Last year I had ACLS. The week before I took it, I did BLS which was awful. I sat in a class of 30 people watching videos. They’ve gotten much better, but oh man! Then they’d test each person one at a time on the floor while everyone else watched and waited. It was b-r-u-t-a-l.
A few years before that I remember watching my then 8-year-old son’s baseball tryouts. At the end of the tryout, the coaches lined all the kids up on the pitcher’s mound. Then, one at time, they had them each throw 15 pitches. The same awful feeling swelled inside of me. Can we please DO something? Anything?
Anyway, I was not looking forward to ACLS, and that year it just so happened to fall on my birthday. No big deal, I just didn’t want to be stuck there all day dying of boredom. Thankfully, my instructor was fantastic!! I wish I had her last name but from here on out we’ll call her ACLS Kathy. She was in EMS for 100 years and has been teaching ACLS for 80 years. She knew what to teach and how to teach it, so that you might have a shot of remembering it in the field one day.
We didn’t comb through the book discussing minutia. We cooked along, and I remember more from that course than anything I’ve been through before. Part of her plan was cut it down, so you don’t get lost. Which is something I love! But, that’s not what I want to talk about today.
Today, I want to talk about ACLS Kathy’s heart block analogy that will save you from ever getting these questions wrong ever again. You’ll be looking forward to them and smiling when you see them.
Here we go.
First degree is easy. Everyone remembers that one. Signal is delayed through the AV node, but it is consistent. The P wave is always just a little too far from the QRS because it is slow getting in. Think the checkout line. Normal line vs line with little old lady behind the register. She moves everyone through, but it takes a little longer. (That one isn’t Kathy’s, it’s mine).
Second degree is where it gets complicated, but it really isn’t. Second degree WILL ALWAYS HAVE A DROPPED BEAT!
This is something I never realized until this course. Just never made the connection. If it doesn’t drop a beat, it’s either 1st or 3rd degree which makes it SO much easier. This was the single biggest takeaway for me.
2nd degree Type 1 = Wenckebach or Mobitz I. Here are two little sayings that may help you remember 2nd degree type 1…
1) Longer longer longer drop, now you have a Wenckebach (This comes from Carol Sadley who is a professor at Rutgers and does the cardiology section of that program)
2) Wencky Wencky Wencky — Bach ( from ACLS Kathy)
Here the P wave gets slower and slower and slower, then it doesn’t get through at all. Then it starts again. (Ok, the P wave doesn’t get slower. The signal slows down after the P wave through the AV node, so there is a delay between P wave and QRS)
Kathy’s analogy here was sending your new assistant out for coffee. Day 1 you get this great idea that your assistant could go out to Starbucks and get real coffee for the both of you. Day 1 he comes back in 15 minutes. Day 2 he stops and gets himself a magazine on the way, and it takes him 30 minutes. Day 3 is a beautiful day and he decides that walking would be better than driving, and it takes him 45 minutes. Day 4 he leaves with your coffee money and never comes back.
Longer, l o n g e r, l o n g e r , drop
What about 2nd degree type 2 or Mobitz II?
P wave stays constant, but some beats get dropped. Standing outside a club and the bouncer lets the three people in front of you in, and then kicks you and your friend out of line. Then lets the next three people in and kicks the 4th and 5th dude out line.
Third degree…
P waves have no relationship to QRS but remember there are also no dropped QRS’s. They are each going at their own rate and don’t communicate at all to each other.
The day turned out to be really good. Passed my class and got to my baseball game on time. 🙂
This discussion about heart blocks was worth me attending the whole day. I hope you see the value here. It can save you hours of studying and lots of missed points. Every few years I relearn this for one reason or another, and this time it’s mine forever.
Want to make sure you hang on to what you’ve learned? Retain more of what you’re studying? Study in less time and very possibly get better grades? It isn’t magic. You have to do the work, but I can help. The course I put together, Maximize Your Time and Efficiency, will help you to do just that. Take a look here:
MYTE
Brian Wallace