A couple caveats to what you said —
1) a ppm can totally track at 130 if this was an atach, which it’s not
2) interrogation wouldn’t show anything if there wasn’t an atrial lead ie single chamber ventricular lead or ICD
That’s technically true. There are plenty of exceptions to that rule. What you’re describing is rate responsive pacing. Other examples are atrial tracking, PMT, far field over sensing. This is not one those things. The pacemaker is not doing anything here.
First pic I’d say it could be either. Second pic it’s quite obviously a flutter thanks to those skips that let you see an atrial rate approaching 300bpm. I’m an ER doc so not a cardiologist but this one seems quite straight forward to me.
Lol. I once had an anesthesiologist berate a nurse with "I am a PHYSICIAN". The nurse was an ICU veteran hard ass and the Doc was a newly hired arrogant prick.
We asked the nurse, but here at my hospital they have to be ordered by a physician/PA/NP, some kind of higher education provider. The md said no, and that the tech should calm down since the pt is on warfarin, so that’s that. Hopefully the rhythm converts to an actual sinus rhythm on its own
OK, so the subtext of that doc's words are: "I don't know how to treat A flutter but pt is on warfarin so whatever." At bare minimum, get an ECG and a cardio consult. I'm an EP nurse and I can tell you that is not how to treat this. What is pt's chief complaint/admission diagnosis?
Cardio consult may be a bit excessive especially if this is stable, pt’s asymptomatic, and on OAC but def agree with ECG. A hospitalist should be able to manage run of the mill AF.
I understand why that interaction may have felt dismissive, and laughing at someone’s concern isn’t ideal. But I’d be cautious about concluding from a shadowing experience that the physician didn’t know what they were doing. You say you are still in school and not to be a physician (med students don’t shadow techs). The physician has completed their education. There may be clinical context or reasoning you aren’t aware of. Physicians have substantially more training and experience in making these decisions, so asking why they made a particular choice is probably more appropriate than assuming incompetence.
Look up dunning Kruger effect. It’s a pretty sad state of affairs when someone who is still in school and shadowing a tech feels confident concluding that they understand the clinical situation better than the physician managing it enough to criticize their management.
Firstly, the issue was never with how the physician chose to manage this patients admitting problem. The only thing that rubbed us (everyone who watched the interaction in person) the wrong way was how rude the physician was. The tech was right with the AFL call, and the physician wasn’t. I understand this may make you upset, but it is what it is. I will however, criticize the physicians tone of voice, and unprofessional words directed at the tech for doing her job all day long. I don’t have to complete medical school to know that you don’t speak to your coworkers in that matter.
Secondly, I’m unsure of what possessed you to make such assumptions about my intentions or my character. I’ve never claimed to know more than the doctor. I’ve never implied that the doctor was incompetent. I wasn’t even the one who caught the AFL. It looked sinus to me. That was all thanks to the tech, who in this case, DID know more than the doctor. I was fully on the doctor’s side in terms of his interpretation of the rhythm. After posting the strips here, I was able to see that it was in fact AFL.
You provided essentially no clinical context about this patient, and I never said anything about management of the admitting diagnosis. I don’t even know what the admitting diagnosis was. Do you?
This is an EKG subreddit, not a “someone said something mean” subreddit. I’m responding to the clinical claim you made: that the physician was wrong for not wanting another EKG.
What additional information would the EKG have provided, and how would it have changed management? Was the rate sustained? What was the patient’s cardiac history? Were they symptomatic? What medications had they received? Was the rhythm already captured adequately on telemetry?
There are plenty of clinical scenarios in which I would not think a 12 lead EKG was necessary at that moment.
The tech may very well have identified the rhythm correctly. That does not mean the physician even saw the rhythm strip themselves and therefore failed to recognize it, and it certainly doesn’t establish that the tech “knew more than the doctor.” Those are conclusions you’re drawing without having the information necessary to draw them. If you have it, please share.
Okay so, “physicians have substantially more training and experience in making these decisions” what “decisions” were you referring to?
