I received an email today from a reader who ripped me a new one. Here’s the email with my replies interspersed.
To Whom This May Concern,
I stumbled upon this site while looking for additional information on poor r-wave progression. I happened to notice that in the wide-complex tachycardia section, there were some errors I would like to address.
So far so good! I generally appreciate it when someone points out my errors.
First and foremost, no one should treat unstable VT and unstable SVT the same, neither chemically, nor electrically. Unstable VT where losing a pulse is imminent, should be defibrillated where unstable SVT should always be synchronized cardioverted.
The 2005 AHA ECC guidelines classify tachycardias as either stable or unstable. Unstable tachycardias get cardioverted. It doesn’t matter if it’s a narrow complex tachycardia or a wide complex tachycardia. The caveat of course is that you should take steps to make sure it isn’t a compensatory tachycardia and attempt to identify reversible causes prior to cardioversion.
To my knowledge, there is nothing in the literature to substantiate unsynchronized cardioversion (defibrillation) for unstable regular wide complex tachycardias with a pulse.
In fact, having discussed this with various electrophysiologists, there’s no clinical reason why you shouldn’t synchronize the shock for a patient who is pulseless. Why not deliver the current at the optimal moment in the cardiac cycle? ICDs do it all the time, and they don’t check a pulse first.
I’ve researched this question extensively, and I’m left with the conclusion that VT without a pulse was thrown into the VF algorithm for simplicity, and because VT occasionally presents as ventricular flutter, during which time the computer may have difficulty differentiating between R-waves and T-waves. To prevent any delay (or mistakes by inexperienced rescuers) the pulseless VT algorithm calls for defibrillation.
If you have a better explanation, my ears are wide open.
Second, though amiodarone is a useful drug, many EMS departments do not wish to carry it because of its side effect profile, its questionable usefulness in upper chamber dysrhythmias, and its long half-life.
Sounds reasonable to me.
The literature supports lidocaine as being as effective as amiodarone for VT. Lidocaine is not as effective as calcium channel blockers in treating wide complex supraventricular irregular tachycardias however.
But is it dangerous? Is it contraindicated? Obviously not, or L-A-P-B (lidocaine, adenosine, procainamide, bretylium) would never have been the ACLS algorithm for wide complex tachycardias of unknown or uncertain origin.
Third, it is academically dishonest and even perhaps illegal to directly quote from an article without a proper citation.
Is there a particular quote you’re referring to?
It is equally dishonest and professionally unethical to make criticisms of published materials using nothing more than mere opinion.
That’s just crazy talk!
Medical professionals criticize published material all the time, whether it be on blogs, editorials, letters to the editor, podcasts, webcasts, or online discussion forums and listservs.
The entire concept of publishing a paper is to put it out there for your peers to criticize. It’s one of the hallmarks of science.
Furthermore, I found your opinions unfounded, misguided, inaccurate, unkind, irresponsible, and lacking an academic foundation.
It would be extremely helpful to me to know what opinions of mine you found to be so irresponsible.
I advise you to use caution, sound judgement, graciousness, sound ethics and humility when publicly critiquing published materials.
Is this some kind of threat? If you’re going to question my ethics, I think I’m entitled to some examples.
It is a shame, but I cannot in good conscious take the contents of this website seriously. It contains more personal opinion than established fact.
For example?
Furthermore, it appears that the author of the wide complex tachycardia section, who has a noticeably high opinion of himself, is more interested in attempting to sell people on his questionable knowledge than promote truths about electrocardiography.
By all means, enlighten me!
He publicly scathes an author of a wide-complex tachycardia article, but bases it on his own personal opinion, not academically sound research or practice.
Finally, a semi-specific criticism!
I assume you’re referring to my comments at the bottom of Differential diagnosis of wide complex tachycardias – Part I.
