You don’t know how many times I fucked up with this drawing. I was so distracted that I’ll mess the ink everywhere, I had to cover a lot of mistakes with white ink, paint and such. However it ended up looking pretty well despite all the problems lol.
The Matter of Britain; Inverness, Caerleon and London, United Kingdom. 1941, Nazi occupied Britain, 12 weeks after the axis victory of the Battle of Britain. The battle lost, the King missing and the Nazis fully occupying England, Wales and the south of Scotland, the capital had been compromised.
INVERNESS, SCOTLAND. The resistance army moves further up north to the harsh winters of the Scottish Highlands and settles in Inverness. They are exhausted of strength and options, their supplies of weapons and food running low and their contact with the remaining allies becoming strained. Merlin sat in a corner and watched his comrades sing songs of heroes and victory. He wondered how they could laugh and sing knowing they would die soon and remembered a man, a long time ago, telling him “A warrior learns to enjoy each day as it comes.” “Because it may be his last” Merlin repeated aloud, then laughed and laughed and laughed. He kept laughing until he was longer laughing but screaming, intense beams of light coming out of his fingertips and shattering the windows of the small pub. His magic was alive. He was alive. When the blinding light ceased Merlin found himself in the middle of the room with the guns of his comrades pointed towards him.
CAERLEON, WALES.He was alive. “Merlin”, was Arthur’s first words, and would be his last. From the other side, he had seen the world change, he had seen revolutions and revelations, deaths and births, the world was ever changing, but Merlin was a constant. He had felt Merlin’s joy when he eloped with a young French noblewoman after she escaped a terrible betrothal to her cousin, and felt his grief when she died suddenly three weeks later. He had laughed when Merlin fell hopelessly in love with Oscar Wilde and dyed his hair blonde because Oscar had once mentioned the beauty of his mother’s blonde hair. He had felt Merlin’s sorrow and his own more when Merlin visited him at the lake three times every year. And at that moment, standing in front of a confused looking woman, dressed in wet armour and a sword in his hand, he had felt Merlin’s fear.
LONDON, ENGLAND. 4 years after the Axis victory of the Battle of Britain and 6 months after the allied victory in the second world war. Th Resistance army flag still hung from Palace of Westminster. The mood in Britain changed after the war, the King abdicated, and the monarchy was abolished. The republic was born, and the public democratically elected a new leader. It was this day 2 years and 6 months ago the resistance, and allied armies regained control of the capital, with Arthur as their lead and Merlin, their secret protection and weapon. They attacked with a battle cry that became immortalised “We fight for the future. The future of Albion. The future of the United Kingdoms!”.
CAERLEON, WALES. It was this day 1 year, and 6 months ago Arthur had wrapped Merlin in his red cloak and carried his body to the shore, laid beside him on an oak boat and drifted off towards a familiar Island on a familiar lake.
I’ve had countless sessions and lectures on ECGs. I don’t know how many websites I have bookmarked, or how many times my eyes glazed over reading Dubin. I’m also terrible at cardiology. I was on my way to accepting my fate of being horrible at ECGs forever, until I had a life changing session on ECGs taught by a great ER doc. I want to post it here because it was probably the most useful thing I learned in med school, and it will stick with me for the rest of my career.
WHEN LOOKING AT ECGs FOR THE FIRST TIME:
1. One ECG is never enough. Always get old ones for comparison. If none available, do another one. Because. One ECG is never enough.
2. RATE. Look at the number on top of the printed ECG. It’s stupid not to use that number. Yes, you should know the rule, 300-150-100-75-60-50. People say you shouldn’t trust the machine because… well, it’s a machine, and it can make mistakes. This is true. I don’t like to look at their “diagnosis” until I have gone through it myself. But the rate is just a number. Plus you should be able to eyeball it and be able to tell if it’s tachy, brady, etc. If the machine is telling you it’s 200 and if it looks tachy, then it’s probably the right number.
3. RHYTHM. Is there a p-wave for every QRS and a QRS for every p-wave? Is the p-wave upright in lead II and down in aVR? Good. Done. BOOM. It’s sinus rhythm. ***if you cannot clearly see the p-waves then you cannot call sinus. move on. 4. AXIS. Again, look at the number at the top of the page. If it’s between 0 and +90, then it’s normal axis. If the number isn’t provided, or if your preceptor doesn’t believe in the convenience of machines/technology, look at the QRS complex of lead I and lead II.
up in lead I, up in lead II: normal axis
up in lead I, down in lead II: left axis deviation (most common causes are left anterior hemi block and left ventricular hypertrophy)
down in lead I, up in lead II: right axis deviation (most common causes are right ventricular hypertrophy…PE)
5. did someone say HYPERTROPHY?
look at V1
is the R wave tall? (greater than 7mm?) right ventricular hypertrophy.
is the S wave tall? (greater than 11mm?) left ventricular hypertrophy.
look at lead II
is it wide? left atrial enlargement.
is it tall? right atrial enlargement.
