EMCrit Wee - ECGs in Acute Pulmonary Embolism

Hey folks, Scott Weingart here, and this is an Mcrit Wii. This would have been a podcast, but my guest has conflicts of interest, so I can't give CME, so it's not a podcast, it's a we. But damn it is a good we. So we did a malpractice case last year. on a patient with like stone cold normal vitals who presented and turned out to be a PE and the doctor was sued and the main crux of the case was the ECG showed a pretty significant

T wave inversions anteriorly and inferiorly, and that was missed by the doc involved as a sign of P. And I made a mental note to myself. Get the E C G cyborg named Pendle Myers on the show to discuss ECGs in pulmonary embolism. Now Jeff Klein also mentioned this topic when we were talking about that malpractice case, and he said if you're not screening the ECG, then that is below standard of care. And so that was even more impetus to get this.

Done. Now, if you don't know Pendle, he's been on the show before. He's basically the creator of the OMI paradigm, the replacement for the STEMI, and it can't come soon enough. STEMI's gotta go. And he is brilliant. He was my resuscitation fellow. He was my resident. And from day one, he was just like a Maven of all things cardiology and ECG. So brilliant. Love the guy. Real soft spoken. Nice. You're gonna love him too if you haven't heard him before.

We'll get right into it in just a sec. Very quickly, the Out on Time Asynchronous Course has just been released. And we had done the synchronous beta version of the course to test out the ideas and we got fantastic feedback. We went back. for I think a year and actually took all the recommendations and then put them into this new course. Now

The purpose of this course is, as the name says, to get you out on time. And not out on time rushed, not out on time frazzled and miserable, but out on time relaxed and joyful, so that you can get home to your family, your friends, and your life and not stay two hours after your shift. But At the same time, we want you to have perfectly supportable, billable.

charts and we want you to have medical legally defensible charts. And we want you to be able to do it without losing the income from seeing patients. So it's it's a tall order, but I think we succeeded. We're gonna get you out on time or damn close to it. Your charts are gonna bill beautifully and you're gonna be safe if anyone takes a look at those charts with the desire to sue you.

In addition to that, we have things like managing interruptions, managing flow, all the things that keep you efficient and happy on shift. It's all the stuff they should have taught you. during your residency and they never did. And I know they didn't because every time I talk to a residency and I

just mentioned charting. They're like, oh, no one ever taught us charting. And I'm like, oh God. Well, now there's a course for it. And if you want to check it out, it's out on time. All one word. Out on time course. All one word. Out on time course. dot com. Outontimecourse dot com. Check it out. If you have questions, let me know. I'm happy to answer them. But I think you're going to love it. And everyone who has been part of the beta test loved it. So check it out. Outontimecourse dot com.

All right, let's get right into the episode on ECGs and Acute Pulmonary Embolism with Pendle Myers. So tell the folks who you are and what you do. You've been here before, but this might be the first time people have heard you. Hello everyone, I'm Pendle Myers. I'm an emergency medicine doctor specializing in E K Gs and critical care. I know Scott very well. I was his fellow back in uh what was that, twenty nineteen, twenty twenty? Yep. Um and uh

Long been listening to M. Crit and happy to be on. Excellent. And now you are some form of cyborg. Now was it actually just a brain implant that they placed in there to allow Easier ascertainment of EKGs or uh has there been additional enhancements?

actual patented implant that got put right in my brain. I I I was thinking about it. I'm like, no, I don't want to mess with this the wet ware. I'm not gonna do it. But yeah, I understand the benefits of it. All right. And just as a conflict of interest, you are a partner in PM Cardio, which is the current, to my estimation, best.

AI integration into EKG readings out there. It As it stands now, it'll tell you if the patient has an MI, though it's not FDA approved, so it's only for informational purposes for studies and such. You can't use it on clinical practice. I wanted you to come on the show because of a case that was recently posted and you actually did a blog post which we'll link to on this specific case. It was the

case on the medical legal reviews and the EKG on it. I think would have been read by many E D docs as just nonspecific T wave changes. But texted it to you as as soon as I figured I was gonna do the post and you're like, Obviously, Scott, you and I both know this is gonna be a pulmonary embolism but you were very clear. I don't think most E D docs know that and I don't think it holds the standard of care.

