I was contacted by Pace Symposia last week and asked if I would consider reviewing their ECG simulation software. I was happy to oblige. Please note that I have received no financial incentive of any kind to perform this review, and what follows is my unadulterated opinion.

Klaus over at the The ECG Blog reviewed the same software recently. You can see his review HERE.

I’m a firm believer in reality based training, and when it comes to training paramedic students (or even veteran paramedics) you can’t beat dynamic cardiology.

In the back of the ambulance, we often treat patients on the fly. It’s not realistic to expect paramedics to print a rhythm strip and break out the calipers. We need to be able to identify complex heart rhythms at a glance.

That’s where the ECG Simulator comes in!

Let’s look at some examples of what this impressive ECG simulator can do.

Courtesy of Pace Symposia

Here I’ve asked the simulator to display sinus rhythm with ST segment depression and occasional multiformed PVCs. If you choose, you can also have the simulator display an acute injury pattern.

Courtesy of Pace Symposia

I can’t save the best for last. I have never in all my years seen a computer program that correctly simulates WPW and atrial fibrillation. This alone makes the ECG Simulator well worth the cost.

Courtesy of Pace Symposia

Here I selected atrial fibrillation with a very rapid ventricular response. If you really want to be mean, throw in a bundle branch block and see how many paramedic students yell, “VT!” and prepare to shock.

Courtesy of Pace Symposia

Here we have a simple 2nd degree AV block, Type I with a 3:2 ratio (and yes, the ratio can be changed).

Courtesy of Pace Symposia

Of course the ECG Simulator offers all of the lethal arrhythmias, including VT.

Courtesy of Pace Symposia

Torsades de Pointes (check the potassium level).

Courtesy of Pace Symposia

The ECG Simulator calls this ventricular flutter, although the general pattern and morphology is closer to a slow, course VF (or Torsades). When I think of ventricular flutter, I think of something more along the lines of the recent case study. Very fast. But not polymorphic.

Courtesy of Pace Symposia

Here we have ventricular pacing with underling atrial fibrillation.

In my opinion, this is an excellent ECG simulator that is as good or superior than anything else on the market today.

Having said that, here are some opportunities for improvement:

1.) The P waves are too big, too round, and too perfect looking.

This is a good thing for new students! It’s a bad thing for more advanced students (or professionals looking for a refresher). I would recommend different settings for students of varying skill levels, or have the computer select a random P wave morphology every time to keep things interesting and challenging.

2.) The QRS complexes are a little too wide.

Am I nitpicking? You bet! The “normal” QRS in this program measures about 110 ms. The bundle branch block, ventricular, and paced rhythms approach 200 ms. At a certain point, you start thinking severe cardiomyopathy, hyperkalemia, or sodium channel blocker toxicity. I’d like to see the “normal” QRS complex in the 90 ms range and the “wide” QRS complexes in the 140 ms range. Make the students squint at the screen! That’s how they get good.

3.) I’d like to see a 3rd degree AV block with a narrow complex escape rhythm.*

I remember the last time I took the NREMT-P practical exam. They gave me a patient in 3rd degree AV block with wide complexes and I wanted to go straight to transcutaneous pacing. The proctor told me “the pacer is broken” (amazing how often that happens in training). I reluctantly said, “Well, okay, then I guess I’ll give dopamine at 5 mcg/kg/min.” The proctor said, “Are you sure you want to give dopamine?” I said, “No, I want to perform transcutaneous pacing.” He said, “Is there another drug you might consider?” I said, “I know you’re not talking about atropine.” He said, “Umm, well… yeah.” I said, “Atropine isn’t indicated for 3rd degree heart block with wide complexes.” We sized each other up for a moment and then he made some marks on my paper and said, “Have a nice day.”

I passed.

*Note: I have subsequently learned that by increasing the ventricular rate you can get the ECG Simulator to switch from wide complexes to narrow complexes.

4.) The Torsades is a little slow and I would like to see it more paroxysmal with an underlying rhythm showing a prolonged QTc.

That’s the key to differentiating Torsades from polymorphic VT. Why not go for the gold?

5.) For the paced rhythms, I would consider allowing the user to set the parameters using the NASPE/BPEG NGB pacemaker code (and various settings like an upper rate limit, a lower rate limit, AV delay, etc.) and then change the heart rhythms with the pacemaker in place.

This would be the next logical step and open up the electrophysiology market. I don’t know if there is a simulator on the market that does this (outside of the labs at the medical device companies) but it would be fascinating to play with and a great learning tool!

I could imagine how awesome it would be for cardiac nurses, medical students, clinical specialists, and field engineers to optimize pacemaker settings for a variety of abnormal heart rhythms.

As I said in my interview with EP Lab Digest, studying implantable medical devices took my understanding of heart rhythms to the next level.

6.) On the subject of pacing, another area where emergency medicine is in desperate need of a good simulator is transcutaneous pacing!

You may recall my article about the problem of false capture. Never has a Class I intervention in ACLS been so poorly understood. A simulator to help students recognize the transition from “false capture” (or echo distortion) to true electrical capture would be a godsend.

Once again, these are just opportunities for improvement. This is an outstanding product and I recommend that EMS educators (or anyone with a love of cardiology) take a serious look!