ER Bear's Heart Notes

No STE, so what makes you say it's occluded? (Six principles for reading the OMI ECG)

Thu, 17 Sep 2026 00:00:00 +0000

This post is built on Helseth HC, Mansur P, El-Baba M, McLaren JTT, de Alencar JN, Smith SW. Electrocardiographic principles for the diagnosis of occlusion myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2026. DOI: 10.1093/ehjacc/zuag114.¹

This month I read a paper that I think every ED man should read.

You'll recognize the authors right away: Stephen Smith, Jesse McLaren, José Nunes de Alencar. The original OMI crew.

Every ED Is Raising Pay, So Why Can't Anyone Find Staff? (Part 2): Patients Can't Get Admitted, and Money Can't Buy People Back

Sun, 06 Sep 2026 00:00:00 +0000

This is Part 2. Part 1 is here. That post worked out three things that run against intuition: the number of board-certified emergency physicians who actually left the ED is not as large as the media claimed (72, not 139); ED patient volume has not particularly grown either: total visits still haven't returned to pre-pandemic levels today, and what changed is the mix inside; and it's not that everyone rushes to the ED with every little ailment: looking at the five-level triage as a whole, the share of low-acuity patients hasn't gone up, and has actually dipped slightly.

Goodbye, Type 1~5 MI? The Fifth Universal Definition of MI, and what everyone on X.com is fighting about

Sat, 05 Sep 2026 00:00:00 +0000

On the morning of August 28, before my shift, I was scrolling X.com. The official ESC account dropped this post:¹

Fig. 1. Post from the official ESC account on August 28 (X.com screenshot)

The post said one thing: the Fifth UDMI is out. Those three hearts in the image are the new three-way classification. More on that later.

Every ED Is Raising Pay, So Why Can't Anyone Find Staff? (Part 1): The Misreported Number, and a Patient Population That Got Swapped Out

Tue, 01 Sep 2026 00:00:00 +0000

This is Part 1. The piece comes in two installments: Part 1 covers "why people are leaving" and "whether there really are more patients"; Part 2 covers "why patients can't get admitted," and "why every hospital is raising pay and still can't find anyone."

On the ground: is the ED broken, or just busy?

Night shift hands off, day shift takes over. The moment sign-out ends, I already have 10 to 15 patients who are boarding or still have nowhere to go.

Moving My Script Next to the Audience's Faces: I Built SlideCue, a G2 Glasses Plugin, and It's Live

Fri, 28 Aug 2026 09:30:00 +0800

I've been putting together an ACLS lecture script lately: 120 slides, nearly 30,000 characters, all of it in Keynote's speaker notes. When I teach, I keep my laptop on the lectern and turn my head to glance at what comes next after every section.

The Sun Can Be Computed, the Clouds Can't: Using AI to Work Out Where to Stand to See the Sun Rise Over Guishan Island

Tue, 18 Aug 2026 20:00:00 +0800

It started with a photo I saw: the sun rising right out of Guishan Island.

My first thought was, where do you have to stand to get that shot? Guishan Island sits off the Yilan coast, so from any point on the shoreline it takes up a certain slice of sky, and the direction the sun rises changes every day. Getting those two to line up should be something you can calculate.

The Casino Next to the Church: Three Talks From a 2026 Value Investing Conference in Taiwan

Sun, 19 Jul 2026 00:00:00 +0000

On July 18, 2026, the 雷浩斯 Value Investing Conference (雷浩斯 is a Taiwanese value-investing author) was held at Zhongshan Hall in Taipei: three talks in one day, from method to market to life, strung together into one complete value investing system. This post condenses the three talks into six themes, using tables wherever a table will do, so they are easy to look up and apply.

Three Talks, One Through-Line

The three talks look separate, but the through-line is a single sentence: don't try to predict which day the market turns; identify where you are standing in the market right now.

SpO2 Drops to 72%. Do You Carry the Kid Off the Mountain? A High-Altitude Medicine Lesson with 21 Junior-High Students on the Jiaming Lake Trail

Thu, 16 Jul 2026 00:00:00 +0000

SpO2 drops to 72%. Do you immediately carry the kid off the mountain? On this Jiaming Lake trip, real data from 21 junior-high students gave me an answer that was the exact opposite of gut instinct.

I'm an ER doctor. On this Jiaming Lake trip, my role was team doctor: I carried a fingertip pulse oximeter/forehead thermometer and a stethoscope, a first-aid waist pack (DS-R7 rescue waist pack), and a handheld first-aid case (DS-R1 model) (packed at the very bottom of my heavy pack), and walked 4 days and 3 nights with 25 junior-high students, sleeping as high as Jiaming Lake Cabin at 3,370 m. Of the 25 kids, 4 didn't go up the mountain; 21 actually made the climb.

We were treating ACS, so how did it turn out to be aortic dissection? Two Type A Aortic Dissections disguised as STEMI

Fri, 10 Jul 2026 00:00:00 +0000

Today I want to cover two cases at once. Both of these patients started out down the ACS diagnostic path, and we treated them by the most standard protocol; but the real killer, from start to finish, was never in the coronary arteries. It was in the aorta.

At first we were treating both of them as acute coronary syndrome: one was a plain-as-day inferior STEMI, and in the other the CAG showed a total occlusion outright. In the end, the final diagnosis for both was Type A aortic dissection.