And so we posted that case. We got a lot of feedback about people petrified now of missing EKGs and pulmonary embolism. And then I had just recently Jeff Klein on the show, and he does a ton of medical legal work on both sides. Defense and plaintiff, and he's like, You know, I just can't defend docs who don't look at the EKG and screen for P E on that E. K. He's I just can't take those cases successfully. So that scared me'cause that puts it in a I think a

You were like, I don't think it's standard of care. And then you have Jeff Klein, the PE guy, saying, Not only is it standard of care, but it's indefensible when these things are not screened for. But then I'm like, we better get Pendle on the line to actually know what we should be looking for. Now, Jeff Klein talked about the Daniel score. Are you at all familiar with this Pendle? I'm not. I don't know.

So the Daniel score is just they took a whole bunch of P E E K G findings and and s assigned point values to them. It scared the hell out of me simply because It's a lot of calculation. Like unless you had a AI doing it, it would be an enormous pain in the ass. Um but Let's talk about it from a more clinically utile stance. So when you are screening an EKG for a patient who comes in with shortness of breath and chest pain, what are you looking for? To know.

Hey, this could be a pulmonary embolism based on the EKG. And then we could delve further into which of those are signs also of right heart strain and which ones are independent of right heart strain. First I'll frame it as w what I expect out of the E C G for P E, right? Very different than acute MI and my experience and training.

I'm using the ECG for PE only as a specific indicator of a bad PE, of a PE that's causing really bad right heart strain. The idea of using a Daniel score as part of my initial like Initial evaluation or initial thought process of whether I should work it up. doesn't really enter my mind that much. Uh I use it the same way I use like bedside ultrasound for many things in emergency medicine, where I'm not an expert at that, but I use it as a specific finding that prompts

recognition of a severe, obvious, immediate disease state. I don't use it at all for sensitivity and that's backed up by the literature. I do look for right heart strain and patients I think is relevant. I just wanna make sure that the listener knows that I think it's useful for specificity. I can describe and I will soon the sort of classic right heart string pattern. And if I see that, then I will act on that, but I'm not really looking too hard at the EKG for PE when I don't see that pattern.

Yeah, that makes sense. But you are screening all the EKGs and these chest pain and shortness of breath players and then it's just a question of how much further you're gonna go in terms of your consideration, is that fair? Absolutely. The findings that would be on this list, a lot of them just aren't really that helpful, right? Like sinus tack be the first one that everybody says and so nonspecific that I can't really say that

is able to guide anyone in a specific way. S one, Q three, T three, very common and normal people. So I don't really change directions in my clinical course based on that very commonly. Well one let's pause there because I want to take these one by one. You're doing a perfect list. So sinus tac, obviously not specific for PE and not as sensitive as we thought for PE either, unfortunately.

Yeah. That being said, you unfortunately will get burned if you don't explain a sinus tachycardia. So that one in a chest pain or shortness of breath player for me certainly makes me say I'm gonna really have to justify in my chart if I'm not going to do a PE workup. Obviously the ty the tachycardia already obviates perk as a rule at criteria. So now you're really left with

a justification. And it could be, oh, patient had fever, the fever is correlating with the degree of tachycardia. I feel pretty safe. And but you better you damn well better be mentioning pulmonary embolism on that chart, I think is the bare minimum. And then Let's talk about S1Q3T3. We know it's insensitive and nonspecific, and yet it's gone into the lore of pulmonary embolism. It's what we were taught as medical students.

I think if they have that pattern, and again, you don't justify why you didn't work them up for pulmonary embolism, you're posed. Is that your practice as well? I agree. And it even when I look in the literature, I find that it's not wholly it's not zero imp importance. I have some little nuggets here that I'll get to later, but some of these studies find like an odds ratio or likelihood ratio somewhere in the two or three range.

Which is not useless. So what I'm trying to say is if it's a patient that I considering P E absolutely all those things are important and I need to work it up or explain why I why I didn't care about these findings, right? But They're just so nonspecific that if I I'm sure that it's not PE clinically, I'm not gonna turn around and change my thought process. Yeah, that's a absolutely fair statement. If you're sure it's not PE clinically.

