Proposed In-Training Electrocardiogram Interpretation Competencies for Undergraduate and Postgraduate Trainees

The use of cognitive load theory to assist in the teaching of electrocardiogram interpretation within paramedical science education

BACKGROUND

Paramedics are expected to record electrocardiograms (ECGs) as part of their clinical assessment; however, it is an extremely difficult skill to learn and understand as it has a high intrinsic cognitive load which can also be challenging to teach effectively.

AIMS

This article will explore the use of cognitive load theory to assist in the teaching of ECG interpretation within the context of paramedical education.

DESCRIPTION

Cognitive load theory can be useful to aid teaching within complex medical and health science domains including clinical skills teaching.

CONCLUSIONS

The application of cognitive load theory to the teaching of ECG interpretation can be useful as it allows for the development of understanding, building schemata linking information currently being learned to knowledge already gained within the long-term memory, which can maximise germane load by the appropriate selection of intrinsic load, minimising extraneous load therefore not overloading the working memory.

Scalar invariant transform based deep learning framework for detecting heart failures using ECG signals

Heart diseases are leading to death across the globe. Exact detection and treatment for heart disease in its early stages could potentially save lives. Electrocardiogram (ECG) is one of the tests that take measures of heartbeat fluctuations. The deviation in the signals from the normal sinus rhythm and different variations can help detect various heart conditions. This paper presents a novel approach to cardiac disease detection using an automated Convolutional Neural Network (CNN) system. Leveraging the Scale-Invariant Feature Transform (SIFT) for unique ECG signal image feature extraction, our model classifies signals into three categories: Arrhythmia (ARR), Congestive Heart Failure (CHF), and Normal Sinus Rhythm (NSR). The proposed model has been evaluated using 96 Arrhythmia, 30 CHF, and 36 NSR ECG signals, resulting in a total of 162 images for classification. Our proposed model achieved 99.78% accuracy and an F1 score of 99.78%, which is among one of the highest in the models which were recorded to date with this dataset. Along with the SIFT, we also used HOG and SURF techniques individually and applied the CNN model which achieved 99.45% and 78% accuracy respectively which proved that the SIFT-CNN model is a well-trained and performed model. Notably, our approach introduces significant novelty by combining SIFT with a custom CNN model, enhancing classification accuracy and offering a fresh perspective on cardiac arrhythmia detection. This SIFT-CNN model performed exceptionally well and better than all existing models which are used to classify heart diseases.

Assessing the Level of Electrocardiographic Interpretation Competency among Emergency Nurses in Palestine

Introduction

The use of electrocardiograms (ECGs) is widespread among emergency room (ER) nurses for diagnosis and triage, making it crucial for them to have the appropriate level of competency in interpreting ECGs. This can lead to better healthcare and patient outcomes.

Objectives

This study aims to assess the competency level of emergency nurses in Palestine in interpreting normal ECG and certain cardiac arrhythmias, and to explore the association between socio-demographic characteristics and their ECG interpretation competency.

Methods

The study used a cross-sectional descriptive design, and 196 ER nurses were conveniently recruited to fill out a self-administered questionnaire based on previous literature. The data collected were analyzed using SPSS with strict adherence to ethical considerations.

Results

The results showed that 70.9% of the nurses were males, 65.3% held a bachelor's degree in nursing, 46.9% had 1-5 years of experience, and 60.7% had received previous courses on ECG interpretation. The mean competency level of the ER nurses was satisfactory at 60.714%, but 38.8% had a poor level of competency. This was significantly higher among nurses with higher educational levels (p-value < 0.001), those who had taken previous ECG courses (p-value = 0.045) and life support (p-value < 0.05), and those who were exposed to more ECG interpretations per day (p-value = 0.001).

Conclusion

There is a need to focus more on ECG competency levels in Palestinian literature and compare them between different departments. It is also essential to evaluate nurses' needs for continuous education.

Designing an ECG curriculum for residents: Evidence-based approaches to improving resident ECG interpretation skills

Residents enter their training with variable comfort and competency in electrocardiogram (ECG) interpretation. Accurately interpreting an ECG is a fundamental skill in medicine and resident physicians would benefit from a longitudinal, dedicated ECG curriculum as part of their training to enhance interpretation skills and improve patient outcomes. Educators currently employ a wide array of methodologies to teach their trainees proper ECG interpretation skills, with no single modality established as the gold-standard for teaching this crucial skill. We present evidence-based guidance on how educators may develop and implement an effective ECG interpretation curriculum as part of residency training.