If the Source Isn't Cleared, the Best Antibiotic Won't Save You: Notes from an ED Antibiotics Seminar

Sat, 04 Jul 2026 00:00:00 +0000

I went to an ED antibiotics seminar (the ER & GIGS Joint Academic Symposium): four talks plus a new sedative. The whole time I was listening I had this feeling: the topics looked like they had nothing to do with each other (fever in chemo patients, cholangitis, complicated infections in the belly), but underneath they were all saying the same thing: if the source of infection isn't cleared, no matter how beautifully you pick the antibiotic, it's all for nothing.

Datong, Yilan, Jiuliao River Nature Trail: Walking to Gaba Waterfall

Sat, 13 Jun 2026 00:00:00 +0000

Today I hiked the Jiuliao River Nature Trail in Datong Township, Yilan, following the Jiuliao River all the way to Gaba Waterfall at the end of the trail. The path hugs the stream nearly the whole way, the water is plentiful and clear to the bottom, and along the way there are suspension bridges, old interpretive signs and a story from the Japanese colonial era. It's a really pleasant waterside trail.

Hiking the Paoma Historic Trail in Jiaoxi

Tue, 02 Jun 2026 00:00:00 +0000

This hike up the Paoma Historic Trail in Jiaoxi was our pre-trip training for Jiaming Lake at the end of June: heavy packs on, a full day of climbing, to build up leg strength and teamwork first.

I left before dawn and followed the group up the Paoma Historic Trail. We walked from Jiaoxi Hot Spring Park in town to Jinmian Daguan at the north entrance, then turned around the way we came. The Apple Watch logged a hiking distance of 12.88 km, with 500-plus meters of climbing, in nearly seven hours. Along the way there were century-old trees, a mountain-god Earth God shrine, watermelon by the stream, parents playing Little Bee (a roving support car) and handing out popsicles, and a view of Guishan Island from the top. A solid day with a lot of warmth in it.

Aerial Footage of the Sanqi Meijing Trail, Dongshan

Wed, 27 May 2026 00:00:00 +0000

An ER doctor on the operating table too: my presbyopia + myopia laser surgery (post-op day 3 edition)

Sun, 10 May 2026 00:00:00 +0000

Here's how it started~~

After I turned 45, presbyopia finally landed squarely on me.

When it's your turn, it's worse than you imagine. Especially in three situations where I absolutely did not want it getting in my way.

1. Physique competitions: me, glaring on stage

I've been training men's physique the past few years, and you can't wear glasses in competition, and I don't like contact lenses.

At my competitions the last two years, I'd watch the video afterward and get a shock. On stage my eyes were bulging wide open and my whole face looked fierce.

Notes on Raising a Lobster: Building an Automated Knowledge-Management Workflow with WhatsApp + Discord + OpenClaw

Wed, 18 Mar 2026 00:00:00 +0000

Raising a lobster: setting up the messaging interface is a lot of fun

I think that when you're raising a lobster, setting up the messaging interface is a lot of fun.

I find WhatsApp really handy, especially since its parent company is Meta. When you hit share on something you see in a lot of social apps, the first button is WhatsApp.

Tap it, and it starts analyzing the content, tags it for me, and saves it into my second brain, Roam.

59-Year-Old Man, Chest Pain, Severe Back Pain

Sun, 01 Mar 2026 00:00:00 +0000

Today we're looking at a really interesting case. There's a lot to learn from these ECGs.

59-year-old man, came to the ED on Lunar New Year's Day. He told me the chest pain had been going on for 3-4 days, sometimes radiating to his back. Tonight it went through to his back, bad enough that he broke out in a cold sweat

Aerial Footage of the Luodong Flood Diversion Weir, Yilan

Sun, 22 Feb 2026 00:00:00 +0000

Yilan Friendship Lettuce Log

Sun, 22 Feb 2026 00:00:00 +0000

An MI, and Now This Rhythm: What's Going On? What Do You Do?

Tue, 13 Jan 2026 00:00:00 +0000

Today let's walk through this case and look at what to do when a patient having an MI develops today's rhythm.

An 86-year-old woman brought in by ambulance. Found collapsed by the roadside, chief complaint chest pain.

On this one you can clearly see STE in the inf. leads with reciprocal STD in aVL/I. Put together with her clinical symptoms, it's highly likely an inf.wall STEMI (Fig.1).

My fantastical journey through the courts: accused of aggravated bodily harm

Tue, 06 May 2025 00:00:00 +0000

As the saying goes, if you want to work in the kitchen, don't be afraid of the heat.

Ever since I started my ED career in October 2005, I've felt that emergency medicine is a specialty that walks on thin ice.

You don't know, and you can hardly predict, whether your next step will crack the ice and drop you into the river.

Here's how it went~~

One day in 2023 (ROC 112), a patient in his 30s came in with a finger that had hurt for 2-3 weeks. There was an obvious foreign body stuck under the nail. We gave a local anesthetic, removed part of the nail, cleared out the foreign body, prescribed oral antibiotics, and sent the patient home.

An 82-year-old grandpa with chest pain

Wed, 19 Feb 2025 00:00:00 +0000

Here's an interesting ECG to share.

An 82-year-old man, complaining of chest pain since the morning, cold sweating, and mild shortness of breath

Yesterday a colleague sent it to me and asked whether it was a STEMI.

I said yes.

