 2021)

Because id Like to think that i was trained to treat my pt, and not the monitor.  The interpretation of a 12 lead (computer) is a TOOL that i read as well and then verify.   We've ALL had artifact that reads as a stemi and We can easily say "nope, thats wrong, do it again"

and Maybe computer reads STEMI, and im not 100%!  Thats what ER consults are for.


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## Combatdoc (Jun 9, 2021)

MMiz said:


> Whenever I see a cardiac strip posted online, in this community or elsewhere, I note how different the interpretations are by so many qualified people.
> 
> With AI, deep learning models, and so much technology, why aren't we better leveraging technology to assess cardiac rhythms?  Why in 2021 are paramedics still interpreting cardiac rhythms?


My first thought when I read this is, there is no such thing as AI, just machine learning. I have a masters in IT (Dont ask, job just sucks) and deep learning is just use of a wider group of sampling for the algorithm. For a machine to interpret a rhythm is like asking who John Smith is... too many possibilities and without human talent (read arts) it won't be possible to accurately use for a long time. Think Tesla and "it'll be ready in ten years" every ten years.
Sorry for the rant, just not a fan of the term AI.


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## Combatdoc (Jun 9, 2021)

NPO said:


> Nor do we have the ability to check it in the field (usually).


Although that be changing with some of the new POC lab units like iStat (Not an endorsement or fan)


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## ffemt8978 (Jun 10, 2021)

Combatdoc said:


> My first thought when I read this is, there is no such thing as AI, just machine learning. I have a masters in IT (Dont ask, job just sucks) and deep learning is just use of a wider group of sampling for the algorithm. For a machine to interpret a rhythm is like asking who John Smith is... too many possibilities and without human talent (read arts) it won't be possible to accurately use for a long time. Think Tesla and "it'll be ready in ten years" every ten years.
> Sorry for the rant, just not a fan of the term AI.


And machine learning is only as good as the people programming it. GI/GO


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## CbrMonster (Jun 10, 2021)

My favorite is that one road we all have in our areas that have nice rhythmic bumps, literally every time we are on said road the monitor reads vtach and freaks out alarms blaring. That is white philips monitors and we recently switched to zoll x/r series and same thing happens still.


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## CbrMonster (Jun 10, 2021)

NPO said:


> Nor do we have the ability to check it in the field (usually).


I would love to have istat machines an ambulances, would be amazing for sepsis testing lactic acid, trop on mi’s/chest pain, dialysis patients, ect we have long transport times to even the closest let alone specialty facilities, 30 mins is short for us, 2+hrs is long, so we could def run a few istat tests but those are extremely expensive.


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## MackTheKnife (Jun 10, 2021)

MMiz said:


> Whenever I see a cardiac strip posted online, in this community or elsewhere, I note how different the interpretations are by so many qualified people.
> 
> With AI, deep learning models, and so much technology, why aren't we better leveraging technology to assess cardiac rhythms?  Why in 2021 are paramedics still interpreting cardiac rhythms?


As medics, we all know about "perishable skills". EKG interpretation is a perishable skill. As per other replies, AI, etc. provide ERRONEOUS interpretations all too often. I had a pt in the ED with peaked T waves, no ST elevation, and it was interpreted as a STEMI. One other pt had an interpretation of LAD (correct), but didn't say LBBB (which was present). Our interpretations fail to recognize LVH routinely. I am not a fan of technology when it comes to my patients. If we rely on technology, we are "treating the numbers", not the pt. If we were to go the route of technology, let's hire The Geek Squad.


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## MackTheKnife (Jun 10, 2021)

wtferick said:


> My main concern is why do Paramedics transport elevated trop levels to non cardiac receiving hospitals? Lol


Is there such a thing?


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