Can Orthopaedic Surgeons adequately assess an Electrocardiogram (ECG) trace paper? A cross sectional study

Objectives

The primary objective was to evaluate the ECG trace paper evaluation current knowledge level in a group of Orthopaedic surgeons divided into juniors and seniors according to M.D. degree possession.

Methods

A cross sectional study through self-administered questionnaires at a university hospital Orthopaedic and Trauma Surgery Department. The questionnaire included five sections: 1-Basic participants' characteristics, 2-Participants' perception of their ECG evaluation current knowledge level, 3-The main body of the questionnaire was an ECG quiz (seven); the participant was asked to determine if it was normal and the possible diagnosis, 4-Participants' desired ECG evaluation knowledge level, and 5-Willingness to attend ECG evaluation workshops.

Results

Of the 121 actively working individuals in the department, 96 (97.3 %) finished the questionnaire, and 85 (77.3 %) were valid for final evaluation. The participants' mean age was 30.4 ± 6.92 years, 76.5 % juniors and 23.5 % seniors. 83.5 % of the participants perceived their current ECG evaluation knowledge as none or limited. For participants' ability to evaluate an ECG, higher scores were achieved when determining if the ECG was normal or abnormal, with a mean score percentage of 79.32 % ± 23.27. However, the scores were lower when trying to reach the diagnosis, with a mean score percentage of 43.02 % ± 27.48. There was a significant negative correlation between the participant's age and answering the normality question correctly (r = -0.277, p = 0.01); and a significant positive correlation between answering the diagnosis question correctly and the desired level of knowledge and the intention to attend a workshop about ECG evaluation, r = 0.355 (p = 0.001), and r = 0.223 (p = 0.04), respectively. Only 56.5 % of the participants desired to get more knowledge, and 81.2 % were interested in attending ECG evaluation workshops.

Conclusion

Orthopaedic surgeons showed sufficient knowledge when determining the normality of ECG trace papers; however, they could not reach the proper diagnosis, and Junior surgeons performed slightly better than their senior peers. Most surgeons are willing to attend ECG evaluation and interpretation workshops to improve their knowledge level.

Exploring Factors Influencing ECG Interpretation Proficiency of Medical Professionals

The electrocardiogram (ECG) is a crucial diagnostic tool in medicine with concerns about its interpretation proficiency across various medical disciplines. Our study aimed to explore potential causes of these issues and identify areas requiring improvement. A survey was conducted among medical professionals to understand their experiences with ECG interpretation and education. A total of 2515 participants from diverse medical backgrounds were surveyed. A total of 1989 (79%) participants reported ECG interpretation as part of their practice. However, 45% expressed discomfort with independent interpretation. A significant 73% received less than 5 hours of ECG-specific education, with 45% reporting no education at all. Also, 87% reported limited or no expert supervision. Nearly all medical professionals (2461, 98%) expressed a desire for more ECG education. These findings were consistent across all groups and did not vary between primary care physicians, cardiology FIT, resident physicians, medical students, APPs, nurses, physicians, and nonphysicians. This study reveals substantial deficiencies in ECG interpretation training, supervision, and confidence among medical professionals, despite a strong interest in increased ECG education.

ECG Interpretation Proficiency of Healthcare Professionals

ECG interpretation is essential in modern medicine, yet achieving and maintaining competency can be challenging for healthcare professionals. Quantifying proficiency gaps can inform educational interventions for addressing these challenges. Medical professionals from diverse disciplines and training levels interpreted 30 12-lead ECGs with common urgent and nonurgent findings. Average accuracy (percentage of correctly identified findings), interpretation time per ECG, and self-reported confidence (rated on a scale of 0 [not confident], 1 [somewhat confident], or 2 [confident]) were evaluated. Among the 1206 participants, there were 72 (6%) primary care physicians (PCPs), 146 (12%) cardiology fellows-in-training (FITs), 353 (29%) resident physicians, 182 (15%) medical students, 84 (7%) advanced practice providers (APPs), 120 (10%) nurses, and 249 (21%) allied health professionals (AHPs). Overall, participants achieved an average overall accuracy of 56.4% ± 17.2%, interpretation time of 142 ± 67 seconds, and confidence of 0.83 ± 0.53. Cardiology FITs demonstrated superior performance across all metrics. PCPs had a higher accuracy compared to nurses and APPs (58.1% vs 46.8% and 50.6%; P < 0.01), but a lower accuracy than resident physicians (58.1% vs 59.7%; P < 0.01). AHPs outperformed nurses and APPs in every metric and showed comparable performance to resident physicians and PCPs. Our findings highlight significant gaps in the ECG interpretation proficiency among healthcare professionals.