But to be more precise, I should have said: this patient doesn't meet STEMI criteria, but has an OMI (Occlusion MI) ➔ the vessel is occluded.

The Angry 50-Year-Old Man

Thu, 30 Jan 2025 00:00:00 +0000

I vaguely remember one day back when I was an R3 resident covering the resuscitation room. An OHCA patient came in.

The resus room being packed was one thing. A level 1 patient gets a spot no matter what.

Halfway through the resuscitation, the family arrived..... and started wailing the patient's name at the foot of the bed.

And then.....

The family member collapsed at the foot of the bed, no strength on the right side........

41-year-old woman, IHCA within 30 minutes of arrival

Mon, 30 Dec 2024 00:00:00 +0000

Let me share a Case a colleague had the day before yesterday. What I find interesting isn't what the diagnosis turned out to be, but how it was handled, which once again shows that emergency medicine is a specialty that walks on thin ice.

A 41-year-old woman arrived pale, short of breath, and tachycardic, in a cold sweat all over. She said she'd had surgery for adenomyosis at another hospital a week earlier. The vaginal bleeding after surgery had already stopped. She had also been transfused at the other hospital, after becoming anemic down to Hgb 4.0.

A 67-Year-Old Auntie with Syncope

Wed, 24 Jul 2024 00:00:00 +0000

A 67-year-old woman whose chief complaint is that she suddenly passed out while exercising just now.

There are lots of causes of syncope, but the final common pathway is an interruption of cerebral blood flow for about 10 seconds ¹.

The table above comes from Auntie Tintinalli's pillow (yes, the Tintinalli textbook) ¹.

The most common causes of syncope are vasovagal (21%), cardiac (10%), orthostatic (9%), medication related (7%), neurologic (4%), and unknown (37%).

The Hidden Threat of a Bee Sting!

Thu, 18 Jul 2024 00:00:00 +0000

I just finished writing the last post, about a case of electrical storm from influenza myocarditis that was eventually shocked with DSD and got ROSC. (Best taken together: portal here)

It reminded me that I had another case with a similar experience. I later presented it at the quarterly joint emergency case conference for eastern Taiwan.

This case happened about 5 years ago.

A 74-year-old woman, brought in by ambulance, wee-woo~~, wheeled straight into the resuscitation room.

Recurrent Vf: Is Prayer All We Have Left?

Wed, 10 Jul 2024 00:00:00 +0000

A little after 6 p.m., we got a patient in prehospital cardiac arrest.

I quickly asked the family what happened. The son said his dad was eating at the dinner table and suddenly collapsed.

EMTs got him to our hospital fast, and our team took him.

Initial rhythm Vf....... the rhythm even the ED cleaning lady can recognize (the old ACLS cliché)

The rest of the team quickly intubated, set up the thumper, got IV access, and started the epi. After CPR the rhythm was still ventricular fibrillation, shocked again ⚡️, continued CPR Started antiarrhythmics Still ventricular fibrillation, shocked again ⚡️ I asked a nurse to bring a second defibrillator and put pads on the patient's anterior chest and back. I was going to do DSD. I held one defibrillator, the nurse pressed the other, and I called 1-2-3 for both to discharge together.

Selfie with My Idol~~

Wed, 19 Jun 2024 00:00:00 +0000

Early on June 19, 2024, I hopped on the Kamalan bus across the street from my hospital and headed to the Taipei International Convention Center for class

A blazing sunny day~so hot

The moment I stepped into the convention center, pure relief~so cool in here!!

Before ICEM2024 officially kicked off, I went to a pre-conference workshop, specifically on Emergency Cardiology.

My First Time Doing That Many Pull-Ups

Fri, 07 Jun 2024 00:00:00 +0000

Posted by @agoodbear

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The Lie-Down Wheelchair

Tue, 05 Mar 2024 00:00:00 +0000

For the past two-plus months, the wards upstairs have been short-staffed, so every day the number of patients boarding downstairs in the ED explodes — they just can't get up to a ward. Waiting for a bed in the ED to get admitted starts at two days. The ED beds are all used up. So we often have 80- and 90-plus-year-olds sitting in wheelchairs getting IV fluids, and once they sit down, you start counting at 5 or 6 hours. They can't lie down. Young people can manage, but the elderly are often utterly miserable.

The trauma that sent the heart into chaos

Tue, 05 Mar 2024 00:00:00 +0000

`A 48-year-old woman, going downstairs, missed a step and tumbled all the way down.`

One simple sentence, and yet it was the start of her tragic story.

Altered consciousness, plus trauma. The patient was wheeled into the resus room.

We put her on the ECG monitor, saw her heart was beating very fast, and right away got a 12 lead ECG

Hmm, the rate on this one is a real problem.

A Young New Mother Who Brushed Past Death

Mon, 04 Mar 2024 00:00:00 +0000

A young mother in her 30s, G3P0A2. This was her only successful delivery so far, and it very nearly became her last.

The baby was breech before birth, so she ended up delivering by C-section.

At noon on the fifth postpartum day, she suddenly developed chest pain. About 10 minutes later her consciousness became impaired, and then she had a seizure-like episode. Right after that, no breathing, no heartbeat.

Anyone who works in emergency or critical care knows that these seizure-like movements aren't really a brain problem. The upstream cause is often a ventricular arrhythmia, like ventricular fibrillation or ventricular tachycardia: not enough cardiac output, so the brain goes ischemic, and that triggers the seizure-like movements (see Fig.1).