I will quote the relevant comments here:
[snip]
I recently discovered this article from the March 2006 issue of Emergency Medical Services. In it, the author states:
With the introduction of new pharmacological interventions that target specific areas of the cardiac conduction system, it has become increasingly important for EMS providers to make an accurate interpretation of an ECG. Though most paramedics have no difficulty distinguishing VT from narrow complex supraventricular tachycardia (SVT), some might fall victim to the “wide + fast = VT” trap when looking at SVT with aberrant conduction. Although VT and SVT with aberrant conduction look similar, they vary greatly in terms of origin, pathophysiology and treatment. Mislabeling dysrhythmias can have severe consequences. Improper identification of VT could place a patient in grave danger by delaying indicated pharmacological and electrical interventions.
Listen carefully.
“Wide and fast = VT” is not a trap! It’s a rule of thumb that exists to protect you and your patient!
The author continues:
A common aphorism among advanced practitioners is, “When in doubt whether a WCT is VT or SVT, treat patients as if they are experiencing VTs.” This stems from a statistic showing that approximately 80% of all WCTs are VT. Though this aphorism is generally a good rule of thumb, it is also important to acknowledge that one in five WCTs is not VT and therefore requires different treatment regimens. One must possess the proper diagnostic tools and knowledge to decide whether a WCT is VT or SVT with aberrant conduction. EMS providers should be able to differentiate VT and SVT with aberrant conduction with confidence and a high degree of certainty.
They do not require different treatment regimens!
Unstable SVT is treated the same as unstable VT! Anyone disagree?
It’s debatable whether or not a stable wide complex tachycardia should be treated in the field at all, but if you do reach for an antiarrhythmic, it better be one that works for SVT and VT (i.e., amiodarone or procainamide).
If you give a calcium channel blocker to a wide complex tachycardia without knowing with 100% certainty that it’s SVT with BBB (or aberrancy) you are a fool.
The article also contains outright errors. Here’s one of the most disturbing.
SVTs with aberrancy will produce either a right or left axis deviation. If the aberrancy is conducted in a RBBB pattern, right axis deviation will be present. If the aberrancy is conducted in a LBBB pattern, left axis deviation will be present. In almost all VT, the axis will be in the extreme right quadrant.
This is nonsense!
In the first place, RBBB and LBBB aberrancy can both show a normal axis. RBBB aberrancy in particular can show a normal axis, right axis deviation, or left axis deviation (bifascicular patterns).
Most cases of VT present with an other-than-extreme axis.
See what I mean about a little bit of knowledge being dangerous?
[snip]
So what it boils down to is I said, “This is nonsense!” and “See what I mean about a little bit of knowledge being dangerous?”
If you’re attacking me on style points, then point taken. I can be a bit brash sometimes. However, I stand by the principle behind my words. Using QRS morphology to differentiate between VT and SVT with aberrancy is a dangerous, error-prone skill.
Use it at your own peril.
Though I do not know the person’s background, it forces one to wonder whether this blogger is educated beyond what his own intelligence permits.
You are entitled to your opinion.
This has the potential to be a good website, but lacks credibility. I will avoid this site and advise others to do so until it can be based on a solid foundation of knowledge. Personal opinion does not cut it.
Thank you,
Matthew Paulus, BME, EMT-P, MS-S NP-S/Cardiopulmonary CNS-S
It’s a big Internet, Mr. Paulus. There are plenty of URLs to choose from. I’m sorry the Prehospital 12-lead ECG blog was not more to your satisfaction.
Have a wonderful day!
Welcome to the Internet big leagues sir!Bjarne Stroustrup, inventor of C++, had this to say about programming languages, but it applies here:"There are only two kinds of languages: the ones people complain about and the ones nobody uses."
Can someone interpret the alphabet soup at the end of his name?
I would say furthermore, it appears that the author of this hate mail, who has a noticeably high opinion of himself (arrogance would hit the point imho), is even less interested in treating unstable tachycardias according to the AHA guidelines 2005 than not respecting the professional standards of constructive criticism.
The way I look at it you really haven't hit the "big time" until you get hate mail. So Congrats! Besides, your response makes for a great post.
