Next, we have a very distinguished lecturer, as in distinguished fellow, as of last night. Our next speaker is Dr. Warren Silverman. You don't know who he is, I don't know what to tell you, you've been living under a rock. Dr. Silverman is currently performing aviation medical examinations and consultations after a very illustrious career in the U.S. Army, he's been working with the FAA, he has performed hazard analysis for all the fatal aircraft accidents, he was the manager of the Occupational Health Clinic at the FAA Civil Aerospace Medical Institute, or CAMI, he's been the manager of the Aerospace Medical Certification for the FAA, he was Oklahoma State Air Surgeon responsible for the Air National Guard Healthcare, he's past chair, that's who I replaced, you can't really replace Warren, but I'll try, he's the past chair of the Aerospace Division here at AOCOPM, he is the chair of the Fellows Group at ASBA and VP of Education and Research, and he has been the president of the Civil Aviation Medical Association, for the longest time he was serving as the Aerospace Medical Education Division at the FAA, he taught me when I was a resident, so he's going to be talking about EKGs and aerospace medicine, so give it up for Dr. Warren Silverman. Hey. Hey. Okay, whoops, uh-oh, I may have to call Howard already, oh no, good, okay, so first of all I want to ask how many A&Es are in the audience, there's a few, okay, there's a few, so I am currently doing what most government people do when they retire from the government, I'm contracting with the FAA, so I'm seeing, I've had a contract with the FAA before I, when I retired the first time, and then I got one when I retired the second time, so I'm currently reading the electrocardiograms for first class pilots, actually the backlog, so fortunately it's not my problem anymore, but I'm very, very hesitant about what I ask for workups since I can imagine what, having pilots whine to me all the time now, I can imagine what a pilot would think when they say, well, your EKG from January of 2023 shows the following, so, but, you know, we do do it, so, but most of the stuff I see is normal. Obviously, all right, so the one thing I've noticed for those that are A&Es out there is that, and I'm not saying it was better when I was there, but I'm not seeing A&Es right in the explanation box, the, what they think the EKG looked like, and when, when they, when they do see something, don't say that the FAA may ask for a workup, do the freaking workup, because then you could issue your pilot after that, because the FAA, I hopefully, has still gone on record as saying that if you find something and you work it up and you get the answer before the 14 days, then you can issue the pilot, and oh, by the way, please send the material in, and oh, by the way, if you have a military pilot, okay, that was prior military, and he has like a bundle branch block, and this is his first EKG, and you say, and he tells you that he was worked up in the, in the Air Force, for example, get the freaking workup, because if I don't see it, I got to ask for it, okay. I'm, I'm thinking of things that I see all the time. If you get an EKG, now, I lowered, now you're going to, I'm going to show you, start off by showing you the normal variants, and that's what it is. It's considered a normal variant, and you don't have to work it up, okay, so you should have this. I mean, we did an informatic thing when I was doing our A&E minutes, which I'm still doing, and that's another thing I have a contract with. I do what is called the A&E minute, so if you, if you get an EKG, and the heart rate is 30, don't put 30 in the pulse block unless you tell me Joe is, you know, is a runner. I love it when an A&E will write, you know, the pilot is a runner, or participates in marathons, or very fit, you know, otherwise, what, if I see somebody with a heart rate of 30, even though maybe last year's was 30, I'm assuming that whoever looked at it last year, which was probably me anyway, but which case, if I saw it, I would have worked it up, so don't use or tell, and tell your, if, if a nurse or the tech does an EKG, don't just copy down the rate from the EKG without, take a freaking pulse, okay, or at least, or at least say something in block 60 that, that I, that, so, because believe me, your pilot, I'm, I know now that, you know, they used to whine to me, and the A&Es would whine to me, now I see why they were whining, because I whine too, so, all right, so, let's do this, so, yes. Can you see block 60? Yes, oh, no, I see, I have DIWS in, at home right now, sitting on, I see the whole damn thing. Okay, awesome. I could look at, I could look at everything that, that one of the docs at the FAA look at. I don't, I'm trying to, I try to be, I am, I'm very good, I'm going, I'm not lying, even though I had resistance training, I'm, I have, I, if I have, if I have one of my pilots is complaining to me, not hearing from the FAA, I force myself not to look him up in the