Face-to-face, online, or blended: which method is more effective in teaching electrocardiogram to medical students

BACKGROUND

Electrocardiogram (ECG) remains an important medical diagnostic and screening tool. This study aimed to compare the effectiveness of online classes instead of traditional face-to-face or blended methods in medical students' ECG learning.

METHODS

Two hundred and fifteen medical students (including 105 (48.8%) males and 110 (51.2%) females) were studied from February 2021 to February 2022. Regardless of their grade, participants were divided into three groups: online, face-to-face, and blended. Then all participants sat for an ECG interpretation exam, and their results were compared.

RESULTS

Twenty-six (12.1%) participants were residents, and 189 (87.9%) were interns. Thirty-five (16.3%), 85 (39.5%), and 95 (44.2%) participants were taught ECG through face-to-face, online, and blended methods, respectively. Regarding participants' preferences on teaching methods, 118 (54.9%) preferred face-to-face learning, and the remaining 97 (45.1%) chose online learning (p < 0.001). The blended method seemed more promising in almost half of the exam questions regarding teaching method effectiveness. The mean total exam score was also significantly higher in participants who were taught blended than in the others (7.20 ± 1.89, p = 0.017). Face-to-face (5.97 ± 2.33) and online teaching methods (6.07 ± 2.07) had similar efficacy according to the mean total score (p = 0.819).

CONCLUSION

While most students preferred face-to-face learning to online learning, a blended method seemed more promising regarding students' skill enhancement to interpret ECG.

Protocol for development of an assessment tool for competency of ECG interpretation: expert consensus by the RAND/UCLA appropriateness method and cross-sectional testing using multidimensional item response theory

INTRODUCTION

Although the ECG is an important diagnostic tool in medical practice, the competency of ECG interpretation is considered to be poor. Diagnostic inaccuracy involving the misinterpretation of ECG can lead to inappropriate medical judgements and cause negative clinical outcomes, unnecessary medical testing and even fatalities. Despite the importance of assessing ECG interpretation skills, there is currently no established universal, standardised assessment tool for ECG interpretation. The current study seeks to (1) develop a set of items (ECG questions) for estimating competency of ECG interpretation by medical personnel by consensus among expert panels following a process based on the RAND/UCLA Appropriateness Method (RAM) and (2) analyse item parameters and multidimensional latent factors of the test set to develop an assessment tool.

METHODS AND ANALYSIS

This study will be conducted in two steps: (1) selection of question items for ECG interpretation assessment by expert panels via a consensus process following RAM and (2) cross-sectional, web-based testing using a set of ECG questions. A multidisciplinary panel of experts will evaluate the answers and appropriateness and select 50 questions as the next step. Based on data collected from a predicted sample size of 438 test participants recruited from physicians, nurses, medical and nursing students, and other healthcare professionals, we plan to statistically analyse item parameters and participant performance using multidimensional item response theory. Additionally, we will attempt to detect possible latent factors in the competency of ECG interpretation. A test set of question items for ECG interpretation will be proposed on the basis of the extracted parameters.

ETHICS AND DISSEMINATION

The protocol of this study was approved by the Institutional Review Board of Ehime University Graduate School of Medicine (IRB number: 2209008). We will obtain informed consent from all participants. The findings will be submitted for publication in peer-reviewed journals.

CRISP method with flipped classroom approach in ECG teaching of arrhythmia for trainee nurses: a randomized controlled study

BACKGROUND

This study aimed to explored the effects of the Cardiac Rhythm Identification for Simple People (CRISP) method with flipped classroom approach for arrhythmia interpretation in electrocardiogram (ECG) by trainee nurses.

METHODS

A total of 120 trainee nurses were enrolled and randomly divided into the experimental group and the control group using lecture-based learning method. We observed the effects of the two methods in ECG interpretation training and investigated the students' attitudes toward the teaching practices.

