The importance of good data quality to a successful prehospital 12 lead ECG program cannot be overemphasized. After all, life and death decisions are made based on the 12 lead ECG. If an EMS system routinely transmits garbage to the emergency department, it should come as no surprise to anyone that the cath lab isn’t being activated while the patient is still out in the field.
I’m not promising that an emergency physician will react appropriately to a “clean” 12 lead ECG that shows acute STEMI, but it certainly increases the probability of achieving a functional program.
Why give them an excuse?
This is an ECG of a 26 year old recruit firefighter. When it was taken, he’s was lying down on the kitchen counter at the fire station. One thing you should know about Station 6 is that it’s almost always cold. They don’t call it the “Ice House” for nothing (t-shirts available). You will notice muscle tremor artifact in every lead.
Now, who do you think feels colder? A healthy 26 year old recruit firefighter, or a 79 year old female who is accustomed to wearing three layers of clothing when it’s 80 degrees outside?
For this ECG we placed a large towel over the recruit firefighter to keep him warm. That’s quite an improvement, isn’t it? Keep your patient warm, have him relax and breath normally, and make sure he’s not propping himself up with his arms on the rail of the gurney (or any other type of furniture). Tension on skeletal muscles may be transmitted into the ECG.
I always follow the same steps when I capture a 12 lead ECG.
In the first place, I undress the patient from the waist up, including the bra (if it’s a female). When I do this, I communicate first. I will say something like, “Mrs. Smith, I need to perform a 12 lead ECG, so I need to undress you from the waist, up; including your bra. We’ll get you covered up just as soon as possible, and I’ll make every effort to preserve your dignity.”
This invariably elicits the response, “Do whatever you need to do.”
There’s no reason to perform a 12 lead ECG while the patient is still wearing clothes. Please don’t be one of those paramedics who reaches down the front of the patient’s shirt to place electrodes. I understand why you might be tempted to leave a female patient’s bra on, but don’t do it. Just be professional. If you need to lift up a patient’s breast, use the back of a gloved hand. When you’re finished, you can lay a towel, sheet, and/or blanket over the patient. Now when the nurses in the ED gown the patient, they don’t have to disconnect the IV (and break sterility) or pass the IV bag through the patient’s sleeve.
Any member of my crew will attest to the fact that I’m very particular about how I organize my patient. When I load the patient, I make sure that the patient is centered, sitting all the way back, and not slouching on the gurney. That way, if I place the patient in high Fowlers (as you might when you’re trying to undress the patient) the patient is actually sitting up.
I strand out each individual ECG lead so that they don’t wrap around each other, and I never allow the ECG leads, oxygen tubing, and IV line to become tangled. When I place the precordial leads on the patient’s chest, the (rectangular) electrodes are lined up with the edges parallel to each other. This is a matter of personal pride for me. When I look down and see a well organized gurney, with a squared away patient, it helps me feel in control of whatever situation I’m dealing with. I also believe that it helps me achieve excellent data quality with my 12 leads.
If you’ve ever been in an ambulance with a critical patient slumped to one side of the gurney, the ECG leads falling off, IV lines wrapped around oxygen tubing, the cardiac monitor beeping, and it looks like a bomb’s gone off in the back of the ambulance, it’s not a pretty sight. I’m not saying that I never trash the back of the ambulance, but it’s rare, and I don’t mind telling you that I’m not okay with it. Generally speaking, you can be as good at patient handling as you make up your mind to be.
Think of the back of your ambulance as your place of business, and your patient care as your product. If you’re okay with your patient looking like a train wreck, you probably don’t mind your 12 lead ECG looking like chicken scratch.
More troubleshooting tips to come!
Tom:”I strand out each individual ECG lead so that they don’t wrap around each other, and I never allow the ECG leads, oxygen tubing, and IV line to become tangled. When I place the precordial leads on the patient’s chest, the (rectangular) electrodes are lined up with the edges parallel to each other.”Bless you, sir. Bless you.IMHO, one of the hardest things to teach new medics (especially flight/critical care medics), is the management of the “spaghetti” of wires and tubing that is always present with a really sick patient. Two IV lines, a Swan-Ganz cath, ECG leads, B/P hose, SpO2 wires…. you end up with a knot of epic proportion if you don’t know what you’re doing.
If you remove the bra of a female patient and you do not have her written consent be prepared for a law suit in most states. There is absolutely nothing to be gained in terms of quality unless you are a novice in removing the bra in doing an ekg. Remember this is not a decision that you make. The patients body belongs to the patient. NOT TO YOU.
Anonymous – I have responded to your comments here:Data quality, lead placement, your patient’s dignity, and undressing female patients Tom
On every 12-lead I do the following:
1) correct anatomical placement of electrodes for 12-lead ECG. (this is a pet peeve of mine)
2) skin prep the pt before placing limb leads and precordial leads.
3) lay the pt flat (supine) as possible
4) make sure the pt lays their head back against the pillow (a pt just holding their head up can create lots of artifact)
5) avoid placing electrodes on bony areas of pt (I.e. Shin, clavicle, knee, ankle, etc) as this is a poor conductor and will reflect poor capture on the ECG.
These are just a few of mine. Skin prepping is one of the most important and can drastically improve the quality of your 12-lead ecg’s. Precordial leads especially can pick up more artifact due to having a much higher frequency than the limb lead electrodes.
References:
http://Www.12leadecg.com/full/
We carry hospital gowns in our ambulances to improve the dignity of pt’s having to have 12 leads done in the field. The nursing staff really appreciate the fact that we already have that much done for them before we arrive at the ED.
not removing clothing to run a 12-lead is like not removing clothing before strapping a trauma center patient to the longboard. LAZY! and way more work later to get those clothes off. clothes come off at the hospital anyway. think.
interestingly the stress lab manages to get a perfect tracing while the pt is sweating, breathing hard, and jogging on a treadmill… I suspect voodoo may be involved…
Neatness is of course good but not at the expense of TIME, which is muscle.
Removing a bra to do a 12-lead in the field is highly questionable. NONE of the 12-lead goes where the bra covers. If you are exposing without medical necessity then you are not really getting patient consent.
Medic511,
I'm not sure where you're placing V3-V6, but all 4 of them go where the bra goes. Perhaps you're placing electrodes underneath the underwire? Or below the inframammary fold?
I certainly organize and detangle my wires every time, otherwise you lose about a foot of wires and I really does bother me when they're tangled. I will admit that I rarely remove clothing, definitely remove in trauma situations, but never really thought about it for medical calls, just worked around clothing, but I might start that now. I don't understand the outrage about removing a bra. I always tell my patient what I want/need to do and make sure they understand and give permission before I do it. I tell all my students to do this as well, for patient consent and so they know what we're doing and why.