A Middle-Aged Woman with Altered Mental Status

Tue, 20 Feb 2024 00:00:00 +0000

Today's case is a fun one~~

I first saw it in the LINE group our Yilan County Fire Department uses for prehospital ECGs.

xx91..... heading to NYCU Hospital

Let's look at this prehospital ECG first

Shaky baseline, very slow rate, looks like there might be STE — that was my first impression the moment I saw a fellow EMT upload this ECG to the LINE group.

A Cobra Came to My House, and It's for Real!!!

Sun, 11 Feb 2024 00:00:00 +0000

In my first year out in the countryside, at Zhudong Veterans Hospital (now Taipei Veterans General Hospital, Hsinchu Branch), something truly terrifying happened.

`A cobra came to my house XD`

So the boss at home (my wife) cut a video to commemorate it😅😅😅

In the end, our EMT brothers caught it and sent it off to live somewhere else🥰

73-year-old man, ongoing chest pain. Does he need cath intervention?

Wed, 31 Jan 2024 00:00:00 +0000

I found this case really interesting, and there's a lot to learn from it. So I pulled it ahead of the many other cases I want to write about.

A 73-year-old man came in in the middle of the night. Because the chest pain was severe, the ED doctor on shift also did a Chest CTA to rule out aortic dissection.

When I took over in the morning, my own habit is to take another look at the ECGs the previous shift did on the handed-off patients whose chief complaint was chest pain. The patient's initial TnI was 0.26 ng/mL, already >99th percentile of URL. A second set of cardiac enzymes was planned for later.

How to detect OMI in 10 Steps?

Wed, 31 Jan 2024 00:00:00 +0000

The basics

The OMI concept was put forward in 2018 by Stephen W. Smith, Pendell Meyers, and Scott Weingart. The main reasoning was that the current STEMI criteria are not a good tool for identifying which patients will benefit from PCI. So they introduced OMI as a better way to find ACO (Acute coronary occlusion).

The new OMI/NOMI paradigm is not limited to the ECG, but the ECG is still the cornerstone of the concept, mainly because it's fast, repeatable, non-invasive, and already in wide use.

Using a knowledge database, and how to build an inspiration-notes system

Sun, 21 Jan 2024 00:00:00 +0000

My note-taking knowledge base (second brain)

A long time ago I used Evernote as my second brain. Later I realized I was using Evernote Clip to grab web pages and save them as read it later.

But all that did was turn a bigger garbage heap (Big data) into a smaller garbage heap (Small Big data)😅. Bottom line, it was all still garbage.

Why would I end up treating these articles — ones I considered important knowledge — as garbage? Because there were so many of them; if I don't sort through them and don't describe the article again in my own words after understanding it, then that article has no value to me whatsoever.

Syntax for Building a Site with Hugo

Fri, 12 Jan 2024 00:00:00 +0000

How to Create Static Site Posts with Hugo

Prerequisites

First, a few things need to be in place:

Install Xcode on your Mac (Windows probably doesn't need it? I don't know about that)
Use Homebrew to install Hugo from the Mac Terminal
Already have an account set up on GitHub
Install VS code and typora
- VS code lets you write markdown code directly
- Typora turns your writing straight into markdown format (sort of a WYSIWYG concept)➔writing posts in this is way more comfortable than in VS code😌
  - When you insert an image in Typora, just right-click on the image to change its size
Already picked out, from the Hugo theme gallery, the theme you want to use and modify
- Download the theme so you can open and run it on your own computer

Once the above is done, you're mostly there～～～

73-year-old man, ongoing chest pain. Does he need cath intervention?

Mon, 08 May 2023 00:00:00 +0000

73-year-old man, ongoing chest pain. Does he need cath intervention?

I found this case really interesting, and there's a lot to learn from it. So I pulled it ahead of the many other cases I want to write about.

A 73-year-old man came in in the middle of the night. Because the chest pain was severe, the ED doctor on shift also did a Chest CTA to rule out aortic dissection.

Heart Warning: Pericarditis vs. OMI — Readmitted

Sat, 25 Mar 2023 00:00:00 +0000

Heart Warning: Pericarditis vs. OMI — Readmitted

Fig.1 The ECG from the first ED visit

Let me tell you about a case a colleague ran into recently. I think there's a ton to learn from it. Let's go panning for gold in this one together~~~

The patient is a 39-year-old man with a history of hypertension, hyperlipidemia, and spontaneous intracerebral hemorrhage.

64-year-old man with epigastric pain, chest pain, and upper back pain

Tue, 07 Feb 2023 00:00:00 +0000

64-year-old man with epigastric pain, chest pain, and upper back pain

Fig.1: Arrival time: 10:02

This Case stuck with me, mainly because of how the patient presented.

A 64-year-old man with a history of diabetes and hyperlipidemia, who'd had three stents placed for CAD. But he hadn't been following up for the past few years.

He started feeling unwell in the morning. The pain began in the epigastrium, then spread to his chest, upper back, and jaw.

Which lead is the most worrying?

Mon, 19 Dec 2022 00:00:00 +0000

Which lead is the most worrying?

Fig.1 ECG on arrival (Revision by PMCardio)

A 58-year-old man had just been released from prison and sent home on the day he got sick. That afternoon, his wife found him collapsed in the bathroom, unconscious.

He gradually came around, with crushing chest pain.