RESULTS

After training, the ECG test scores in the experimental group were significantly higher than that of the control group. Six months later, the ECG test scores of the experimental group was still higher. Self-learning enthusiasm, understanding of teaching content, satisfaction of teaching mode, satisfaction of teaching effectiveness, and interest in learning ECG were significantly higher in the experimental group.

CONCLUSION

CRISP method with flipped classroom approach is a new and effective mode worth trying in ECG teaching for trainee nurses.

Competency and confidence in ECG interpretation among medical students

Objectives

To assess competency and confidence in ECG interpretation in medical students across years of medical school and evaluate the associations of various factors, a curriculum change, and student confidence with ECG competency.

Methods

Four hundred and fourteen (414) third- to sixth-year medical students participated in this cross-sectional study conducted in 2019 in the Hebrew University of Jerusalem, Israel. A voluntary response sample of participants answered a validated, web-based questionnaire, composed of eight ECG strips. Participants were also asked about confidence and sources for ECG education and exposure. Competency and confidence across medical school years were compared using the ANOVA and chi-square tests.

Results

Competency was low overall (mean score, SD (standard deviation) 3.23±1.81 out of 8), and higher in sixth-year students compared to third-, fourth- and fifth-year students (4.37±1.69 vs. 2.90±1.82, 2.90±1.54, 2.50±1.56, respectively, F(3,337)=24.425, p<0.0001). There was no difference between students before and after the curriculum change. Work experience in medicine was associated with competency (odds ratio (OR), 7.97; 95% confidence interval (CI), 4.03-15.77, p<0.0001). The reported confidence level was low (median 2 out of 5) and was found to be correlated with the total score achieved (r(332)=0.5, p<0.0001).

Conclusions

Student competency was shown to be insufficient throughout medical school. Competency and confidence in ECG interpretation seem to be significantly improved by increased and repetitive exposure to ECG. Thus, strategies to facilitate better ECG skills should involve an extended focus on ECG in the undergraduate and graduate curricula and include competency-based educational programs.

Assessment of electrocardiogram interpretation competency among healthcare professionals and students of Ardabil University of Medical Sciences: a multidisciplinary study

BACKGROUND

Electrocardiogram (ECG) interpretation is a core clinical skill that helps to rapid diagnosis of potentially life-threatening diseases. Misinterpretation of the electrocardiogram can lead to inappropriate clinical decisions with adverse outcomes. The main aim of this survey was to assess the competency of electrocardiogram interpretation and related factors among healthcare professionals and students of Ardabil University of Medical Sciences.

METHODS

This descriptive cross-sectional study included 323 staff and students of Ardabil University of Medical Sciences in northwestern Iran. Data were collected randomly from November to January 1400 using the Badell-Coll ECG Interpretation Competency Questionnaire and analyzed using SPSS V.14. Statistical analysis included descriptive statistics, independent t-test, ANOVA, Pearson correlation coefficient and multiple linear regression.

RESULTS

The results showed that the mean and standard deviation of electrocardiogram interpretation competency of health professional staff and students was 5.13 ± 2.25 (maximum score = 10). The large number of participants wasn't able to identify normal sinus rhythm (n = 251, 77.3%), acute myocardial infarction (n = 206, 63.8%) and pathological Q waves (n = 201, 62.2%). The results of multiple linear regression showed that the variables of education level, self-assessment of electrocardiogram interpretation competence, work experience, and type of hospital were able to predict the competence of ECG interpretation in participants.

CONCLUSIONS

Our findings showed that the participants' level of electrocardiogram interpretation competency was low. Hence, regular, standard training and education are recommended. Also, managers and educators of the health system should consider the role of positive self-assessment and exposure to ECG interpretation in improving the competence of staff and students to interpret ECG.

Online team-based electrocardiogram training in Haiti: evidence from the field

BACKGROUND

The electrocardiogram (ECG) is the most relied upon tool for cardiovascular diagnosis, especially in low-resource settings because of its low cost and straightforward usability. It is imperative that internal medicine (IM) and emergency medicine (EM) specialists are competent in ECG interpretation. Our study was designed to improve proficiency in ECG interpretation through a competition among IM and EM residents at a teaching hospital in rural central Haiti in which over 40% of all admissions are due to CVD.

