I noticed a telemetry fixed to a patient with 5 electrodes for cardiac monitoring.
The next day she told the nurse that one of the light is on for 3 hours. But the nurse ignored her. She acquired chest pain at 4am but was dismissed as MSK,
The day after, the same thing happen, this time, 4 hrs was lost despite informing the "monitoring" nurse (the patient did not realise that the wires were unhooked because she was hooked with IV and IDCs too). Same chest pain occurred, MSK was diagnosed at 2am.
On the third day, the patient, who lost 7 hrs out of 48 hrs was cleared by the "cardiologist" and discharge immediately.
The patient asked the cardio why despite the lost of 7 hrs and "MSK", she was discharged?
He said only black electrode matters and none other.
The patient queried why then the need to fix another four electrodes?
He walked off pretending the question never existed.
Is his diagnosis correct? Only the black electrode matters and that it is the only electrode that confirm if a patient has or has not acquired heart problems?
Are the other four electrodes for cosmetic reasons only?
Thanks - Mariam
Hi,
I will have to make several assumptions because not enough information is provided to be sure. For example, no indication is given as to the particular locations of the remaining electrodes that were attached in the two cases where 2 electrodes came off. It isn't stated if different electrodes came off in the two cases. Did the pain reported by the patient occur only during times the electrodes were off?
A cardiologist can determine if there are heart issues based on a single Lead, (e.g., Lead I, Lead II, Lead III). In fact, there are 3-electrode monitoring systems. Typically, an issue is seen using a 3- or 5-electrode system and the cardiologist wants to isolate the location of the issue, then a 12-lead ECG may be ordered. Some cardiac arrhythmias, such as periodic ectopic beats may not warrant an 12-lead ECG.
Based on the information you provided, the system is using the IEC electrode coloring convention, not the AAMI convention (typically used in USA). see http://intl.welchallyn.com/documents/Cardiopulmonary/Electrocardiographs/CP100/2007_11_12_ElectrodePlacementPoster.pdf
Some background: By convention, the right-leg electrode is the "reference electrode" All measurements are made relative to this common reference. e.g. Left-arm - right leg; right-arm - right leg, left-leg - right leg. chest - right-leg. For many systems if the right-leg electrode is removed all monitoring stops. (Other systems can move the reference electrode location in the event the right-leg electrode is removed, but that is outside the scope of this response). From these electrode measurements, standard Leads (e.g. Lead II = (right arm - right leg) - (left leg - right leg) = right-arm - left leg) are calculated.
If we assume that the telemetry system used stops monitoring when the right-leg electrode is removed, but would continue measuring Lead II (if for example the left-arm electrode and chest electrode were removed, we can understand that the the most import single electrode is the one on the right leg.
Since it is not stated what electrodes came off: Assuming the chest (V-lead) electrode came off and one of left-leg, right-arm, left-arm, then the system would still be able to derive one valid Lead (Lead I, Lead III, Lead II, respectively). On the other hand, if the chest electrode remained on and two of the three electrodes from left-leg, right-arm, left-arm were removed, then the system cannot generate a standard Lead: none of Lead I, II, III can be generated. With a chest electrode, and the two leg electrodes connected, for example, a vector from the chest electrode to the left-leg could in theory be calculated, but that is not a standard Lead. The V-lead is typically used to make measurements of ST-segment elevation, but this can be measured with only a few heartbeats. Note diagnostic ECG systems typically take a 10-second sample that might be as few as 5 or 6 heartbeats.
Yes, we may consider it bad form for a clinician to walk off leaving an unanswered question from a patient.
Without seeing the ECG waveforms, the question of the correct diagnosis can't be answered.
41 hours of ECG monitoring is often enough to detect any issues. Again, without knowing the patient history and seeing the ECG waveforms, one can't decide if 41 hours were sufficient. IF the chest pain complaints occurred during at least part of the time when all electrodes were attached and/or if the chest electrode was one of the electrodes that detached, then we would know a valid Lead was measured during the complaint. In that case, the missing data seems relatively unimportant.
All electrodes contribute to building various clinical Leads (ECG traces), but not all electrodes must be connected to have at least on valid ECG trace.
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