Everyone will have picked up on the fact that Mr Paulus is the author of that article from the March 2006 issue of Emergency Medical Services.Can dish it out but you can take it, eh?Anonymous, EMT-B,-I,-P,-Y,-Z, WTF, BFF, MSN-BC, ROTFL
@akroeze, nice comment on the alphabet soup. Recently, there's a guy on our dept that has taken to putting a litany of letters after his name. Most people who see that usually think, "insecure." As if all those whatever-they-mean letters somehow make your comments that much more valid.
I read the article. Paulus says, "By contrast, the rhythm in SVT is often irregular." When I hear the word often I think "more times than not" which would be more than half.I have seen many narrow tachycardias and quite honestly, most have been regular. Maybe it's the air or the water here but I can't recall any SVTs that were irregular and I run lots of calls.
G.W. -How about AF w/ RVR?Tom
A real A-Fib with RVR or one that the LP12 says is AF/RVR? LOL I laugh about that because it seems to be the most prevalent interp on the LP.I can't say I have seen one that is regular.This guy also says, Unstable VT where losing a pulse is imminent…. I wish I knew what was imminent with my patients. Wouldn’t that make our job easy!Speaking of your article he states, It contains more personal opinion than established fact. When I read his published article, there appeared to be a good deal of personal opinion.Okay, I'm not the kind of person that can just sit back and not respond to such a letter. In fact, I would have already picked up the phone and called the guy. Though I doubt he would take your call. I’m thinking he prefers to hide behind all those letters after his name. To the men and women who slug it out everyday on the street, we all know those letters mean nothing.
I'm actually sorry I offended him, and perhaps I could have been more gracious in my choice of words.Having said that, I don't pull my "opinions" out of thin air.There are dozens of articles in the peer reviewed literature that express concern about the sensitivity of the algorithms for the differential diagnosis of wide complex tachycardias, the lack of agreement between physicians who use the algorithms, and the danger of presuming that failure to rule-in VT indicates SVT with aberrancy.Rather than cut and past dozens of citations, you can click HERE to search Google Scholar.To read the PubMed abstracts, click on "All x versions" under the search result you want to read and select the version from ncbi.nlm.nih.gov.The bottom line for me is the first rule of medicine, which is "do no harm."If the patient is unstable, then cardiovert. If the patient is stable, then capture a 12-lead ECG with excellent data quality, start an IV, draw labs, and take the patient to the hospital. Maybe there's an "old" ECG for comparison.Or, use an IV medication that won't kill the patient if the regular wide complex tachycardia turns out to be VT. Personally, I don't see how you can justify giving a CCB to a regular wide complex tachycardia in the field.That's extremely risky behavior, but one a disturbing number of paramedics seem willing to take.Tom
Gentlemen – While I sincerely appreciate the support, I've deleted the comments with creative name-calling.Thanks,Tom
I am curious of Mr. Paulus' credentials…what do these mean? BME, MS-S NP-S/Cardiopulmonary CNS-SThis blog is not only factual but based wholly on evidence and best practices – Bravo for questioning a practice that increases patients' risk for harm!Signed, a nurse with alphabet soup
I found that my response was a bit long for the comment section. I was not very creative in the title. My post title is The Prehospital 12-Lead ECG blog receives its first hate mail. I guess I will receive criticism for lack of creativity. I hope it is not illegal.Rogue Medic, FUBAR, SNAFU, TARFU, WTF, LMAO, EIEIO, AEIOU TIPS, GIGO, YADA YADA YADA, ETC.
PSAs far as I know, sedation (if appropriate) and electricity are the treatments for unstable shockable rhythms. Of course, nobody asked for my opinion.
Tom, I didn't see this until just now. Highly entertaining, but way too academiccally (academmik? Akkademmically? Academic-uhly?) chalenging for my abilities. I just think up opinions and jot them down with this heere laptop box and throw them up on the interwebs.You'll get use to hate mail
But I like ya. It was great meeting you in Baltimore, BTW.
I'm actually sorry I offended him, and perhaps I could have been more gracious in my choice of words."Don't be. Your words were far more gracious than his.As far as all the letters behind his name, the translation is "I'm insecure, and compensating."
You can't make everyone happy!