METHODOLOGY

The 33 participants included 17 EM residents and 16 IM residents from each residency year at the Hôpital Universitaire de Mirebalais (HUM). Residents were divided into 11 groups of 3 participants with a representative from each residency year and were given team-based online ECG quizzes to complete weekly. The format included 56 ECG cases distributed over 11 weeks, and each case had a pre-specified number of points based on abnormal findings and complexity. All ECG cases represented cardiovascular pathology in Haiti adapted from the Association of Program Directors in Internal Medicine evaluation list. The main intervention was sharing group performance and ECG solutions to all participants each week to promote competition and self-study without specific feedback or discussion by experts. To assess impact, pre- and post-intervention assessments measuring content knowledge and comfort for each participant were performed.

RESULTS

Overall group participation was heterogeneous with groups participating a median of 54.5% of the weeks (range 0-100%). 22 residents completed the pre- and post-test assessments. The mean pre- and post-intervention assessment knowledge scores improved from 27.3% to 41.7% (p = 0.004). 70% of participants improved their test scores. The proportion of participants who reported comfort with ECG interpretation increased from 57.6% to 66.7% (p = 0.015).

CONCLUSION

This study demonstrates improvement in ECG interpretation through a team-based, asynchronous ECG competition approach. This method is easily scalable and could help to fill gaps in ECG learning. This approach can be delivered to other hospitals both in and outside Haiti. Further adaptations are needed to improve weekly group participation.

Telecardiology in Rural Practice: Global Trends

The management of cardiovascular diseases in rural areas is plagued by the limited access of rural residents to medical facilities and specialists. The development of telecardiology using information and communication technology may overcome such limitation. To shed light on the global trend of telecardiology, we summarized the available literature on rural telecardiology. Using PubMed databases, we conducted a literature review of articles published from January 2010 to December 2020. The contents and focus of each paper were then classified. Our search yielded nineteen original papers from various countries: nine in Asia, seven in Europe, two in North America, and one in Africa. The papers were divided into classified fields as follows: seven in tele-consultation, four in the telemedical system, four in the monitoring system, two in prehospital triage, and two in tele-training. Six of the seven tele-consultation papers reported the consultation from rural doctors to urban specialists. More reports of tele-consultations might be a characteristic of telecardiology specific to rural practice. Further work is necessary to clarify the improvement of cardiovascular outcomes for rural residents.

Effectiveness of Large-Scale Preparedness Training on Electrocardiogram for Medical, Surgical, and Pre-clinical Doctors: A Need-Based Initiative for COVID-19 Patient Care

INTRODUCTION

One of the competencies expected of all doctors posted in coronavirus disease 2019 (COVID-19) wards, is ECG rhythm identification, interpretation, and intervention for immediate management of patients. This study was undertaken to evaluate the effectiveness of the ECG training module as a component of preparedness training to combat COVID-19.

METHODOLOGY

This was a cross-sectional study conducted during training on ECG rhythm identification, interpretation, its management in COVID-19 patients. Study participants included faculty, senior residents, junior residents, and interns of medical, surgical, and paraclinical disciplines. The training session included one hour of didactic lecture and one and half hours of interactive session during which case scenarios were discussed. An objective assessment was conducted through pre-test and post-test. Mean of pre and post-test scores were compared using paired t-test for evaluating statistical significance. Feedback was also taken from participants.

RESULTS

Out of the 800 participants who gave consent, only 682 who completed both pre and post-test were included in the final analysis. Mean pre-test and post-test scores were 9.29/15 (61.9%) and 11.63/15 (77.5%), respectively, with a mean improvement of +2.34/15 (+15.6%). Of the participants, 38.6% obtained low scores in pre-test and 82% of respondents agreed that knowledge and skills gained from training would be useful in providing patient care.

CONCLUSION

 Low baseline knowledge on ECG highlights the need for re-training doctors posted in COVID-19 care on cardiac rhythm identification and interpretation. Interactive training is effective in improving ECG interpretative skills among doctors across disciplines and is the appropriate method to retrain/reskill, especially for large-scale capacity building.

Effects of peer learning on nursing students' learning outcomes in electrocardiogram education

BACKGROUND

Nurses should have the ability to interpret electrocardiograms (ECGs) quickly and accurately, but their ECG interpretation skills may be suboptimal. The best evidence for effective teaching methods is lacking.

OBJECTIVES

This study aimed to compare the effects of peer and self-directed individual learning methods on nursing students' learning flow, interpretation skills, and self-confidence in web-based ECG education.