Plots like this are strange. Sometimes joy turns to sorrow; sometimes tragedy piles on tragedy.

Besides STE, Which Other ECG Signs Can Mean an Occluded Artery? (Introduction)

Fri, 18 Nov 2022 00:00:00 +0000

Besides STE, Which Other ECG Signs Can Mean an Occluded Artery? (Introduction)

Let's look at a few ECGs first, then come back to the question above~~

Fig.1 60-year-old man, chest pain for one hour

Fig.2 46-year-old man, chest pain and discomfort since this morning

First, let's ask ourselves: do these ECGs meet STEMI criteria?

If not, would we Call CV man right away?

Arriving hypotensive and hypoxic: is there something wrong with the ECG?

Wed, 07 Sep 2022 00:00:00 +0000

Arriving hypotensive and hypoxic: is there something wrong with the ECG?

Fig.1 ECG on arrival

72-year-old woman, brought to our hospital by ambulance, wee-woo~~~~wee-woo.

That day the ED was, as usual, boarding hell: patients who couldn't get an inpatient bed. After handover from the night-shift doc at 07:30, I already had a whole string of patients on my hands.

About an hour into the shift, triage wheels a patient in from outside.

Answering a reader's ECG questions

Fri, 02 Sep 2022 00:00:00 +0000

Answering a reader's ECG questions

Fig.1 Left: the original ECG, Right: the reader's questions

OnDecember 17 last year I published a post, and recently a reader asked some questions about it. I'll answer them here.

The questions boil down to a few points:

Q1 → Could Af+VT be happening at the same time?

Q2 → I thought WPW driven by A-fib goes down the Accessory pathway. If it takes the same path, shouldn't the QRS complexes be more stable — shouldn't the beat to beat QRS difference be smaller than this?

43-year-old man, chest pain and diaphoresis. Is something wrong with this ECG?

Wed, 17 Aug 2022 00:00:00 +0000

43-year-old man, chest pain and diaphoresis. Is something wrong with this ECG?

Fig.1 ECG on arrival

I remember this case was in April this year, one morning just as the COVID (Wuhan pneumonia, as it's often called in Taiwan) outbreak was taking off.

Back then, every day I was either at the quarantine facility, or at hotels screening migrant workers, or on my way to an ED shift.

OHCA arrives at the ED: do we activate the cath lab?

Sat, 16 Jul 2022 00:00:00 +0000

OHCA arrives at the ED: do we activate the cath lab?

Fig.1

On one dark and stormy night, the fire department EMS radio outside the ED crackled:

This is Yilan 91, we're bringing in a medical OHCA to NYCU Hospital (National Yang Ming Chiao Tung University Hospital) shortly.

The ambulance arrived: a middle-aged woman, roughly 50 years old, pale, with no color in her face at all.

67-year-old woman, chest pain for 1~2 days, severe pain this morning

Thu, 09 Jun 2022 00:00:00 +0000

67-year-old woman, chest pain for 1~2 days, severe pain this morning

Fig.1 ECG on arrival

This case was from a night shift last month, in the last half hour of the morning before I was about to go off duty. Out of nowhere I was told a chest pain patient would be arriving shortly (a VIP, apparently — the patient hadn't arrived yet, but the phone call asking for a favor already had).

Which Practical ECG Websites and Resources Do I Recommend?

Wed, 11 May 2022 00:00:00 +0000

Preamble (rambling)

Back when my attendings were teaching me on the floor, they'd often say there are two specialties in the hospital whose doctors need to be really good at reading ECGs. Cardiology, of course. The second is emergency medicine.

EM has to know a lot: medicine, surgery, OB/GYN, peds, ENT/ophtho, major trauma, EMS, tox, POCUS. Maybe not at a specialist level, but we at least have to have a working grasp of all of it. After all, we can't control where our patients come from; we just wait quietly for them to arrive, relieve their suffering, and find the cause.

Abdominal pain and chest tightness after drinking~~

Wed, 30 Mar 2022 00:00:00 +0000

Abdominal pain and chest tightness after drinking~~

Fig.1

A 67-year-old man had a little kaoliang (Taiwanese sorghum liquor) at lunch, then started feeling chest tightness and epigastric pain~~~

As soon as the nurse finished the ECG, they told me right away: Dr. Bear~~~~ it's a STEMI~~~

ECG reading:

Rate:77 bpm, sinus rhythm, Normal axis, 1st degree AVB

Ischemia ECG findings are as follows:Hyperacute T wave in inf.leads with reciprocal STD change over aVL/I, STD in V1~V6(Maximal STD at V2~V3)

Chest pain: is it Wellen?

Tue, 01 Mar 2022 00:00:00 +0000

Chest pain: is it Wellen?

A 70-year-old man with chest pain for three days. At night it hurt so much he couldn't sleep. Past history of HCC treated with transarterial embolization, still under treatment.

On closer questioning, his upper abdomen was also uncomfortable, and he was a tiny bit short of breath, but chest pain was the main thing.

Going further: rate about 90, P waves upright in Lead I/II/aVF and inverted in aVR, so it's sinus rhythm.

Can You Tell It's an MI?

Tue, 15 Feb 2022 00:00:00 +0000

Can You Tell It's an MI?

A grandma in her 70s. Chest pain started in the afternoon, bad enough that she broke into a cold sweat. She got to the hospital 2~3 hours later.

