the 100% directionless thread

Jim37F

Forum Deputy Chief
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Just signed up for cable specifically to watch red sox. I even told the lady at the office "I am only doing this NESN so I can watch the red sox". Get home and hooked up and...wait for it...NESN is "not authorized". hate hate hate comcast.
But isn't Comcast America's most loved company with the absolute best customer service??
 

PotatoMedic

Has no idea what I'm doing.
2,688
1,527
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I'm tempted to make a cheese cake. Kinda want to make a cherry cheese cake... Oh the high calorie decisions.
 

NomadicMedic

EMS Educator
12,058
6,794
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I fought with Comcast for months to get a payment credited to the correct account. Hate isn't a strong enough word for how I feel about Comcast.
 

CALEMT

The Other Guy/ Paramaybe?
4,516
3,342
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Just signed up for cable specifically to watch red sox. I even told the lady at the office "I am only doing this NESN so I can watch the red sox". Get home and hooked up and...wait for it...NESN is "not authorized". hate hate hate comcast.

Time Warner Cable and we get almost every Angels game this season, yeah I'm pretty happy about that.

EDIT: Oh and happy national beer day!
http://www.msn.com/en-us/health/nutrition/10-reasons-to-have-a-beer-right-now/ss-AA2fRan#image=1
 

RocketMedic

Californian, Lost in Texas
4,997
1,459
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Can anyone explain, what looks like a paced rhythm, but the patient does not have a pacemaker, she has had 5x bypass....I'll have a strip when I get off if that helps.

Decent-sized hemiblocks can look a little like paced rhythms IIRC...
 

Angel

Paramedic
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I'll look that up, I completely forgot to take a pic of the rhythm so I'm kinda SOL on that.

Thanks

ETA yea it looked just like in this pic:
ekg_02.jpg
 
Last edited:

Handsome Robb

Youngin'
Premium Member
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Was told I need to get off my "high horse" and that "being an FTO doesn't give you the right to be a ****" today after politely asking a student to reck in their shirt on three separate occasions when I saw them in the ER during their clinicals today and then bringing it to the attention of their instructor after the third time when I ran into the instructor later in the day.

This is why we can't have nice things. If we want to be viewed as professionals we need to both act and look the part.
 

Aprz

The New Beach Medic
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663
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@Angel That's still a ventricular paced rhythm. If it looked like that, but without pacer spikes and known that the patient has no pacer then I would call it a sinus rhythm with an intraventricular conduction delay (IVCD). #1 cause for IVCD is hyperkalemia. A fascicular block alone wouldn't make it that wide, but if it was a bifascicular block such as RBBB + LAFB then there would still be left axis deviation and the RBBB in V6 would look funny. I have also been tricked before because the EMT I was with put the leads on wrong, or at least I think she put them on wrong (it was LBBB with ERAD so probably LA and RA switched). That's all I can really think of... really would need to see the actual 12-lead to come to any conclusion.
 

Angel

Paramedic
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@Handsome Robb, omg yes! I've seen sloppy arsed crews before and it annoys me to no end. It's embarrassing and that company already has a bad reputation already which doesn't help. Who cares if they get mad, the students preceptor should've done something about it already.

@Aprz, I seriously need to review. Axis deviation and polarity is something I've always had difficulty wrapping my head around.
 

SandpitMedic

Crowd pleaser
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You ever sneeze so hard your arms hurt?
 

MonkeyArrow

Forum Asst. Chief
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SandpitMedic

Crowd pleaser
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Nah I don't mean like post workout muscle gainz painz...

I mean like owwwewwwwwwweee a lesser man would call 911 pain.
 

Aprz

The New Beach Medic
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663
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@Aprz, I seriously need to review. Axis deviation and polarity is something I've always had difficulty wrapping my head around.
http://www.ems12lead.com/2008/10/04/axis-determination-part-i/

If you memorize and visualize Einthoven's triangle, I think that makes it a lot easy.

RA to LA = lead I
If mostly positive, the mean QRS vector is going right to left or towards 0 degree.