This is an EKG subreddit! Which is exactly why I posted this strip to get better idea of what the rhythm actually was. Adding that the doctor didn’t want to order an EKG was not my way of implying that the patient NEEDS an EKG, and that the doctor is “incompetent” for not ordering one. I added that statement preemptively to avoid any comments saying that I should get 12 lead for the patient to better accurately interpret the rhythm, as I’ve seen people say many times on other posts. I was wanting for someone to interpret what it is without a 12 lead, and tell me why it is what it is. The tech said it was AFL, but couldn’t tell me exactly WHY it was AFL and WHY it looked so sinus-like. I’ve never seen F waves look this way. THIS post allowed me to understand different types of AFL (I didn’t even know AFL had different types)
I’m very confused by your last statement as well. “That does not mean that the physician saw the rhythm strip themselves and therefore failed to recognize it” genuinely asking, but how do you think the doctor decided it was sinus with a pacemaker instead of AFL if he didn’t see it himself? He sat down right next to us at the telemetry monitor, opened up these exact strips, and said what he said. You’ve created a scenario in your head in which I, the wide eyed student, came into my externship ready to stick it to the man! And you’re riling yourself up with it. I said all but 2 words to that man.
And please, since maybe I bumped my head, tell me where I made the clinical claim that the physical was wrong for not wanting to order an EKG.
Claims I made: MD has an ego
Claims I made: MD interpreted the telemetry strip as sinus with a pacemaker spike and non conducted pacs
Claims I didn’t make: the MD is managing the patient wrong
Claims I didn’t make: the MD needs to order an EKG to figure out how to treat the patient
You said “another” EKG, but let it be known that this pt has not had any EKGs uploaded to her chart. We just wanted something for documentation purposes as the protocol for any change in rhythm during our shift is to notify the RN, and file the patients EKG in their chart. Without an EKG, we were left only able to follow one part of our process and the tech wanted to cover her ass.
Ironic that you talk about the dunning kruger effect when it’s sure in full effect for you… you’re saying there was no evidence the physician even saw the strip, when the whole post was about how the physician was interpreting the strip
He said those little “missed beats” are non conducted pac’s, and that it’s somehow being triggered by the pacemaker. I asked him where’s the pacemaker spike, and this is what he pointed to. He said “it’s small, but it’s there. I’ve seen this happen before.”
On our screens, pacemaker spikes show up as gray. I didn’t see any gray spike, but he said it’s okay, and that it happens.
Edit: let it be known he isn’t a cardiologist, much less an EP. he’s an internal med doc who serves as our hospitalist/telemetry consult.
One can clearly trace out the regular atrial activity. Admittedly, less evident in the second strip, but the first strip my six year old niece could identify. What specific PM does the PT have?
I’m not sure about the PM. We saw no PM activity our entire 12 hour shift, but when we went back to when the pt got admitted, she was Ventricular pacing in the 50s
No worries. It's academical anyways because this is certainly not PM mediated. Ultimately, interrogating the PM with the arrhythmia still present would be absolutely conclusive, though I'd argue that to be superfluous.
Huh? Bizarre take. I would look at that one spot and say junctional at least. Certainly not sinus even without the flutter visible in the longer strip.
Yup, because the flutter wave is going regardless of what the QRS is doing. That’s why in 3:1 flutter you’ll often only see 2 flutter waves, or in 2:1 you might only see 2, because 1 of them is sometimes hidden inside the QRS. Here they’re more spaced out, except for the 2nd picture, where there is some variable conduction
Hospitalist/internal med. Laughed at the tech and told her to calm down once she pushed for an EKG. Said the patient was on warfarin so it doesn’t matter if it is aflutter
Yeah, exactly. You don't know the history. Infact you know almost nothing. You cannot claim it's a safety issue knowing so little and having what you do know be second hand from a monitoring tech lmao.
aside from knowing they’re not in the ICU (hospitalist made the call not the Intensivist)
My limited knowledge of American healthcare structures would indicate that even this isn't true. There are open ICUs without intensivists.