Usually V1 and II are where you can see P waves most clearly, i.e., what the atrium is up to.

In V1 there seem to be a lot of P waves.

This Is a STEMI. Do You Believe It?

Tue, 28 Dec 2021 00:00:00 +0000

This Is a STEMI. Do You Believe It?

Let's look at a case from my night shift yesterday. A 50-year-old man who worked catching glass eels (baby eels).

Risking your life to earn 200,000 in one night? Glass-eel fishing by lamplight in the dark at Hualien's Dagangkou | ETtoday Travel | ETtoday News (in Chinese)

After reading some reports, I learned that glass-eel fishing is actually that dangerous. I'd assumed it was just kind of cold (standing in seawater).

What Is This Twisted, Distorted ECG?

Fri, 17 Dec 2021 00:00:00 +0000

So what is this twisted, distorted ECG?

A man in his 50s went to a local hospital with palpitations and chest tightness. ECG above. The doctor on shift read it as newly onset LBBB and suspected ACS, so he was transferred to our hospital.

On arrival he was alert, BP 70/40 mmHg.

Never mind what rhythm this is for now — whether you look at the 2015 or 2020 ACLS guideline(Fig.1), it's spelled out clearly: unstable tachycardia should get Synchronized cardioversion.

Can You See What's Wrong with This ECG?

Sun, 28 Nov 2021 00:00:00 +0000

Can You See What's Wrong with This ECG?

Fig.1-ER+0 min ECG

A 74-year-old man with chest pain, hurting so bad he almost passed out. On arrival he said it had been happening a lot over the past few days but always eased off quickly; today it was especially bad.

The ECG machine's interpretation usually isn't very trustworthy, but ECG machines are very sensitive at detecting a pacemaker rhythm¹. Fig.1 is the ECG done within 10 minutes of arrival, and in the long lead II along the bottom row you can see the tiny pacemaker spikes it picked up.

Can a VPC be the little soldier who wins the battle?

Thu, 04 Nov 2021 00:00:00 +0000

Can a VPC be the little soldier who wins the battle?

Let's see why a VPC can be the little soldier who wins the battle

A VPC originates in the ventricle. Like LBBB, a VPC has discordant ST segments, so when there's excessive discordant STE or concordant STE, you need to be careful. There's no evidence that the MSC applies to VPCs the way it applies to LBBB. But in Stephen Smith's experience, the rule works for VPCs very much the way it does for LBBB, though it's a bit less specific¹.

IHCA → Pulmonary embolism, or something else?

Sun, 31 Oct 2021 00:00:00 +0000

ER arrival

IHCA → Pulmonary embolism, or something else?

Let's look at an interesting case.

85-year-old woman with a history of cancer. On arrival: dyspneic, hypotensive, confused.

ECG interpretation (see the image above): unstable baseline

Rate: 120

Rhythm: Sinus

Axis: RAD

New RBBB (not on her prior ECG), 1st AVB

The baseline is unstable, but there seems to be STD over V2~V6 and I/aVL (maximal in V3~V4). It would be clearer if we could repeat it, but given how sick she was, this may already be as clean as it gets. STE over aVR and III.

Chest Tightness That Started 2 Hours Ago: Is It AMI?

Mon, 11 Oct 2021 00:00:00 +0000

Chest Tightness That Started 2 Hours Ago: Is It AMI?

A 56-year-old man with no significant past history. In the small hours of the night he had chest tightness and discomfort, radiating to both arms.

Before handing off to me, my colleague asked whether this one had a problem.

I took a quick look on the spot. As I recall, I said: SB, minimal STE over inf.leads, TWI over aVL but no STD seen, STE over I, STD over V1~V2 with TWI

With LVH, how do you tell whether there's also an AMI?

Tue, 05 Oct 2021 00:00:00 +0000

With LVH, how do you tell whether there's also an AMI?

The week before last, Amal (Mattu) posted a tweet on Twitter showing everyone just how hard it is to pick out a STEMI in LVH. Flip it around, and the secondary STTC of LVH changes the ST segments and T waves in ways that make it even easier for us to mistake LVH strain pattern changes for STEMI. Lately both Amal and Smith have written quite a bit about LVH. There's only one conclusion………

Guess Which Vessel Is Occluded?

Sun, 19 Sep 2021 00:00:00 +0000

Guess Which Vessel Is Occluded?

A case from a while back: a middle-aged man in his 40s. He suddenly collapsed at work.

He was altered on arrival. Vital signs:

Temp: 34.7, HR: 73, RR: 12, BP: 59/34 mmHg, SaO2: 94%

After arrival, he gradually woke up over about 3 minutes, and his blood pressure slowly came back to normal after about 20 minutes.

The arrival ECG is the image at the top of this post

Narrow QRS tachycardia

Sun, 19 Sep 2021 00:00:00 +0000

Narrow QRS tachycardia

50-year-old man with prior Aortic valve surgery. Chief complaint: palpitations (the ER ECG is the top image of this blog post).

Fig. 1

Quick read: Rate about 150, there seems to be a P, but it doesn't look like a typical P wave shape. RAD. Narrow QRS tachycardia, with obvious aVR STE with multiple leads STD

Always remember: the best lead for checking whether there's a P wave is either lead II or V1. Amal Mattu especially likes V1.

Diagnosing AMI in LBBB or paced rhythm: have you filled in all the gaps?