system, okay, I don't, so, so, plus that way, I, it's plausible deniability, and I can curse at the FAA, and they can, and then, you know, everybody's happy that, all right, so, let's, oh, here we go, we're starting off, all right, so, let me, all right, here we go, so, here's the list of normal variants, okay, so, let's, first of all, listen to the, the limitations. I want to tell you, you know that the FAA wants you to have, like, an interpretive EKG done, look at, I, I look at, I, I, I look at the, the numbers, because it's a computer, the numbers, the intervals don't lie, although sometimes they do, so, if, if I see where they say that a QRS complex is, you know, 0.136, and I look at that, I say, that's not 0.136, it's, it's rare that it happens, but I don't, I rarely look it over at the diagnoses, because most of the time, they overread, and sometimes they underread, but most of the time, it overreads, I, I sometimes glance over there, but I, I do my own thing, okay, so, here we go, all right, so, sinus bradycardia, and I lowered it, okay, because most pilots these days, most are in good shape, is anything greater than a heart rate of 44. Sinus tachycardia, anything less, is less than 110, so, 110 and over, gets a workup, unless you tell me something, Joe is nervous, every time he comes in, Joe is nervous, and I, I mean, I, I've had some guys come in, and they're, it's all, it's up, okay, so, just tell me that, all right, a low atrial rhythm, I'm going to show you what that is, that's a normal variant, recently, in the last two weeks, I saw somebody work somebody up for this, you don't have to work it up, I'll show you what, what looks, what looks like a low atrial, it's very easy, PVCs, you got to work them up, if there's two or more on a EKG, and it's never been worked up, if it's been worked up before, you don't have to do anything, okay, it's for information only, but if you got two or more, you work it up, okay, and I'll tell you what the workup is in a bit, PACs, they don't work them up anymore, unless the pilot's symptomatic, okay, first degree AV block, all right, so this, you would not believe the storm that this caused, because of some nincompoop flight surgeon at Rucker, who, Tucker, who normally does good, interviewed her, she didn't even know what the federal air surgeon was even called, but nevertheless, the first degree block, and it's been this way, if the, so remember, the PR interval, but you'll notice the Europeans, it's P, though a lot of times the EKG will say the PQ interval, it's the same thing, if it's, it's 0.2, anything over 0.21 is abnormal, okay, but the FAA doesn't work it up, unless it's greater than 0.30, okay, milliseconds, and that is not, by the way, you guys probably know this, since you're preventing medicine, that's not one of the side effects of COVID, is a prolonged PR interval, okay, that's the least of their problems, if they have cardiac side effects, okay, an incomplete right bundle branch block is a normal variant, an incomplete right bundle branch block that becomes complete is, you don't do anything about it, okay, and we'll talk about the intervals, because that's a lot of this, an ectopic atrial rhythm, you know, that's where you have multiple different looking P waves, it's normal variant, sinus arrhythmia is a normal variant, left axis deviation, okay, and I'll show you some of this, I'm going to show you a drawing, a drawing that when I saw this in a textbook, and I can kick myself in the butt for not bringing that, because I left a bunch of my stuff in my practice when I was in with the guys in Arizona, but whatever, but I remembered it from memory, and I've never seen that picture somewhere else, but the picture that I drew for you, which is rudimentary, but you'll get it, otherwise I would have to ask Jeffrey for a word or something, so I figured, oh, I tried something that my daughters bought me for Christmas, so as minus 45, so minus 45 and above could be a left anterior hemiblock, less than minus 45, just it's a left axis deviation, you don't worry about it, just don't worry about it, right axis deviation, anything greater than plus 120 could be a left posterior hemiblock, anything less is just right axis deviation, yes, and a combination of things, it depends, I'm not going to work somebody up, okay, indeterminate axis, and you see a lot of this, and I've noticed that the computer on these EKGs will give you an axis, but you look, and if you see, and I can explain it to you, but you know, what you do is you count the number of boxes above, that's plus, the number of boxes below, and whichever ends up being the largest, if you subtract the two, that's what the axis, that's what it would be, and then you add all of them up, and the tallest one, or the one with the most positivity is what the axis, where the axis will lie on the graph, so, but a lot of indeterminate axis, and the computers don't, will say it, but the coding at the FAA doesn't have one for that, so, and I've asked them, I've