I and I'd add the additional statement, if you're not sure it's not, then I think that should probably prompt a workup with a D dimer. unless you find an alternative diagnosis that really is compelling. And the case that I dealt with in the early part of my career was a patient who actually had an infiltrate.

and had sinus tac and the infiltrate was it was vague. It was a vague infiltrate. And that patient wound up having a pulmonary embolism. And I've must have told you this hundred times during our time when we were training together, but

For me, when I say alternative diagnosis, I mean one you're willing to bet your house on. If you have, oh, this is a dissection, okay, that's not gonna be a P E. But if it's I don't know, it's probably a viral syndrome and they're probably like they said subjective temperature and that's probably why their tachycardia is there. No, that that's vague. All right. So far we said sinus tack, we said the classic S one Q three T three. And that that is a right heart strain sign as well, right, Pendle?

Yeah, it is it is related to that. It's telling you that the QRS is changing a little bit because of that struggling right part and then the T wave inversion in three is part of the what I'll call like the poster child like classic acute right heart strain pattern that I'll describe soon. All right. What's next?

Well let's just do that one. So the most important one to me is this sort of simultaneous inferior and anterior T wave inversion that I can put in those words, but there's additional detail that comes with like pattern recognition that is A little bit harder for me to describe, but I'm gonna do my best and I'm gonna give you a link to one of our blog posts that has ten of them in a row where we can just really train this particular little muscle in the EKG world. So

It has essentially V2 through V4, I think, is the most important part of it for my like subjective learning. And these leads usually have a QRS that has a little R wave, big S wave. followed by a coved kind of concave S T segment that then like roller coasters into a big T wave inversion. That pattern is to me recognizable as specifically right heart screen. And that happens in V one through V four and I usually find that it's most pronounced or important in V two three four.

V one kind of usually has a T wave inversion for most people with normal QRS, so I don't find V one to be the best lead, most important lead there. Now, based on where the right heart is, which I find this is like usually uh the first time a resident that I'm teaching learns where the right heart is on an EKG when they see this case, because

You know, the right heart is underneath V one through V four. It's also spatially represented by the inferior leads a bit because that right heart is t twisted a little bit more inferior than the left heart. So

lead three is kind of is that's why lead three is involved too. So for some reason when the right heart has a Q right heart string, that is the way that it looks to me when I recognize it specifically on the ECG. So The classic PEE KG for me, i the severe PE, is sinus attack, hopefully, usually, not always, and this simultaneous inferior anterior T wave inversion with that.

Small R, big S, roller coaster, S T T wave inversion. So you mentioned V one through V four, the classic, right heart strain. Then the inferior leads could be involved and that would be three in AVF as the real ones you should be looking for. For whatever reason, what's come up in the literature bunch is

Again, that three in AVF and then V one V two as a a four lead combination that had high specificity for right heart strain. I guess we're looking at V one, three, V four, and three in AVF for those T wave inversions. All right. And how much of the pattern recognition really matters? Would you look at an EKG that had T-wave inversions in the anterior and inferior leads and just say, yeah, but the pattern's not right, so I'm not really concerned? Or is it that

It's a agglomeration. And if you saw all all those T wave inversions, but you're like, Yeah, the pattern's not right, but I'm still concerned like Uh how much is the pattern matter and how much does the actual anatomical location of those weeds with T-wave inversions matter. Oh that's a perfect question. And I I have a couple of things I'll say in response. It's definitely pattern recognition is far beyond just the word.

And I can prove that. One of the studies I'll talk about in a minute has an odds ratio of T wave inversion V two through V four at four point zero, which is relevant and important. But I'll say that like when an expert does this and sees that pattern with the way I described it, I think the odds ratio is a lot more than four. And so there's a gap between the words and like expert recognition.

The other thing that I think you brought up is I wanna give the listeners what I give my residents for an anterior T wave inversion differential.

because I think not all of the work has to be done by memorizing squiggly lines here, right? When I see an answer to inversion and I'm talking to my residents about it, I tell'em five things. So number one Check and make sure it's not the QRS's fault. Okay, so abnormal QRS always causes abnormal repo. And the more abnormal the depull, the more abnormal the repo.

So everybody with a write bundle or any kind of big upward QRS in V123 is going to have TWA inversions in those leads. And that's because of the QRS. Right bundle, separate topic, we'll do that in a second for PE. If you have a baseline right bundle, you're gonna have a T wave aversion in V one, two, three. That's because of the QRS. That's number one on the differential. Number two is anterior reperfusion or Wellens syndrome.