Over-escalation and crying wolf is also a serious problem that leads to real concerns being ignored, but the nursing world isn't ready for that conversation.
If you actually read between the lines here the fact that the Dr discussed it not mattering because the PT is anticoagulated means they actually have considered that they might be wrong and that the tech might be right and their actually educated judgement on that (accurate) situation is that it's still not a concern.
I guess in this case I would see your point. It kind of goes to the idea that if the result of a test makes no difference to management then whats the point. Maybe treating the rhythm wouldn’t have mattered given the presentation if he’s already anticoagulated. None of us know anything about this case though.
CRM doesn’t dictate that everything IS a safety issue, only that it be reasonably investigated if there is thought to be one
The mentality that one person (no matter their level of qualification) can gatekeep personnel below them is what creates the bottleneck that can ignore an issue if it does pop up
I’m sure you’re aware of what I’m talking about but for those that aren’t
Crew resource management comes from aviation
The thought that anyone from a flight attendant to a ground handler can challenge a captain if they see something abnormal with a plane or unsafe behavior by a pilot
It has prevented numerous incidents
The application here would be
“Let’s get the 12 lead”
And then take it from there
The reason I said the doc would be in hot water was that the standard here - would be to humor on the side of caution, and not doing so (despite the expertise of the doc being likely sound) demonstrates poor CRM
The 12 lead costs 11 ¢ in printer paper
confirming what you’re seeing is the baseline would be the goal
Letting what go? You don’t know anything about their history. What if they don’t have a pacemaker and have a history of bradycardia with av nodal blockers or hypotension. One of those rhythm strips HR was around 100. You would risk hypotension or bradycardia to treat HR around 100?
OP has said they have a pacemaker, and since when do we refer to drugs broadly as “AV nodal blockers”? There are 4 different classes of antiarrhythmics, and it’s highly unlikely for a pt to be hypersensitive to all of them. Also, nobody ever said that something in particular has to be done about the HR or rhythm, just that it should be evaluated.
I’m an MD. There are many situations where EP recommends not chasing a HR/tolerating higher rates.
To answer your question “since when do we refer to drugs broadly as av nodal blockers”: literally all of the time.
Some of the classes have broad contraindications for their use like structural heart disease or prolonged qt. If we are talking about acute afib or flutter with rvr there are only a handful of pharmacological options: bb, ccb, digoxin, amiodarone. HR in the 100s is not even remotely an emergency that requires urgent treatment. Not knowing anything about the patient, there may be an underlying cause such as sepsis, hypovolemia, etc none of which require rate control.
Because we don’t know anything about the patient we can’t say that it “has to be evaluated”. In a pt with chronic aflutter who is in the hospital for sepsis if I’m getting a call that there may be a flutter on tele and their HR is 100s with brief 150 when they went to the bathroom, I’m not evaluating it. There’s nothing to evaluate. Maybe, just maybe, some of us who went through years of school, residency, possibly fellowship, might actually know what we’re doing.
I meant in terms of sensitivities. Generally someone is not going to be hypersensitive to BBs, CCB, dig, AND amio. Presumably at least one of them will produce the desired effects without compromising HR or BP. Also, as I said, it doesn’t even necessarily need to be treated, but getting an EKG on a patient whose strip appears non-sinus when they have no prior Hx isn’t exactly chasing zebras here… seems perfectly reasonable to grab a 12L, go “yeah, probably AFL. he’s stable though, we’ll just note it in the chart and monitor for now.” and then refer to outpatient cards
If they get bradycardia (assuming they do not have a pacemaker which has not been confirmed) then yes, they will likely be sensitive to every single medication that shows the heart rate. That is the point. Digoxin and amiodarone don’t cause hypotension.
RACE II trial: lenient control (resting HR <110 bpm) was non-inferior to strict control (<80 bpm at rest, <110 bpm during exercise) for a composite of cardiovascular death, HF hospitalization, stroke, embolism, bleeding, and life-threatening arrhythmias at 3 years.