7. PR interval
should be between 0.12 sec and 0.2 sec (3-5 small boxes). I used to always get this interval and QRS complex (less than 0.12 sec) mixed up. Think: atria depolarizing + shit getting to ventricles is gonna take longer than ventricles depolarizing. [2 things happening] versus [1 thing happening]. [0.12 sec-0.2 sec] versus [<0.12 sec].
long PR interval means there’s some sort of block at the AV node.
1st deg block. PR interval is long. everything else is normal. cool.
2nd deg block
type I: PR interval progressively gets long. eventually a dropped QRS.
type II: PR interval is constant, but randomly dropped QRS.
3rd deg block “complete block”
there is no association between P waves and QRS. they run separately. **QRS does NOT have to be wide. Just look for P wave/QRS complex disassociation. I sometimes get this and 2nd deg type II mixed up. The only difference I try to remember is that PR interval is constant in 2nd deg type II, but is variable in 3rd deg.
8. QRS complex
narrow or wide?
narrow: good. signal coming from somewhere above ventricles.
wide: think BBB (bundle branch block)
LOOK AT V1 ONLY.
if the last deflection of QRS is DOWN, then it’s a left BBB
if the last deflection of QRS is UP, then it’s a right BBB. super easy. no more of this bunny ears crap.
9. ST segment
always look from J point, and compare with the isoelectric line of T-P segment (NOT PR interval).
look for reciprocal changes of the heart. if ST elevation in lateral leads, could see ST depression in the septal leads. PAILS:
posterior up, anterior down
anterior up, inferior down
inferior up, lateral down
lateral up, septal down.
LBBB can look like STEMI. How to tell?
disconcordant changes is normal. (QRS and STEMI on opposite sides of the isoelectric line.)
concordant changes is abnormal.
massive discordance is abnormal. (STEMI is greater than 5mm)
this isn’t that important. Moving on.
Inferior STEMI. Could right ventricle be involved?
DO NOT GIVE NITRO DO NOT GIVE NITRO DO NOT GIVE NITRO.
order a 15 lead
is STE in lead III > lead II? likely RV involvement
INFERIOR MI? 15 LEAD NO NITRO
INFERIOR MI? 15 LEAD NO NITRO
INFERIOR MI? 15 LEAD NO NITRO
10. T waves
is it inverted? indicates recent ischemic changes.
11. Q waves
is it significant? indicates old ischemic changes. will likely be present if followed rule number 1 of reading ECGs. (1 ECG is never enough= look at old ECGs).
I literally go through this list of 11 points in my head when I’m reading an ECG, regardless of whether or not I have an atrial flutter jumping at my face or if I see a massive anterolateral STEMI. Obviously I needed background knowledge on ECGs and the physiology of the heart before constructing this list, but this basic checklist has been very, very useful to me so far. It might look lengthy, but it doesn’t take a lot of time at all- a patient is not likely going to have all these issues with their heart.
Anyway. I still don’t love ECGs, but it feels pretty wonderful to be able to be able to evaluate it in a systematic manner, and get the theory behind interpreting the scribbles of an ECG reading. I don’t get these moments as much as I would like to, but it’s that crosspoint where my classroom learning actually meets real-life applications that gives me happy brain-gasms for days. I love knowing things and more importantly, knowing why.
natgeotravel 📽 by @renan_ozturk // The full spectrum of summertime conditions in the climbing hotspot of the East Creek Basin, Bugaboos Provincial Park, BC, Canada. On this particular day we had sun, classic afternoon thunderstorms and then a lighting show illuminating a cloud layer below the Milky Way. A sheet of green Northern Lights even floated through late in the night. This 4-axis motion control timelapse (which took most of a day to set up with @robfrostmedia@jimmy_chin@conrad_anker@alexhonnold) even caught some climbers starting to climb the majestic South Howser Tower by headlamp. As technology and the demand for virtual reality content rises everyday, I can’t help but dream of shooting scenes like in this and being able to look around in full 360°!
roderich’s mansion would probably be a mess if he was left to his own devices, but it is usually in immaculate order, considering that he will find the smallest and most mundane of excuses to make ludwig come over (ie retrieving a jar from a shelf that is slightly higher than roderich is willing to expend the effort to reach). there is an austere atmosphere to the place, though it feels somewhat more welcoming when roderich is playing, or if he has been baking recently. there are beautiful views of the mountains from many of the windows.
if roderich had his way, his home probably wouldn’t even have electric lighting, but ludwig tries to drag him into the 21st century whenever it is pragmatic. it’s for this reason that the kitchen in particular is full of modern appliances, and he even owns a fairly new computer, even if he barely ever uses it.
Consider this: A superhero Au where Alfred starts out as a super-strong preteen whose strength could only be compared to his strong sense of justice. Ultimately his goody-goody ways leads to sacrifice in his teenage years which dooms him to a path of crime.