This is hard to put in words about why it's different than the PET Wim versions. However, maybe that leap three thing helps with Kosuge Kosuge's article. I'll show pictures of Wellens in the show notes too. Number three is a Q right heartstrain, what we're talking about, usually PE but not always PE. Number four is hypokelemia, causes T wave inversions, usually like a long QT with S T depression, downward T wave, and then upward T wave at the end. So down up, long QT, down up.

That's hypokelemia. And Takasubo causes big impressive T wave inversions sometimes when it does the classic thing on the EKG. So for those five things. Usually the first one, the QRS, you can just tell immediately. And then you're left with a differential that is important and you don't have to be an EKG whiz to figure this out. So an ultrasound is certainly gonna be helpful in the first in the most important steps of that differential.

A patient whose pain is over and now they feel better points you towards wellens. And a patient that has a huge right heart strain on their echo and has active symptoms is more like a PE. So there's ways to do that where you don't have to just be an EKG whiz, but that's my differential that I give. I love that. That's fantastic. And it anticipated another question I was gonna ask, which is let's say you s hey folks, but you know we're not getting right to the show because

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Totally normal. Does that now obviate the likelihood ratio of those signs for pulmonary embolism? Or do they precede actual echocardiographic heart strain? I think that's I would say that in my experience, I I think that the echo is more sensitive for right heart strain than the EKG.

Every time that I find this pattern I just described, I go to bedside even with my very mediocre echo skills and it's the most obvious right heart strain that I could see. And I'm very primed for it'cause I think it's going to be there already, but

The echo is very is usually severe when the EKG is obvious to me. Gotcha. All right. That's super helpful. All right. What's next, Pendle? Well, I do have some other patterns that I wanted to mention that are a little more complicated, so I don't want to annoy or scare people with it, but I there are some other patterns that have tricked me in the past with PE that I wanted to mention. So number one is things get hard when the right bundle happens in PE.

Uh it's tempting to think that it's the right bundle is l literally being stretched or affected some way by the strain, but for some reason bundle branch block can happen in association with or maybe because of the acute PE. When that happens, a lot of the visual things that I told you to look for are now changed a lot by the abnormal QRS. And I lose a lot of ability to see acute right heart strain when the patient has that right bundle from the PE.

So I feel much less confident that I know exactly what it is, but the what I'll say in response is If you have a sick patient who has a new right bundle. then I want you to be worried about acute PE and acute LAD occlusion. And so be very careful with those patients because

I don't think that the EKG has quite the power that it does without the right bundle. Okay. Tell people, because I'm sure they learned it during med school and then promptly forgot it. What are they looking for to diagnose a right bundle on an EKG? Sure. Most of them are looking at the words on the top of the page to diagnose the right bundle. Yeah. That's the problem, isn't it? And I'll start I'll say that you can have an incomplete right bundle or a complete right bundle with this situation.

The complete write bundle, you'd have to have a wide QRS, which would be by definition 120 milliseconds for your QRS, so at least three small boxes. And the whole point of the right bundle is that the end of the QRS is wide and rightward. So the beginning of the QRS might be very narrow and normal looking, but the end of the QRS is the reason it's wide. That's because the right bundle is depolarizing late and last and all of that

QRS will rush towards the right ventricle. So you'll have the R prime, the big nasty wide R wave in V one, and you'll have the nasty wide S wave in V six, which is exactly the same thing in the other direction.

leads that one and A V L will also have that little that wide S wave and that's the definition of that's how I find right bundle. If everything is just a little bit more narrow than that, it's not quite wide enough, you could call that an incomplete right bundle. And both of those are relevant for the situation.

All right, so just to recap, wide QRS greater than one twenty, an R prime in V one and an S wave in V six is a right bundle. And if it's not quite the one twenty, but it's has that same pattern, then we could call that an incomplete right bundle.

Yes, I'll change one little thing. It doesn't have to be R prime. It just has to be a terminal R. Next thing I'll say is Um sometimes I've seen severe PE patients and their EKG to me looks more like global subendocardial ischemia rather than specific right heart strain. So global southern cardioschemia looks like depression everywhere in most leftward and downward leads with reciprocal elevation and A VR.