added a few, but I didn't add this one, left atrial enlargement is a normal variant, an intraventricular conduction delay, that's a QRS complex that's greater than 0.120, 0.120, but I'm telling you that the EKG interpretive things on the machine is going to call something like 0.118, they may say, is a intraventricular conduction delay, but this, all this stuff that I tell you came out of the Air Force, it was proven by multiple EKGs, and what was that, what else was I going to say, oh, I'll remember, my mind went to Bermuda for a minute, okay, short, short QT, a short QT interval with no history of arrhythmia, you know, could be, you know, some sort of drug or whatever, or like, electrolyte imbalance, it's a normal variant. Early repolarization, normal, that's seen most times in younger folks, is a normal variant. Low voltage, and low voltage is only for the limb leads, so you look at the limb leads, always make sure, because I've seen the nincompoops that are interpreting the EKGs, which are techs at the FAA, say that low voltage, what they call low voltage, they don't even know what they're talking about, if you add up, remember I told you that the isoelectric line is 0, the boxes above are plus 1, 2, 3, 4, all the way up, and below is, you know, 1, 2, 3, 4, and you add them up, and if they're less than 5 millimeters, 5, okay, if each one of the complexes in the limb leads is 5 millimeters or less, then it's low voltage. However, make sure, because I think I'm going to do an AME minute on this, is when you look at the EKG, you're going to see, look, I'm sure I may be talking below some of you guys, but I want you to just know, okay. You'll see the EKG, you know, the machine is set. Yes, what? You're like the right of the wall. This is, you can write here. Here's your marker. Oh, cool. Very good. Let me put one on the lapel. Yeah. Don't have it in. Yeah, that's good. I'm a wandering Jew, is that it? Sir, I am. Yes, look. You said one. Oh, yes. Are you gonna put me on the lapel? All right. He's there. Okay, let's make sure it cooks. So it's off. It's off. All right. Oh, no. Can you hear me? It's there. I think it needs a battles. Can you hear me? Well, you know, I got a big enough. I think these guys will be able to take them. Oh, that's good. But I can't. All right. You're fine. Let me just, I can't draw on that wall. They won't like that. Okay, so I will draw. Okay, so the machine is set. You want it set at 10 millimeters, meaning that, and look at this, because they'll call the, the people at the FAA will call low voltage, but they didn't look over to see where the machine shows you how many millimeters it's set at. So when you see the little, and normally it's at the beginning, sometimes at the end. If you see that and you count, oh yeah, it's 10 millimeters. But if you see like this, okay, that's five millimeters. There's five, you know, remember each one of these blocks, you know, you have the graph paper and each box is one millimeter. Okay. Right. Okay. Not very good squares, but each one, one, two, three below, one, two, three above, that's zero. But you'll see where it does the 10 millimeters. And lots of times if you look up top or you look at the bottom of the graph, it says 25, you want 25 millimeters, 25 millimeter per second speed, not 50. Europeans, they like 50. Oh, I beat them up good. Most of them do the 25 now, so always look over at the side to see or the end to see what it's set at. Okay. I have this one AME, he's a good guy. I've known him for years. Every one of his fricking EKGs, I've sent the FAA notes saying beat this guy up. He's, every one of his EKGs is at five millimeters. I could kill him sometimes because some of it is so flat, you could barely, if I can't see it, they're going to get a repeat. Let his AMEs beat, let his pilots beat him up. All right, so let's keep going. LVH by voltage criteria. There are several criteria is a normal variant. All right, so now, all right. So now let's talk about the intervals. Okay, so these intervals were taken from the Bible of EKGs, which is Marriott, okay? These are the intervals. I don't know where they stick the stuff in, in these machines. Maybe, no, I won't, I won't. I'll be politically correct. Okay, I was going to say some, but I won't. I thought twice. All right. Although being retired, the titles of DB not correct and both politically correct, but oh, for the sake of the group, I will. All right, so PR or PQ is, like I said earlier, is 0.21 seconds or more, okay? Is a prolonged PR interval, all right? Or PQ. QRS is, can't be greater than 0.12. Anything less than that is not an intraventricular conduction delay. Right, I told you about left axis. And left axis less than minus 30 is not a left axis. The machine says left axis at minus, I don't even look and see, I don't know what it's being told, but there'll be something that says minus eight, and that's not left axis. Minus 30 or greater, what can I do? Just go, go, go for it. Oh, you're gonna change the