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 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 EKG 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 EKG examples they have access to in their textbooks, classes, and whatever adjunct material they may find. Together, that represents...
Current State of EKG Education
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 EKG tracings.
Educators and institutions responsible for teaching and testing EKG interpretation do their best to collect catalogs of tracings. Clinical EKGs are printed with heat printers and don't lend themselves well to long term handling. Many places end up with collections of photocopied EKG printouts that are of low quality.
Medical texts tend to have the highest quality reproductions of EKG tracings, either real clinical examples or medical artist drawings. Unfortunately, in most medical fields the breadth of material the textbook covers limits how much space EKGs can take up. In the most popular nursing and paramedic textbooks less 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 dysrhythmias they do cover.
Educational institutions deal with this by assigning adjunct text books 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 which 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 mean even in a 400 page book only a handful of examples of each rhythm and variation can be presented. Displaying an extended rhythm can take several pages as time is represented by length on EKG tracings.
The most famous EKG 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 provide practice tracings. Still, most of the images are the same photocopies from the original black and white printing in the 1970's.
Hardware, Software, & Simulation Suites
The problem with printed material, even of high quality, is that it is static. Reading an EKG 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 monitoring solutions built-in. The price ranges from free to tens of thousands of dollars.
Analog Rhythm Generators
Analog EKG rhythm generators haven't changed much since the 1980's. Their upside is a realistic experience, but it comes at the cost of needing a real cardiac monitor to use them. The cost is anywhere from a few hundred dollars to $2,000. Because they are hard wired circuits, they only provide a limited range of rhythms and can only produce one example of each.
Software EKG Simulators
There are several android and iPhone apps that offer ECG practice. The most popular software solution among students is probably the free SkillStat "6 Second ECG". Unfortunately they only offer 27 rhythms and only a single example of each. They are well done tracings, but are artist renderings of actual EKG rhythms.
Medical Simulation Suites
The two most widely used simulation packages are Laerdal SimMan and Corpuls Simulation. EKG generation / interpretation is just a part of overall medical simulation and both of these simulation suites rely on libraries of digital EKGs as solutions. This results in students quickly becoming familiar with the examples provided.
A Word on Testing
Eventually, every student responsible for learning to read EKGs has to be tested on that ability. There's no standardized way medical educational institutions handle this and the quality of EKG tracings on tests varies widely. Whether EKG tracings for testing are digital or hard copy, they suffer all the same pitfalls discussed here.
Large organizations such as the National Registry of EMTs, the National Council Licensure Examination - 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 EKG tracings but still rely on static libraries of tracings to create their test questions.
Books, hardware EKG generators, and software or simulation suites all rely on fixed libraries of rhythms, displaying them when selected. Hardware rhythm generators might only produce one example of four or six rhythms. As students are repeatedly exposed to the same version of a rhythm they start to answer based on recall, having seen the tracings before. That is the common problem across all strategies of EKG education.
Nothing compares to actual clinical experience when it comes to reading EKGs. With modern tools we should be able to do better than faded photocopies and limited examples. That's where DialedMedics EKG Simulator comes in. Our application creates novel and clinically valid EKG rhythms on any device with a modern web browser. An example screen capture:
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