It really pains me that the E K G isn't showing right heart strain, but is showing global. I I wish it would I wish all PEs would just show me right heart strain. But for some reason I've seen terrible PEs with only that pattern to my eyes. So I'll put that on those two. And finally, the most confusing one I think for learners is When the supply-demand mismatch is so bad for the for any part of the heart, you can have a type two OMI pattern or a type two STEMI pattern.

that when that ratio of supply demand reaches some critical level, it's functionally like there's no blood supply at all. And that looks like STEMI and looks like OMI. So you can see a patient who has an inferior OMI or an anterior looking OMI and it's actually PE is it's rare.

And it's complicated but I'll put it on the list. That's petrifying. We worried about going to the cath lab and missing a dissection. Now we could go to the cath lab and miss a pulmonary embolism as well. Now those while a little bit scary don't have to be a little bit more than a little concern me as much'cause I think where all of us are petrified is the patient who doesn't look sick. Like the sick ones I

We we are gonna do something. We're gonna figure it out one way or another. We might miss it for a little while, but but a lot of these could be presenting in a relatively silent patient. They have the chest pain or the shortness of breath that has brought them in, but they don't look super sick. And this is the real quintessential aspect of the case we posted that was so torturous was the patient had normal vital signs. And yet with an EKG, not just

subtly representative of right heart strain. He had deep T wave inversions in V one through V four and three and A V F it was not subtle if you knew what you were looking for. How of and you might not know the answer to this pedal, how often does that happen? How often do you have a patient who's not having the vital signs you'd expect from a bad right heart strain and yet has the EKG. And we would have imagined the echo if we had done it on that page.

Yeah, it's hard and I'm sure the real answer is scary. I'll say th the one that has really petrified me over the years is the heart rate. I have s I just my preparation for talking with you, I looked through our old blog cases on PEs and I over and over the heart rate's eighty-five and just not something that people would say is clearly corresponding with what they were taught. That one, that really bothers me. I've seen plenty of terrible PEs that are not profoundly hypoxemic.

It's just scary and it's just not the way to to rule out PE, sadly. Even these EKGs with horrible looking strain, I got'em over and over. At ninety beats a minute, seventy beats a minute. Yeah, absolutely. All right. Are there others, Pandel? I think that's the most important ones to think about, other than y there's the idea of low risk and I don't think it's a P E and so we gotta make sure we think about S1, Q two, G three and tachycardia.

and like write bundle and then I need to make sure I explain that I've thought about that. And then there's the other side of the spectrum where you're trying to recognize specifically terrible right heart strain. And that's the classic pattern I talked about. So that's I think the most important stuff about the EKG MP. All right, let me share this'cause I will get your impression.

So this is the Daniel score. But just looking at it, it's pretty much exactly what you said. But they're giving points to these four relative weight. But you've hit all of them. So If if nothing else, it would be a way to prompt people to check all these things when they're screening an EKG. This is maybe a tool that you could use as like uh help you safely

Know when you need to explain an EKG finding for a patient that you think doesn't have a PE, I I guess is what you're going for. Yeah, just as a checklist, even if you didn't do the score, it might be helpful to people.

All right. Yeah, the only things they don't have that you mentioned are the ones that are just signs of gruesome PE, which again the patient would be so sick that they I think would be recognized. Thinking about the negative unpredicted value of those, yeah. Absolutely. Hey, so future Weingard here. So should you be using the Daniel score in your clinical practice? I don't think so.

Its actual purpose is to screen patients you already know are a PE for prognostic signs, which really boil down to right heart strain. I think you're much better off if a patient has a PE throwing an echoprobe on rather than looking at the EKG. So in terms of it as a scoring system, not so much. Now, what does the Daniel score actually boil down to? It boils down to these four things, sinus tack, right bundle branch block, either incomplete or complete.

S1 Q3T3 and the various components of that, and anterior T-wave inversions. I think, and this is just my personal opinion, I'm actually gonna write to Jeff Klein and see if he could clarify his statements, but I think You should be screening every EKG for a patient who comes with chest pain or shortness of breath for those four things.

And if they have it, it doesn't mean you have to work'em up for PE, but it does mean you have to make a notation on the chart saying you recognize this is here, but you don't think this is a PE because and then write something. I think if you saw these and you're like, eh, I don't think this is a PE. It might behoove you if you're not going to work it up.

to throw an Echo probe on. Because I think if the heart is stone cold normal, then it obviates the New Right bundle, the S one Q three, T three and the anterior T wave inversions, as being from A pulmonary embolism. Now the sinus tactic still remains, but you already knew that you have to explain sinus tachycardia if you're not gonna work it up on a chart.