batteries, okay. So between minus 30 and minus 45, and anything greater than minus 45 could be a left, could be, may not be. All right, and I'll tell you a little bit about, oh, let me tell you now while I'm thinking about it. So left anterior hemiblock, what was I going to say before I stuck my foot in my mouth and forgot? Oh yeah, okay, so if you're looking at EKGs, remember, this thing is, if you're looking at EKGs, and you see that the EK, always, you know, if I don't, if you don't know this, this is EKG 100 before, even before 101. If you're EKG, okay, my brain is always faster than my mouth. So if you're, what was I going to tell you about that? Oh God, I forgot. If you're EKG, see, I'm thinking, oh yes, if you're EKG has an axis of, let's say, 20 plus 20, and then the next time it's minus 50, and you're pretty sure it's right, of course, remember, it's a computer, it should be right for the intervals, then that's probably a left anterior hemiblock, and should be worked up. But if you see like minuses and minuses, and all of a sudden it's beyond minus 45, then I wouldn't, I don't really don't call that a left anterior hemiblock, and I don't work it up, okay? So just make sure, because you know, left anterior hemiblock isn't as ominous as a right, as a left posterior, but it still needs to be worked up the first time, okay? And I told you that right axis is anything greater than plus 120, is less than 120, okay? All right, so now I'm going to show you my drawing. Okay, so this is very rudimentary, but if you know this drawing, like Mike Myers used to say, let me show you my drawings. It looks rudimentary, but I want you to think, okay, so I would normally have drawn this one at a time, you know, very separately and added stuff on it. I thought about, should I do that? And I'll just show you, okay. So this is the heart, may not look like a great heart, but it's the heart. And all right, so remember the, okay, for EKG purposes, the heart lies, I'm going to spend a lot of time on this drawing because if you know this drawing, you can read an EKG, okay? The heart lies on an axis, a circle, okay? Where zero and 360 are at the top, plus 90 is below, okay? So of course, you know, it's kind of like a plane too. Over here is zero degrees and over here is plus 270, okay? And then of course, these are the axes you ought to remember. Minus 150, that's, all right, so let's start on this side. So minus 30 is where AVL sits, okay? Plus 60 is where lead two sits. Plus 90 is where AVF sits. Plus 120 is where lead three sits. And minus 150 is where AVR sits, okay, on the axis. There are four axes. Yeah, you're talking about like vector cardiography, but I'm not, you know, but that's sort of where it takes off from what this is, is there are four vectors of the EKG. The first vector, here's the SA node, okay? Then remember the AV node. The second vector is the septal vector, which goes from, notice, left to right, that's important. Then you have the main vector of the QRS complex, which is at plus 60. That means that the tallest lead on your EKG should be at, would be lead two. Okay, then you have plus 90 where AVF is, and then plus 120 is where lead three lies. And then, so then you take the precordial leads and you'll throw them on there. So V1 and V2 look at the right side of the heart. V3 and V4 is where your transition is. You know, there's enough, there's as much above as below, and I'll show you how, sort of how you get that. You gotta have a little imagination, but that's where you'll see the transition, okay? So obviously, if lots of times, if you see like the transition maybe at V5, then there's a good chance, meaning there's enough of, there's as much of the complex above the isoelectric line as there is below. I would think that it probably had something to do with the lead place, okay? That's something you think about, unless all of, unless V1, V2, V3, and maybe V4 are all Q waves, then it could be an old anterior wall MI. But if there's a little R in them, you know, you have to, you know, some of the stuff you have to, two heads are better than one, but that's something that you need to know, okay? And then V5 and V6 look at the left side of the heart, okay? So now let's say you take, you know, a little electrode, okay, so remember, isoelectric line is zero, above is plus, low is minus. So let's say, and I'll show you sort of how we get this. So let's say I'm looking at AVL, what should be a normal AVL. Now I've got EKGs and I was thinking, should I, I was gonna initially make a packet of, and so if you've got questions that you can come up, we could talk about it on the screen, because I don't know how well it'll come out. So these are the EKGs I showed you right from the FAA. So, but I redacted the names for the, to protect the innocent. Okay, so, okay, so let's say your electrode is sitting up here, okay? So the first vector, so the first thing is the P wave, okay? This is the, be the vector of the P wave. Notice the P, it's coming towards this way. So