Reading or interpreting an electrocardiogram (EKG / ECG) is one of those iconic things that students imagine themselves doing when deciding to pursue a medical career. Every medical drama has scenes of providers working on a critical patient and the chaos pausing while the monitor is interpreted and treatment is decided. That's not far from the truth, some of the time.

Learning cardiac rhythm interpretation is less dramatic. In part, that's due to the difficult subject. EKGs are dynamic, abstract, and somewhat subjective. Two patients in the same cardiac rhythm can have drastically different looking ECG tracings. There are a host of reasons for that, from normal anatomical differences to the placement of electrodes on the skin. This means that learning to interpret EKGs takes more than rote memorization and pattern recognition.

The only way to develop this skill is through practice. While learning, students are limited to ECG examples they have access to in their textbooks, classes, and whatever adjunct material they may find. Together, that represents the...

Current State of EKG Education

EKG Printouts

Many medical instructors who work clinically have a collection of EKGs they use for teaching. Above is one such collection. Some of these aren't in great shape and some are over a decade old at this point.

This certainly works; however, it takes years of clinical practice to collect a library of tracings that cover everything a student needs to know. Providing extended examples of rhythms is difficult as printouts get very long. It's easy to end up with multiple foot/meter rolls of ECG tracings.

Photocopies

Educators and institutions responsible for teaching and testing EKG interpretation do their best to collect catalogs of tracings. Clinical ECGs are printed with heat printers and don't lend themselves well to long-term handling. Many places end up with collections of low-quality photocopied EKG printouts.

Textbooks

Medical texts tend to have the highest quality reproductions of EKG tracings, either real clinical examples or drawings by medical artists. Unfortunately, in most medical fields, the breadth of material textbooks cover limits how much space ECGs can take up. In the most popular nursing and paramedic textbooks fewer than 40 pages are dedicated to cardiac rhythms. This means that not only can these textbooks not cover all dysrhythmias, but they are generally limited to a single example of covered dysrhythmias.

Adjunct Texts

Educational institutions deal with this by assigning adjunct textbooks with additional instruction or practice rhythm strips. Almost everyone working in clinical medicine has a copy of "Rapid Interpretation of EKGs" by Dale Dubin, MD (~$40) or another book that offers more in-depth explanations of reading EKGs. Most also have something like "ECG Workout: Exercises in Arrhythmia Interpretation" by Jane Huff, RN (~$60), which is an entire 400-page book of practice ECG tracings.

Books published specifically for practice tend to have excellent quality, but still have the limitations of size. The breadth of variation in cardiac rhythms means that even in a 400-page book, only a handful of examples of each rhythm and its variations can be presented. Displaying an extended rhythm can take several pages since time is represented by length on EKG tracings.

The most famous ECG book, Dubin’s "Rapid Interpretation of EKGs," uses poor quality photocopies of short strips throughout (pictured above). In all fairness, the goal of "Rapid Interpretation of EKGs" is to teach the steps of reading rhythm strips and not to provide practice tracings. Still, most of the images are the same photocopies from the original black and white printing in the 1970s.

Hardware, Software, & Simulation Suites

The problem with printed material, even of high quality, is that it is static. Reading an ECG in a clinical setting, especially in emergency or critical care, is dynamic. A host of different tools have come along to try to recreate the clinical EKG interpretation environment, including analog rhythm generators, smartphone and web apps, and full proprietary simulation systems with built-in monitoring solutions. The prices range from free to tens of thousands of dollars.

Analog Rhythm Generators

Analog ECG rhythm generators haven't changed much since the 1980s. Their advantage is a realistic experience, but it comes at the cost of requiring a real cardiac monitor to use. The cost ranges from a few hundred dollars to $2,000. Because they are hard-wired circuits, they only provide a limited range of rhythms and typically only produce one example of each.

Software EKG Simulators

There are several Android and iOS apps that offer EKG practice. The most popular software solution among students is probably the free SkillStat "6 Second ECG". Unfortunately, they offer only 27 rhythms with a single example each. They are well-done tracings, but are artistic renderings of actual EKG rhythms.

Medical Simulation Suites

The two most widely used simulation packages are Laerdal SimMan and Corpuls Simulation. ECG interpretation is only a part of overall medical simulation, and neither of these simulation suites focus on EKG interpretation specifically, using libraries of static EKGs as a solution. The result is that students quickly become familiar with the examples available and answer from memory rather than interpretation.

A Word on Testing

Eventually, every student learning to read ECGs has to be tested on that ability. There is no standardized way medical educational institutions handle this, and the quality of EKG tracings on tests varies widely. Whether ECG tracings for testing are digital or hard-copy, they all suffer the same pitfalls discussed here.

Large organizations such as the National Registry of EMTs (NREMT), the National Council Licensure Examination for Registered Nurses (NCLEX-RN), and the American Board of Emergency Medicine all have EKG rhythm interpretation on their licensure exams. All of these use computer-based testing and have good quality ECG tracings, but rely on static libraries to create their test questions.

Conclusion

Books, hardware EKG generators, and software or simulation suites all rely on fixed libraries of rhythms, displaying them when selected. As students are repeatedly exposed to the same version of a rhythm, they start to answer based on recall, having seen the tracings before. This is the common problem across all strategies of ECG interpretation education.

Although nothing compares to real-world clinical experience when it comes to reading EKGs, with modern tools, we should be able to do better than faded photocopies and limited examples. This is where Dialed Medics EKG Simulator comes in. Our application creates novel, clinically valid ECG rhythms on any device with a modern web browser. An example screen capture:

Find out more about Dialed Medics EKG generator: Our Solution: Software EKG Generation or get started now:

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