Fri, 10 Sep 2021 00:00:00 +0000

Diagnosing AMI in LBBB or paced rhythm: have you filled in all the gaps?

First, a question

Can LBBB be treated as AMI?

Way back when, we were taught that a new LBBB should be treated just like a STEMI: call the CV man and rush to the cath lab!!!

But study after study showed that's not the case. The proportion of these LBBBs that are true AMIs is low (leading to a high false positive rate), and patients who don't actually have an AMI end up getting PCI or rTPA, which may do them more harm than good.

Whole-'Heart'-ed

Tue, 03 Aug 2021 00:00:00 +0000

Whole-'Heart'-ed

Thread by @shahrukh_bakar on Thread Reader App

An interventional cardiologist replied to a case posted by someone on Twitter. This patient was delayed for 10-plus hours before finally getting PCI. Over those 10-plus hours, the patient's chest pain kept waxing and waning.

The cardiologist pulled together some key concepts for patients like this one (Non-STEMI, waxing-and-waning chest pain, delayed cath). I found it really practical.

My rough translation, plus my own notes from studying ECGs:

No matter what the ECG looks like, ongoing chest pain is a major Red flag sign➡cath lab immediately, no delay
A Q wave does not mean there's no viable myocardium; Q waves can also be a very early finding in ischemia

Key points on Early Q waves

- In one study of STEMI patients, all treated within 12 hours, myocardial salvage still mattered a lot in patients with Early Q waves. The main finding was that patients with STEMI/Early Q waves (even though transmural, irreversible myocardial damage was presumed) still had a better prognosis after ART➡so patients within 12 hours with STE + Early Q waves should not be excluded from PCI

- In Ant.wall STEMI, 50% develop Q waves within 1 hour➡this does not mean a late or subacute MI

Hypokinesis/akinesis does not mean the myocardium is non-viable➡it may be myocardial stunning

A case of out-of-hospital cardiac arrest — what was the cause?

Thu, 17 Jun 2021 00:00:00 +0000

ECG on arrival (Fig 1)

A case of out-of-hospital cardiac arrest — what was the cause?

76-year-old woman.

Arrived at an outside hospital in out-of-hospital cardiac arrest; after resuscitation, she got ROSC. She was transferred to our hospital, and the first ECG on arrival in our ED is shown above (at this point she was about to crash). Her heart stopped very soon after. After roughly another 10 minutes of CPR, she got ROSC again. We did another 12-lead ECG (Fig 2).

Is this Post. Wellens syndrome or De Winter?

Fri, 11 Jun 2021 00:00:00 +0000

Is this Post. Wellens syndrome or De Winter?

From:https://ecg-interpretation.blogspot.com/2021/06/ecg-blog-232-47-what-is-bigeminy.html

The latest ECG blog¹ posted an ECG. The ECG seems to show STE in the Inf. wall, plus STD and large T waves in V2~V3. But Ken Grauer felt V2~V3 looked like reperfusion after a Post.wall MI, which is why the T waves are tall.

When we used to learn ECG, diagnosing a Post.wall MI required a few conditions:

1.R/S>1 in V1 or V2 (i.e., Tall RV1) 2.STD in V1~V3 3.Upright T waves in V1~V3

Medium's Various Formatting Features

Thu, 10 Jun 2021 00:00:00 +0000

Medium's Various Formatting Features

Type ` and the text after it gets a gray background

Type : and then some English, and emoji symbols pop up

Type ``` and a gray-background block appears (you have to type it at the very start)

Press CMD+K on an image to add a Hyperlink to it
Press *+space or 1. → to get indented formatting
Type TK in the body → marks a body paragraph that isn't finished yet (a handy marker)
All kinds of keyboard shortcuts

Medium Keyboard Shortcuts: Demo and Usage Notes (in Chinese)

Roam Tutorial: Episode 4 - Four Ways to Display Reference Material in Roam research

Thu, 10 Jun 2021 00:00:00 +0000

Roam Tutorial: Episode 4 - Four Ways to Display Reference Material in Roam research

Still Hyperkalemic?

Thu, 10 Jun 2021 00:00:00 +0000

Still Hyperkalemic?

Fig 1: K:6.1

A dialysis patient came to the ED short of breath. The X-ray looked like pulmonary edema — probably fluid overloaded. Fig 1 is the ECG on arrival. Potassium: 6.1

When the patient was handed over to me, it was right when the second cardiac enzymes and potassium were due to be followed up.

Fig 2

Is This Wellens Syndrome?

Fri, 09 Apr 2021 00:00:00 +0000

Is This Wellens Syndrome?

70-year-old man, chief complaint generalized weakness. No chest discomfort at all.

You May Have Only Five Minutes to Catch the Reviewer's Eye!

Thu, 05 Sep 2019 00:00:00 +0000

This is the write-up I did after attending InnovaRad's Figures and Figure Legends Workshop in September 2019 (originally posted on their official site).

Author: Dr. Tsao Jian-hsiung, Department of Emergency Medicine, NYCU Hospital (National Yang Ming Chiao Tung University Hospital)

The landmine maker tells you how to dodge the landmines.

Whatever field you're in, there's one way to make huge leaps: follow the right teacher, walk behind someone strong. A strong person can tell you straight up about every landmine they've stepped on — whether it's square or round, how much explosive is inside, how high it can blow you — every last detail.