it's gonna be upright above the isoelectric line, okay? So now the septal vector goes from left to right, so it's going away from this, so it would be negative. So you're gonna have a little Q wave. Then you got the main vector of the QRS, and then so that it goes above the isoelectric line. And then the fourth vector is the vector of the T wave, which goes up this way, cushion of the heart is repolarizing, and it repolarizes, you know, from the base up. So, you know, the T wave, you know, most of the T waves are upright, okay, when you look at an EKG. When they're inverted, then you gotta get concerned, and it depends on what they look like, and that just takes experience, okay? So let's talk about the, like, and for example, think about this. Any of the complexes that are over on the left side of the heart, which is AVL1, V5, and V6, and 2, are gonna sort of look the same, right? Because the vectors, and they'll just be taller or less, you know, or shorter, depending on, you know, where the electrical activity is coming to. Okay, so let's talk about the transition one. That's a crappy drawing, but whatever, you get the point. So once again, you got the electrode sitting down here, and so you got the vector of the P wave, so it's gonna be upright. Then you have the septal vector, which goes from left to right, so there'll be maybe, it may not even be a Q wave there. Oops, I, let me put that back. All right, so then you've got the main vector of the QRS, but it's going away from the septal area, so it's gonna be below the isoelectric line, and then it comes, boom, goes back, so then it returns, and the T wave will probably be, it might be inverted, okay? So, but it won't look like an ischemic T wave. What is, Warren, what does that look like? Well, I'd have to sit, we'd have to sit and look at EKGs, a lot to them to see, well, that T wave, you know, might not be, okay? So, okay, every time I touch this, okay. So once again, it's gonna look sort of similar with three, but see, notice this, in lead three, you might have an inverted P wave because the vector is sort of going away from that, okay? And AVR, AVR is the best lead to tell if some person, the tech, put the limb leads on raw because AVR, notice, is sitting up here at minus 150, so what happens is the P wave vector is going away, so the P wave is inverted. That's a big deal. I have some examples. I didn't, they're not always as good. We'll see how it shows up on the screen there. Okay, so, but that's a big thing. The P wave in AVR is inverted normally. Okay, so then you have the septal vector, and that's sort of going towards AVR, so you're gonna have a little R in the oven, and then the main vector of the QRS is going away, so you're gonna have a deep S wave, and then it comes back, you know, to the isoelectric line because you have repolarization. Now, let's look at some, got any questions about that? I mean, I've got plenty. This lecture is not gonna last the full time, although I'm moving along here. Too much shooting the trap off, but that's all right. We'll do it. We'll finish it. All right. Okay. So now let's look at some EKGs straight from the FAA. So let's look at the intervals here. First of all, oh, there's a perfect example of what I was telling you. You see there? That is 10 millimeters, okay? I don't know if I got one where some yay who put it at five, but that's what it should look like. So that's 10 blocks. Okay. That's normal. All right. And by the way, the way you know that it's, I don't even have to look that it's notice it says 25 millimeters per second. I'm telling you, I had an argument with one of my prior associates at the FAA. She, what she gets on these jags. So, so she got on a jag about 50, the difference between 50 and 25. She thought it should be 50. I said, if you start sending me EKGs that are 50, I quit. Okay. Because what happens is it slows everything and pulls everything out. So you have to look at the intervals, which will record it correctly, but then you can't tell I'm serious. You can't read it. It'll take much more time to read an EKG. EKGs that are 50 millimeters. Okay. And who used to do that the most? The internationals. Okay. So, but they look down at their nose at us, but no comment. All right. So does anybody want to get, of course it says up top and this time it got it right. Now I don't know that it's a left, that it's a left anterior. It says it's minus 48. I don't know what the old EKGs look like. Okay. So notice the axis is minus 48. So it falls above minus 45. So it might be a left anterior hemiblock, but this is a classic right bundle branch block. Notice the QRS is 128. Okay. So it's a classic and oh, guess what? It's also a first degree AV block. Okay. So, but that's it. Okay. The big thing is, oops, I wanted to show you what a right bundle, that's a classic right bundle period. Okay. Let's go to the next one. What are your key? Well, you've got, all right. So here's the key thing to look at. Okay. The key thing to look at is what