DESIGN

This study employed a nonequivalent control group with a pretest-posttest design.

SETTINGS

This study was conducted at two colleges of nursing in the Republic of Korea.

PARTICIPANTS

Nursing students were conveniently assigned to either a peer learning group (n = 45) or a self-directed individual learning group (n = 51).

METHODS

A self-administered questionnaire was used to measure the nursing students' learning flow and self-confidence in ECG rhythm interpretation. ECG interpretation skills were measured using a web-based interpretation skills test. Data were analyzed using a paired t-test and a two-sample t-test.

RESULTS

Nursing students in both groups showed improved learning flow, interpretation skills, and self-confidence after ECG education compared with before learning. However, there were no significant pretest-posttest differences in learning flow, interpretation skills, or self-confidence between the two groups.

CONCLUSIONS

Peer learning was as effective as self-directed individual learning in improving nursing students' learning flow, interpretations skills, and self-confidence in web-based education. Nurse educators should educate nursing students to have optimal ECG interpretation abilities, and web-based peer or individual learning are effective education methods.

Clinically contextualised ECG interpretation: the impact of prior clinical exposure and case vignettes on ECG diagnostic accuracy

BACKGROUND

ECGs are often taught without clinical context. However, in the clinical setting, ECGs are rarely interpreted without knowing the clinical presentation. We aimed to determine whether ECG diagnostic accuracy was influenced by knowledge of the clinical context and/or prior clinical exposure to the ECG diagnosis.

METHODS

Fourth- (junior) and sixth-year (senior) medical students, as well as medical residents were invited to complete two multiple-choice question (MCQ) tests and a survey. Test 1 comprised 25 ECGs without case vignettes. Test 2, completed immediately thereafter, comprised the same 25 ECGs and MCQs, but with case vignettes for each ECG. Subsequently, participants indicated in the survey when last, during prior clinical clerkships, they have seen each of the 25 conditions tested. Eligible participants completed both tests and survey. We estimated that a minimum sample size of 165 participants would provide 80% power to detect a mean difference of 7% in test scores, considering a type 1 error of 5%.

RESULTS

This study comprised 176 participants (67 [38.1%] junior students, 55 [31.3%] senior students, 54 [30.7%] residents). Prior ECG exposure depended on their level of training, i.e., junior students were exposed to 52% of the conditions tested, senior students 63.4% and residents 96.9%. Overall, there was a marginal improvement in ECG diagnostic accuracy when the clinical context was known (Cohen's d = 0.35, p < 0.001). Gains in diagnostic accuracy were more pronounced amongst residents (Cohen's d = 0.59, p < 0.001), than senior (Cohen's d = 0.38, p < 0.001) or junior students (Cohen's d = 0.29, p < 0.001). All participants were more likely to make a correct ECG diagnosis if they reported having seen the condition during prior clinical training, whether they were provided with a case vignette (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.24-1.71) or not (OR 1.58, 95% CI 1.35-1.84).

CONCLUSION

ECG interpretation using clinical vignettes devoid of real patient experiences does not appear to have as great an impact on ECG diagnostic accuracy as prior clinical exposure. However, exposure to ECGs during clinical training is largely opportunistic and haphazard. ECG training should therefore not rely on experiential learning alone, but instead be supplemented by other formal methods of instruction.

The Development of Visual Expertise in ECG Interpretation: An Eye-Tracking Augmented Re Situ Interview Approach

Phenomenon: Visual expertise in medicine involves a complex interplay between expert visual behavior patterns and higher-level cognitive processes. Previous studies of visual expertise in medicine have centered around traditionally visually intensive disciplines such as radiology and pathology. However, there is limited study of visual expertise in electrocardiogram (ECG) interpretation, a common clinical task that is associated with high error rates. This qualitatively driven multi-methods study aimed to describe differences in cognitive approaches to ECG interpretation between medical students, emergency medicine (EM) residents, and EM attending physicians. Approach: Ten medical students, 10 EM residents, and 10 EM attending physicians were recruited from one tertiary academic center to participate in this study. Participants interpreted 10 ECGs with a screen-based eye-tracking device, then underwent a subjective re situ interview augmented by playback of the participants' own gaze scan-paths via eye-tracking. Interviews were transcribed verbatim and an emergent thematic analysis was performed across participant groups. Diagnostic speed, accuracy, and heat maps of fixation distribution were collected to supplement the qualitative findings. Findings: Qualitative analysis demonstrated differences among the cohorts in three major themes: dual-process reasoning, ability to prioritize, and clinical implications. These qualitative findings were aligned with differences in visual behavior demonstrated by heat maps of fixation distribution across each ECG. More experienced participants completed ECG interpretation significantly faster and more accurately than less experienced participants. Insights: The cognitive processes related to ECG interpretation differed between novices and more experienced providers in EM. Understanding the differences in cognitive approaches to ECG interpretation between these groups may help inform best practices in teaching this ubiquitous diagnostic skill.