RA to LL (or towards the foot) = lead II
LA to LL (or towards the foot) = lead III
If both lead II and III are mostly positive, the mean QRS vector is going south towards 90 degree (II is about 60 degree and III is about 120 degre)

aVF (F for foot) starts perpindicular to lead I (lead I is 0 degree) and goes through the LL lead (or foot). aVF is 90 degree.

In Dubin's book, he uses I and aVF to determine which quadrant the mean QRS vector is going.

+I, +aVF = normal axis (between 0 to 90 degree)
cause I is right to left, aVF is going towards the foot
note: II and III mostly go in the same direction as the foot (60 and 120 degree) and will probably most likely be mostly positive

+I, -aVF = left axis deviation (between 0 to -90)
cause I is right to left, but now aVF ia going away from the foot.
note: II and III mostly go in the same direction as the foot so they would be mostly negative if it is going away from the foot a lot such as in a left anterior fascicular block.

-I, +aVF = right axis deviation (between 90 to 180 degree)
avF is going towards the foot, but now the direction of the mean QRS vector is going left to right. I associate this usually with pulmonary disease or left posterior fascicular block (rare). Even with right ventricular hypertrophy/pulmonary disease, this is kinda rare in my opinion cause of the size of the right ventricle. I am usually suspicious of lead reversal of RA and LA if I see this, or I take into consideration of it.

-I, -aVF = extreme right axis deviation
This is also pretty rare and I will consider lead reversal. If somebody has LAD on their normal ECG and RA and LA lead are reversed, it would make it look like ERAD on the 12 lead. Specific for ventricular rhythm, but not sensitive. Just because there isn't ERAD doesn't mean it is not ventricular (see people say "no ERAD, it can't be VT" all the time).

I draw the augmented leads on top of Einthoven's triangle.

aVF is perpindicular to I and goes through the LL lead. (again, I is 0 degree so aVF is 90).

aVL is perpindicular to II and goes through the LA lead. (-30 degree)

aVR is perpindicular to III and goes through RA lead. (-150 degree)
note: If this is positive, the mean QRS vector is towards ERAD.

It is usually pretty mind blowing to people when I tell them and draw if at the same time, lol.
 

Aprz

The New Beach Medic
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Then Dubin's book goes into calculating specifically what it is.

You find out which quardrant it is to figure out if it is normal (0 to 90), LAD (0 to -90), RAD (90 to 180), or ERAD (-90 to -180).

I then look for the smallest QRS complex in the frontal axis. I will find the lead that is perpindicular to the smallest QRS complex because the difference between + and - are about equal making the lead small / near isoelectric.

normal (0 to 90), +I, +aVF
0 = aVF is smallest
30 = III is smallest
60 = aVL is smallest
90 = I is smallest

LAD (0 to -90), +I, -aVF
0 = aVF is smallest
-30 = II is smallest
-60 = aVR is smallest
-90 = I is smallest

RAD (90 to 180), -I, +aVF
90 = I is smallest
120 = aVR is smallesr
150 = II is smallest
180 = aVF is smallest

ERAD (-90 to -180), -I, -aVF
-90 = I is smallest
-120 = aVL is smallest
-150 = III is smallest
-180 = aVF is smallesr
 

Aprz

The New Beach Medic
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663
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I was asking about lead reversal with the neutral lead RL and why if you flip it with another lead then it "collapses" Einthoven's triangle online the other day or week. The guy I spoke with drew it in angles showing that the difference betweem RL and LL is acute (almost 0). You can consider RL and LL equal. RL doesn't record positive or negative like other leads so normally the EKG isn't messed up. If you put the wrong lead there, it is as if it is the same spot as LL so it isn't going towards or away that lead (since they are near equal) and making isoelectric lines in lead reversal with the netrual right leg lead.

If the RA lead is placed where RL/N is at, II will be isoelectric.

If the LA lead is placed where RL/N is at, III will be isoelectric.

You can safely switch RL/N and LL because the spot is about equal with each othef and they don't record the difference between each other.

For everything else, the triangle will be flipped/rotated.
 

Anjel

Forum Angel
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I wish I had a quarter of the time that Aprz has to type out those responses lol.

I don't even have time to read them.
 

Anjel

Forum Angel
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Aprz

The New Beach Medic
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I typed it on my phone too. :p
 
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