Muscle Tremors, Your Patient's Dignity, and Staying Organized

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!