Electrocardiogram Interpretation Competency Among Paramedic Students

BACKGROUND

Electrocardiography is an essential emergency tool used in the pre-hospital setting. However, no studies have yet assessed electrocardiogram (ECG) interpretation among emergency medical services (EMS) students in Saudi Arabia. This study aimed to determine the ECG interpretation competency of paramedic students.

METHODOLOGY

Cross-sectional, single-center study, a pre-validated, self-administered, two-part questionnaire first created by Coll-Badell et al was used to assess the ECG interpretation competency of paramedic students at Prince Sultan College for Emergency Medical Services (PSCEMS) in King Saud University. Participant data were collected and analyzed to identify factors associated with improved competency.

RESULTS

All students of PSCEMS were included, and 137 of 248 paramedic students completed the questionnaire (55% response rate); 88 students (64.2%) scored >7.5 points, indicating competency in (ECG) interpretation. Factors such as grade point average (GPA) (>3.5) and enrollment in cardiology and advanced cardiac life support courses were found to be significantly associated with competency (p<0.001).

CONCLUSION

The majority of paramedic students were found to be competent in ECG interpretation. GPA and enrollment in cardiology and advanced cardiac life support courses were significantly associated with improved competency.

Old teaching tools should not be forgotten: The value of the Lewis ladder diagram in understanding bigeminal rhythms

As medical education evolves, some traditional teaching methods often get forgotten. For generations, the Lewis ladder diagram (LLD) has helped students understand the mechanisms of cardiac arrhythmias and conduction disorders. Similarly, clinicians have used LLDs to communicate their proposed mechanisms to their colleagues and trainees. In this article, we revisit this technique of constructing the LLD and demonstrate this process by describing the mechanisms of various bigeminal rhythms.

The Electrocardiogram: Still a Useful Tool in the Primary Care Office

A 12-lead electrocardiogram (ECG) is the most commonly ordered cardiac test. Although data are not robust, guidelines recommend against performing an ECG in patients who are asymptomatic, even if they have a higher risk of developing cardiovascular disease in the long term. Conversely, patients with cardiac symptoms, including chest pain, dyspnea, palpitation, and syncope, should have an ECG performed in the office. Computerized algorithms exist ubiquitously to guide interpretation, but they can be the source of erroneous information. A stepwise approach is given to guide the primary care physician's approach to the systematic interpretation of ECG tracings.

Why complicate an important task? An orderly display of the limb leads in the 12-lead electrocardiogram and its implications for recognition of acute coronary syndrome

Background

In the standard ECG display, limb leads are presented in a non-anatomical sequence: I, II, III, aVR, aVL, aVF. The Cabrera system is a display format which instead presents the limb leads in a cranial/left-to-caudal/right sequence, i.e. in an anatomically sequential order. Lead aVR is replaced in the Cabrera display by its inverted version, −aVR, which is presented in its logical place between lead I and lead II.

Main text

In this debate article possible implications of using the Cabrera display, instead of the standard, non-contiguous lead display, are presented, focusing on its use in patients with possible acute coronary syndrome. The importance of appreciating reciprocal limb-lead ECG changes and the diagnostic and prognostic value of including aVR or lead −aVR in ECG interpretation in acute coronary syndrome is covered. Illustrative cases and ECGs are presented with both the standard and contiguous limb lead display for each ECG.

A contiguous lead display is useful when diagnosing acute coronary syndrome in at least 3 ways: 1) when contiguous leads are present adjacent to each other, identification of ST elevation in two contiguous leads is simple; 2) a contiguous lead display facilitates understanding of lead relationships as well as reciprocal changes; 3) it makes the common neglect of lead aVR unlikely.

Conlusions

It is logical to display the limb leads in their sequential anatomical order and it may have advantages both in diagnostics and ECG learning.