ER Bear's Heart Notes

No STE, so what makes you say it's occluded? (Six principles for reading the OMI ECG)

Every ED Is Raising Pay, So Why Can't Anyone Find Staff? (Part 2): Patients Can't Get Admitted, and Money Can't Buy People Back

Goodbye, Type 1~5 MI? The Fifth Universal Definition of MI, and what everyone on X.com is fighting about

Every ED Is Raising Pay, So Why Can't Anyone Find Staff? (Part 1): The Misreported Number, and a Patient Population That Got Swapped Out

On the ground: is the ED broken, or just busy?

Moving My Script Next to the Audience's Faces: I Built SlideCue, a G2 Glasses Plugin, and It's Live

The Sun Can Be Computed, the Clouds Can't: Using AI to Work Out Where to Stand to See the Sun Rise Over Guishan Island

The Casino Next to the Church: Three Talks From a 2026 Value Investing Conference in Taiwan

Three Talks, One Through-Line

SpO2 Drops to 72%. Do You Carry the Kid Off the Mountain? A High-Altitude Medicine Lesson with 21 Junior-High Students on the Jiaming Lake Trail

We were treating ACS, so how did it turn out to be aortic dissection? Two Type A Aortic Dissections disguised as STEMI

Today I want to cover two cases at once. Both of these patients started out down the ACS diagnostic path, and we treated them by the most standard protocol; but the real killer, from start to finish, was never in the coronary arteries. It was in the aorta.

If the Source Isn't Cleared, the Best Antibiotic Won't Save You: Notes from an ED Antibiotics Seminar

Datong, Yilan, Jiuliao River Nature Trail: Walking to Gaba Waterfall

Hiking the Paoma Historic Trail in Jiaoxi

Aerial Footage of the Sanqi Meijing Trail, Dongshan

An ER doctor on the operating table too: my presbyopia + myopia laser surgery (post-op day 3 edition)

Here's how it started~~

1. Physique competitions: me, glaring on stage

Notes on Raising a Lobster: Building an Automated Knowledge-Management Workflow with WhatsApp + Discord + OpenClaw

Raising a lobster: setting up the messaging interface is a lot of fun

59-Year-Old Man, Chest Pain, Severe Back Pain

Today we're looking at a really interesting case. There's a lot to learn from these ECGs.

Aerial Footage of the Luodong Flood Diversion Weir, Yilan

Yilan Friendship Lettuce Log

An MI, and Now This Rhythm: What's Going On? What Do You Do?

My fantastical journey through the courts: accused of aggravated bodily harm

Here's how it went~~

An 82-year-old grandpa with chest pain

The Angry 50-Year-Old Man

41-year-old woman, IHCA within 30 minutes of arrival

A 67-Year-Old Auntie with Syncope

A 67-year-old woman whose chief complaint is that she suddenly passed out while exercising just now.

The Hidden Threat of a Bee Sting!

Recurrent Vf: Is Prayer All We Have Left?

Selfie with My Idol~~

My First Time Doing That Many Pull-Ups

The Lie-Down Wheelchair

The trauma that sent the heart into chaos

A 48-year-old woman, going downstairs, missed a step and tumbled all the way down.

One simple sentence, and yet it was the start of her tragic story.

A Young New Mother Who Brushed Past Death

A Middle-Aged Woman with Altered Mental Status

A Cobra Came to My House, and It's for Real!!!

A cobra came to my house XD

73-year-old man, ongoing chest pain. Does he need cath intervention?

How to detect OMI in 10 Steps?

The basics

Using a knowledge database, and how to build an inspiration-notes system

My note-taking knowledge base (second brain)

Syntax for Building a Site with Hugo

How to Create Static Site Posts with Hugo

Prerequisites

73-year-old man, ongoing chest pain. Does he need cath intervention?

73-year-old man, ongoing chest pain. Does he need cath intervention?

Heart Warning: Pericarditis vs. OMI — Readmitted

Heart Warning: Pericarditis vs. OMI — Readmitted

Let me tell you about a case a colleague ran into recently. I think there's a ton to learn from it. Let's go panning for gold in this one together~~~

64-year-old man with epigastric pain, chest pain, and upper back pain

64-year-old man with epigastric pain, chest pain, and upper back pain

Which lead is the most worrying?

Which lead is the most worrying?

Besides STE, Which Other ECG Signs Can Mean an Occluded Artery? (Introduction)

Besides STE, Which Other ECG Signs Can Mean an Occluded Artery? (Introduction)

Arriving hypotensive and hypoxic: is there something wrong with the ECG?

Arriving hypotensive and hypoxic: is there something wrong with the ECG?

Answering a reader's ECG questions

Answering a reader's ECG questions

The questions boil down to a few points:

43-year-old man, chest pain and diaphoresis. Is something wrong with this ECG?

43-year-old man, chest pain and diaphoresis. Is something wrong with this ECG?

OHCA arrives at the ED: do we activate the cath lab?

OHCA arrives at the ED: do we activate the cath lab?

67-year-old woman, chest pain for 1~2 days, severe pain this morning

67-year-old woman, chest pain for 1~2 days, severe pain this morning

Which Practical ECG Websites and Resources Do I Recommend?

Which practical ECG websites and resources do I recommend?

Preamble (rambling)

Abdominal pain and chest tightness after drinking~~

`A 48-year-old woman, going downstairs, missed a step and tumbled all the way down.`

`A cobra came to my house XD`