the complexes look like. Notice how tall the wave is. Because remember, it's on the right side of the heart, right? Okay. V1, V2, V3. And you're getting most, what you're seeing mostly is from the, I'm not even touching the thing here to advance the slides. All right. So that's it. So that's what it is. Yes. It's rabbit ears. Right. The rabbit, the classic rabbit. Very good there, Naomi. That's it. But it's over on the right side of the heart. If it was over on the left side of the heart, which I'll show you, then it's a left bundle branch block. Okay. That's okay. But I will go over what the workups are. We got some time. All right. Okay. So now, okay. So this is a left bundle branch block. All right. See, look at the, now, instead of it being over V1 and V2, now it's over the left side of the heart. Okay. And one of the, one of the classic things with the left bundle is that they lose their, their Q wave. There's usually no Q waves with a left bundle. But this is a left bundle. All right. And there, look, there's the 10 millimeter thing. Okay. So this is a left bundle. Now, normally the T waves in a left bundle are inverted. If they're upright, that's a primary T wave change. Okay. Which, what a primary T wave means is that something caused those T waves when they're normally inverted to become upright. Was it ischemia? I don't work. You're going to work this up the first time anyway. Okay. You work this, this is a workup, one workup. Okay. So this is, these T waves are where they're supposed to be. Okay. So let's go to the next one. All right. So what's this here? Ah, does anybody want to guess what this is? Flutter? Come on, come on. Flutter. Very good. It's atrial fib flutter. Okay. Fib flutter. Atrial flutter. Fib flutter. You see these multiple sawtooth waves. Okay. And notice the machine didn't read a PR interval because it can't. And the QRS is 110. So it's within normal range. Okay. And notice the machine called it atrial fib flutter. That's, I just say atrial fib flutter. It's going to get a workup. It's got to have a workup. One workup. Okay. All right. So let's see what this is. Okay. So look at the QRS says it's 144 milliseconds, but notice it doesn't look like a typical left bundle. Matter of fact, I'm not a hundred percent sure it is 144, but definitely they don't look right. Okay. So this is intraventricular conduction delay. No workup. No workup. Okay. No workup on this. All right. Let's see what this is. Ah, now I don't know how well you can see this. Notice now you got, once again, 10 millimeters. Notice the P wave in this complex. It's upright. Okay. So think about my drawing. Okay. So if the P wave is upright, how can that be when the septal vector, when the P wave vector goes this way, if the node or the whatever setting the atria off is in the lower part of the atria and firing the atria off up this way, it would have to cause an upright P wave. Notice the, you can't see them, but look at the P wave in lead two, which is remember the main vector it's inverted. You don't see that. So this is a low atrial rhythm. It's a normal variant. You don't work it up. Okay. You don't work it up. How do you tell it? You tell that apart from junctional because that's. It's junctional. You don't work it up either. Okay. Yeah. If it's junctional, if it's a junction, it'll call it, matter of fact, the machine will call it junctional. I don't work it up. Okay. Unless it's really slow and the guy didn't say anything. Okay. All right. So what's this? Okay. This is an overread. This is a normal EKG. Notice the interval. Let's look at that. 76 rates. That's good. The P wave, the PR is 188. That's fine. QRS is 98. That's good. The QTs are all right. And the axis is, oh, by the way, the intelligentsia at the FAA, I don't know where they're getting stuff, but the axis you want, you're interested in is the QR axis, which is the middle one here. And it read it as plus 15. Okay. You don't read the others on the P and the T, the two outer ones, because, you know, they're always separated by slants. You don't look at those. Those are not relevant to reading it, at least for a moron like me. But that one is, you have the EKG. Oh, always, always, always, always look at the old EKG. Also note, now this is, you know, this is a typical, fairly normal EKG. So notice it looks kind of like that lead two is the tallest lead, right? Notice AVR, inverted P. There's not much of an R here, but there's a deep S. Okay. And you got your transition at lead three and four, a little bit on five, but it's still, this is a normal EKG. Okay. I would, you know, if I was the AME reading this, I cross out the septal crap and the abnormal EKG and just put negative and sign. Okay. All right. So now let's talk a little bit. I mean, I, that's as many as I found before Rhonda started to beat me up about sending her the lectures. So, so, but, you know, I obviously see everything. All right. So let's talk. So, you know what, all right. So this is what the workup is. We got a few