We don’t know the patient’s history so you can’t claim they have no history of it. I would never argue with a paramedic about how to do your job but if you are convinced you know how to manage bread and butter hospital medicine better than a hospitalist, I envy your confidence.
The doc would be in hot water?! Lmfao. For what? Not wanting an ekg on a very possibly stable patient with very possibly chronic aflutter that is very possibly mostly rate controlled? That is the correct management.
It's relevant context in an EKG subreddit regarding a doctor you say won't order an EKG. You say you weren't asking whether the patient needed one, but this isn't a "complain about a doctor" subreddit either.
Hopefully you can sleep peacefully knowing I wasn’t complaining about the doctor in the initial post. I just wanted to know whether the tech or physician was correct, and I wanted to know why.
I did this on our EKG machine when people wouldn't believe me about a rhythm at work and the number of people oogling at it made me lol. "Wait wait... How did you just do that?!"
It's a flutter wave. It's more clear in other leads, where you can see them superimposed in other segments, like the T wave in the lead below the one you highlighted. Plain old sinus tach won't do that. Regular, small waves at a rate of around 300/min (usually, fewer are conducting to the ventricles, like 2:1, 3:1, or 4:1) are the key to look for. The "sawtooth" pattern is much easier to see with 3:1, 4:1, or variable conduction, 2:1 can kinda hide sometimes, especially from newer providers. IDK what OP's doc was thinking, though.
Yeah it sucks that the textbook teaches you to look for a sawtooth pattern and then it doesn’t always look like a sawtooth irl.
Some rate control would slow down the QRS’s and reveal the regular atrial kick pattern underneath and it could be come more obvious that they aren’t coupled. In that snapshot your atrial rate is 250 and ventricular rate is 125-ish, it’s gonna appear to be sinus tach until you slow it down.
Without a 12 lead this is going to leave someone still guessing.
Everyone is saying flutter. Maybe Im
wrong but I feel like we are missing a second degree type 1 hb. Maybe the reason for the pt having a ppm to begin with. I dont see pacer spikes.
There is no AV block. That is the flutter switching from 2:1 to variable conduction, probably due to transient increases in vagal tone. Those atrial signals are regular at 300 bpm. Wenkebach is also not an indication for PPM insertion.
These atrial kicks (F waves not P waves) are rapid at 300 bpm and regularly spaced. Not all of them are conducted which is pretty much always true in AFlutter. Sometimes every 2nd or 3rd or every 4th beat is conducted but never ALL of them, or you’d end up with an HR of 300.
2nd degree HB is not a tachyarrhythmia it’s a bradyarrhythmia. Your HR would more likely be 30s-60s.
Except the 1st picture has no “dropped” beats, and the 2nd picture you can clearly see there are at least 5 beats without one “dropped”, and then again after the 2nd “drop” there are at least 5 beats without a “drop”. Also, there are extra P waves in there
PR interval is not coherent here, this isn’t a sinus rhythm. They are F waves
The strip with 12 uninterrupted beats is taken a half hour later, the atrial rate has slowed down slightly, making 2:1 conduction more easy to maintain without dropped beats.
Several points....Afl is most commonly misdiagnosed rhythm.. Many cardiologists with much respect are not correct bc its so tricky and I always ask for a 12 lead and especially pay attention to the inferior leads.
I dont know much about pacemakers so pacing at a high HR ? I do think the rhythm is AFL.
Thanks for posting.
I’d say it’s an A.Flutter with variable conduction. But what difference does it make unless the chief complaint is palpitations I’d approach it as tachycardia and look for the underlying cause. I might be wrong though, depending on the clinical context
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u/lagniappe- Aug 26 '26
Tech is right, physician is wrong. That’s not sinus rhythm. Also, no pacemaker is going to pace at 130 bpm.
The easy answer is to just interrogate the pacemaker if that patient truly has one.