Where are you:
You are an FY2 in Cardiology Department.Who is the Patient:
Jaden Smith, a 5th year medical student (or a Nurse) who is undergoing a rotation in your department has come to you to learn about ECG (They might hold 3-4 ECG in their hands)What you must do:
Talk with Jaden and teach him ECG.Special Note:
None
1. Introduction
Hello I am (Your name) A junior Doctor in this department.
You must be Jaden right?
2. IDcheck
Yes Dr. (Your name) I am Jaden.
3. Buildrapport
How are you doing? / Ask about work/ Ask about the weekend/ Studies… etc.
4. Main concern (how can I help you)
I want to learn about the basics of the ECG can you please teach me?
I can see that you are very much interested in learning about the ECG.
I really appreciate it.
(Praising) Positive reinforcement.
5. Assess knowledge(4w)
What do you know about it (past)
- Can you please tell me how much you know about the ECG?
- Doctor I know how to record ECG on a machine but or I don’t know much about how to read it. Doctor please teach me here I got you some ECG.
What do you want to know (future)
- What are the Waves?
- How are the waves produced?
- How to check the Heart rate?
- What is a normal and an abnormal ECG?
- What is S.T segment elevation?
Why we do it (for colleague)
- We use ECG to diagnose if there are any heart related issues like Arrhythmias, Heart Attack, Coronary Heart disease and Cardiomyopathy. Am I clear so far?
- Yes Doctor.
6. Teach the ECG (Now let me tell you how to/ What to do next)
- Explain the student/Colleague ECG by Drawing Heart and Waves
- Then tell him to take consent when he has to do ECG
- Then Attach leads
- Ask about patient if he shows you some ECG where did he get them and did he take consent from the patient or are they for teaching purpose.
Waves
- Ok, so firstly we need to know how ECG is recorded. Sensors are attached to the skin which are then used to detect the electrical signals produced by your heart each time it beats
- These signals are recorded by a machine and are looked at by a doctor to see if they’re unusual. - These signals are waves.
- There is a spark that is initiated from this point - SA Node
- You will have a paper and pen to draw a simple figure of the heart. Show him what the structure of the heart is: Point to SA Node, These are the Atria and those are the Ventricles.
- This spark created from the SA Node travel through gates to reach all of the heart, creating impulse that resemble life (try to choose your own words, but please choose simple words and to the point)
- Hold ECG and show what everything of the draw can be translated to a wave in the ECG
- This impulse of SA node creates P wave and when these large chambers (Ventricles) Contract they create QRS wave (point at it)
- After that it must have time to rest (milliseconds) that equal this wave, which is T wave.
- Now you know the unit of the heart and check with the colleague or the nurse that he understood what you have said
Then, you move to the Next:
Rate and Rhythm
- We will determine either the beats of this heart’s tracing are regular or not
- If the distance between each R wave are the same, so it is regular
- And then you can calculate the heart rate, how?
Calculate Rate for Regular Rhythm.
- If Regular then you need to count the number of large boxes between 2 R waves and divide it with 300.
- So, for example if you get 4 large boxes between 2 R waves then it will be 300/4 = 75 bpm. Which is actually a normal heart rate.
- Do you know the normal heart rate? Yes between 60-100 bpm
- What if it is higher and lower than this rate? DO you know what they are called?
- If you see them please involve your senior because most probably there is something that may need to be assessed quickly.
Calculate Rate for Irregular Rhythm.
- What if the rhythm of the heart is irregular? How can we calculate the heart rate then?
- But before that I want to highly stress on the point that if you find the rhythm of the heart is not regular, it is very important also to involve your senior.
- So to calculate irregular heart Rate, you will count 30 large squares and whatever the number of R waves present in these large 30 squares and then multiply by 10
- For example; you found 8 R waves in 30 large boxes, then you multiply the & with 10 you will get 80 that is the HR in irregular Rhythm
ST Elevation
- Now I will teach you about S.T elevation which we use to detect M.I
- If you see ST Elevation in any leads when they have symptoms of sudden severe crushing central chest pain radiating to the left jaw/ neck/ shoulder/ arm then it means the patient might have MI and needs urgent management calling for help and seniors.
- Only teach what he/she requested
- If you finish and still have time check understanding and thought retention: Ask do you want to learn anything else / do you want to learn about? No Doctor this much knowledge is enough for me.
- After tracing and reading ECG remember to note it down in the patient notes and thank the patient. - - And always look for red flags and safety net,