minutes. We'll, we can bump this up pretty good. And plus you've got my slides. All right. So a prolonged PR, which is, you know, anything greater than 0.30 is a cardiovascular eval. Okay. A maximal, every, when you working up a first-class person, other than a right bundle, everything is normally a nuclear stress test. Cause that's the silver standard. I tell the pilot that the bronze is a regular treadmill. The silver is a nuclear, or maybe a stress echo. The gold is the calf. Okay. So, so, and then a 24 hour halter. Okay. Cause you want to see what's going on during the day. All right. And at night, okay. Sinus bradycardia, hopefully I don't, shouldn't have to work this up, but nevertheless, it's a CVA and just a regular stress test. You want to see if the guy, remember what the FAA says, make the person exercise and then repeat the EKG and send that. Okay. So, and right. So the AME should have exercised and repeated the EKG. All right. Sinus tach. Okay. I told you that the physician noted, note anything such as cause nervous when arrived. Check, right. Check. Always, I always checked. I'm not, I'm trying not to get these guys worked up because I'm looking at EKGs over a year old. So I looked and I did this even no matter what, look at the pulse block on the exam. And if it's up at somebody must've taken their pulse. And if it's higher than 44, I don't do anything. And I said, it was still, if not, if it's still elevated and nobody said anything, then you got to do a workup, which is a CV, a cardiovascular, a nuke stress, and a 24 hour halter. What about a new onset complete right bundle? So the FAA has broken it down. So if they're less, if they're 35 or younger, you do nothing. If they're 36 or older, then it's a CV. And this one, they're letting you get a stress echo. The reason why the FAA doesn't like stress echoes is because it's not done the same way at every institution, whereas a nuke is very standard. Okay. What about a new one set left bundle? It turns out that when you do a nuke, a regular nuke on a left bundle branch block, and you do a nuke, it shows like a septal defect. It, you know, it's just part of the shtick that you see with the left bundle. So the form nuclear, meaning they give like Lexiscan normally to stimulate the heart. It rarely brings the rate up, but whatever. The FAA doesn't normally like a farm nuke unless the guy is got, you know, some sort of debilitation. They can't walk, you know, they can't walk on a treadmill once they start to elevate it. As long as the, the cardiologist or the tech puts that Joe, Joe had, you know, hurt his knee and couldn't, and then they do the farm nuke, then, you know, I just let it go. Okay. So if they don't say anything, then, you know, unless the A&E comes back and says, hey, Joe can't walk, you know, up a hill. All right. Then we'll, we'll, we'll prove it. By the way, a farm nuke costs more than a regular nuke. None of them are cheap. All right. What about a, a fib or flutter? First of all, this is one of those circumstances where the pilot's grounded. You, you it's going to be, there's going to be some, the pilot's going to be treated in some way. Yes, sir. All right. Yes, sir. And so it's a CVE and echo, because you want to know if the, the person has some sort of valve problem that caused it. A maximal Bruce nuclear, a 24 hour holter, because you want to see, but I tell them, don't do the holter until after you get treated. Otherwise you're kind of wasting your time. TSH, because in some cases, you know, thyroid can cause a, a fib. Okay. And then now the FAA wants a sleep study. Okay. And I've heard it's nothing to do with me that they're going, some of the docs are going back and ordering sleep studies when the guy has already been cleared. I'm not going to say anything. You read between the lines. Okay. And then try two or more PVCs is a CVE, a holter, a nuke stress, and an echo. You know, the echo you're looking for, you know, like a cardiomyopathy or something. And also multiple PVCs can cause a cardiomyopathy over a period of time. So you may, you may end up occasionally repeating it, especially if the guy, you know, continues to have it by rights, his doc should, should do an echo eventually. So let's see what else I got. Oh, that's it. Now there's a lot, you know, I had five minutes, but if you guys have any questions, I see there was two in the chat. Does anybody, do I have to look at that there, Jeffrey? All right. Let's see what we got. Flubber on previous EKG. That's Pat. Pat, as I know, is an internist. I don't know what she meant on that one. It was a 1050, a flubber. Okay. We can, we can, we can hear you. Hallelujah. All right. So, all right. So you got any, any questions before I get the hook? No questions? All right. I hope, I hope, I mean, you know, they asked me to do this. I hope you picked up a few things.

electrocardiograms

aerospace medicine

EKG interpretation

heart conditions

cardiovascular evaluation

diagnostic tools

aviation safety

pilot health