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Letter to the Editor

Beware of Who is Ordering ECGs and Why

doi: 10.1097/01.EEM.0000578664.41003.1a
Letter to the Editor


Kudos to Dr. Edwin Leap for a great article! (“Pile on the Fear, the ECGs, and the Debt,” EMN. 2019;41[6]:9; He articulated my own concerns eloquently, especially the number of ECGs performed, the reasons for doing them, and the overwhelming number of normal or baseline results.

After practicing emergency medicine for 36 years, I have retired from clinical practice and now teach advanced electrocardiography. I have found that many physicians grossly overestimate their skill at ECG interpretation. Reading and interpreting an ECG are two completely different skills. Interpretation involves arriving at a differential diagnosis, a presumptive working diagnosis, and a suggestion of other problems to watch for based on the findings.

Most physicians have never had any formal ECG training. Some rely solely on the machine diagnosis, while those who do look at the ECGs frequently overlook or misinterpret subtler pathological findings (not only EPs but also hospitalists, critical care physicians, and even some cardiologists). As you do the backup reading of a large number of unremarkable ECGs, I'm sure you have thought, “How many of these patients really had an acute ischemia that just hadn't presented yet? Did the ordering physician understand that a normal ECG cannot rule out an acute MI? And who in triage ordered all these ECGs?”

I once had an 18-year-old patient who had developed a significant mastitis from breastfeeding. She arrived back in my area with a 12-lead ECG. When I asked the triage nurse who ordered the ECG, I was told, “Well, she has pain in her right breast, and her breast is on her chest, so duh! She has chest pain!”

It's really difficult to argue with logic like that!

Jerry W. Jones, MD


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