There is a quote unquote better ECG score, and it's called the novel ECG score. And I have it in the show notes. And when you see it in the show notes, you're gonna be like, That is not clinically utile at all because it is immensely complex. It is like I think even Pendle will be like, This is too much. I I think I need a break. So it might be something good. for a Computer to do.

And and this time I mean a real computer, not like a pendle type computer. You know, if it was part of an EKG screening algorithm in the machine, I think it would be pretty good. The the testing characteristics are much better. than for the Daniel score and most of the other stuff we do. It it's been validated once. I think you'd probably want multi center validation before we said it was good for primetime, but it's a better score.

than Daniel for screening for pulmonary embolism. But like I say, there's two separate algorithms, one for patients with and one for patients without a right bundle branch block. And then once you find which one, there's like five sections and each of these sections has like six sections.

it it would be like your entire shift to use this algorithm. But you could check that out in the show notes. We also have a bunch of literature. We have cases from Steve Smith's ECG blog where you could see that were, you know, stone cold normal vitals with

Horrible pulmonary embolisms, just like the malpractice case. So there's all sorts of good stuff. All right, I'll let you get back to Pendle to finish up the episode. All right. So is there anything else we should hit that we haven't discussed, Pendle?

I'm gonna give you a bunch of EKGs to put in the show notes for kind of my differential of T-Wave inversion because a lot of it's so visual. And the last thing that I wanted to riff on was listening to the case and your podcast of it. I wanted to emphasize how how alone we are with EKG interpretation and expertise in emergency medicine and critical care. For every other image that we order.

You know, even if we're not the best in the world at it, there will be somebody that can help us, somebody that who's more of an expert than us. radiology, of course, for almost all the other ones. This is the only imaging study that we order where there are death threats that are in little squiggly lines that people have to recognize. And we in EM just don't have good training for it. The cultural like average is so low for what's out there and the ceiling is so high for learning ECGs.

And we take everything else so seriously, a radiologist reading an image, or we spend years learning echo and emergency medicine. We have fellowships and boards. And this is the one image that no one will back you up on and people will die from if you can't get good at it. So

I just wanna make sure people are scared enough. I think after this they're scared enough. That that brings up another idea in my mind, which is there seems to have been a sea change in Steve Smith's writing on this that I've never seen before and I've seen recently. Which is He had a very egalitarian stance on the ability of every emergency physician to gain true expertise in E. K. Gs. When I first started reading

the blog. And now I read a post recently where he's like, It takes a very special subseted person in emergency medicine to become truly expert at this. What do you make of that change in stance? Steve and I, and mo and m mostly Steve, since two thousand eight have been trying so hard to teach all of this for free and to make sure that people understand that there's so much Such a higher ceiling than is usually taught.

And I know that we've affected a lot of people and made a lot of patients more safe by people reading and learning. But overall it's hard to change the whole world and especially with Omi, I think. I think that that that is mostly about Omi is what he's talking about in that the post. I think that's right. And I we haven't made that much of a change yet. because it's just so hard to teach this by person to person free online blog.

the style. That's one of the reasons why we're now heavily interested in making AI do it, because it's just pattern recognition. It's just a two-dimensional squiggly line that has to be memorized. And humans can do it. Should humans spend their whole life doing it? Probably not. I'm a testament to that. So it's a job that seems so perfectly set up for AI that.

once that's available, the idea of spending years of every physician this training learning this versus using AI that's probably better than most of them. I think it does change the mindset a little bit. That said, Steve and I both want everybody in the world who's interested and motivated to to learn this stuff and and we always will help them do that. That's really put your feet to the fire then.

So will there be a point in Pendle Meyer's life where it's so busy in the department that he just gets handed an EKE that already has the Queen of Hearts interpretation on top and doesn't bother to look at it. Oh man, that that's painful. I think it'll that will happen for years farther than it should.

We'll we'll put it that way. All right. All right. I can't thank you enough for coming on the show. It's great to talk to you. Thanks for having me. You hate that sound. I hate that sound. Why are you hearing that sound? You're hearing that sound because You are a

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