The basics of Axis Deviation of the EKG

In this post you'll learn about axis deviation of the EKG, and how you can use it to determine the underlying pathway of the patient.

Axis deviation is the general direction the electrical signal takes from the AV nodes through the ventricles. The direction of depolarization (vector) and size of the QRS arrow (amplitude) change with certain disease processes.

If the axis is not depolarizing normally, this can help clue you in to underlying pathology.

So, to determine axis, check out the hexaxial reference. Examine the QRS complex in the limb leads (I, II and III). Now find the one that has the largest deflection (amplitude). Now determine if it's upright (positive) or downward (negative).

If the largest amplitude is lead II, and the amplitude is positive, then you know you have an axis deviation of about +60, which is normal. If, on the other hand, the amplitude was negative, then the deviation is about -120, which is severe right axis deviation.

Basically, if the QRS is upright (positive) in the lead with the most voltage, the mean axis must be very close to the position of this lead on the circle. If the QRS complex is downward (negative), the mean axis must be located in the opposite direction from the location of this lead on the hexaxial circle.

It's that simple.

To make it even easier (we RTs love to keep things simple), if you look at the standard EKG, the axis will be noted for you, so you shouldn't even have to use this hexaxial reference.

Now determine axis (again, this should be noted on the EKG):

• Normal axis is 0 to +90 degrees.
• Left Axis Deviation is anything between 0 and -90
• Right Axis Deviation is between +90 and 180
• Severe Right Axis Deviation (no man's land) is anything less than -90

22. Right Axis Deviation: (axis between 9 and -90)

• a. QRS negative in lead I
• b. QRS positive in AVF
• c. QRS negative in AVF and lead I if extreme RAD
• d. QRS in V1, V2 isoelectric
• e. Slender person with ventricular heart
• f. Ventricular hypertrophy
• g. Pulmonary disease
• h. MI on left side of heart
• i. Q-wave of inferior MI
• j. Pulmonary embolism
• k. Anteriolateral MI
• l. Emphysema

23. Left Axis Deviation: (axis between +90 and 180)

• a. QRS positive in lead I
• b. QRS negative in AVF
• c. QRS in V5 and V6 are isoelectric
• d. Obese patients
• e. Left Ventricular Hypertrophy
• f. MI right side of heart

24. Severe Right Axis Deviation: (Axis between -90 and -179)

• Called no mans land
• Severe Left Axis Deviation
• Emphysema
• Lead Transposition
• Artificial cardiac pacing
• Ventricular tachycardia

24. Left Ventricular Hypertrophy:

• a. QRS complexes with exaggerated amplitude both in height and depth
• b. S wave in V1 is deep, large R in v5
• c. Height of S in V1 + R in V5 = or greater than35 mm
• d. T wave inversion in V5 and V6 with a gradual downward slope

For more, check out this link to understanding axis deviation. Check out this link to help you determine underlying pathology using this hexaxial reference. For a basic rhythm strip reveiw, click here. See the EKG library here. * Reference for axis deviation hexaxial reference is "Respiratory Disease," ed. by Robert L. Wilkins and James R. Dexter, 1993, page 41. Please note that I'm learning much of this as I research, so if you find something that's not accurate, or have a tip for making the process of learning easier, please let me know.

Do you have RT Deja Vu?

As I was performing an EKG on a patient the doctor asked the patient who her family practitioner was, and the patient said, "Dr. Pepperhead."

A minute later I was typing in my information on the EKG machine and I asked, "Who's your family doctor."

"It's Pepperhead," the patient politely said.

The RN said to me, "And she already said it."

"What?" I asked.

"The patient already said who her doctor was.

"Now that I think of it, I did hear you ask. I guess I have selective hearing

Along with selective hearing, I also have:

1. Selective hearing.
2. Lack of attention.
3. Habit of asking questions automatically at that point in the procedure.
4. Burnout
5. Brain infarct
6. Exhaustion
7. Combination of the above
8. Selective hearing

Chances are the reason I ask repeat questions is #7, or simple exhaustion from working nights

It's funny, but many times I find myself asking the patient the same questions, especially late into my shifts.

It's funny, but many times I find myself asking the patient the same question, especially late into my shifts.

"Is there anything I can get for you?" I say.

"No." Says the patient.

I proceed to wrap up the nebulizer and put it away, then say, "Is there anything I can get for you."

"No," says the patient. "I'm fine."

I do the same with EKGs. We need to put reason for visit on the EKG when they are done in ER. I ask, "So, are you having chest pain?" The patient says, "Yes." A moment later, as I'm typing in the information , I ask habitually, "So, are you having chest pain."

"Yes," the patient says.

I ask the question the second time, and then I feel a sense of deja vu.

It's funny patients, nurses, or even doctors don't make fun of me regarding this as often as I make fun of myself. Am I alone in doing this?

Perhaps we can call this situation RT deja vu, and add it to our RT Lexicon.

RT Deja vu: When an RT asks a patient the same question over and over again. When an RT askes a patient the same question over and over again."

KUDOS TO THE ADMINS

I have to give kudos where kudos are due. I have to give kudos to the ER boss and the nurses of the ER for listening to and incorporating the advice of this and other RTs.

As I have written on this blog before, it was getting to the point that EKGs were ordered for such frivolous orders, or the patient wasn't available when the RT dropped what he was doing and rushed to ER, that many of us RTs stopped rushing to do EKGs in the ER.

It got to the point our EKG response time was really bad, like 20 minutes. That's not good, especially when you have a patient who is having life threatening chest pain -- or an MI (a heart attack). In these situations, an EKG should be done within 10 minutes from the time the patient entered the door.

ACLS also recommends such EKGs be done within 10 minutes. Yet, still, there were so many stupid EKG orders that we RTs stopped rushing down. I suppose they desensitized us to the word STAT.

Now, I recommended to my RT Boss that ER should call us stat for ACLS EKGs, and ASAP for all others. That way we can prioritize, and if we can't get down right away we can call and the ER staff can do the EKG. My boss said, "There is no reason you should ever not get down to ER right away to do an EKG."

That ended the discussion. A while later I talked to the ER Boss, and she liked my idea. But, five years later, nothing ever changed.

Now, however, my idea is implemented and going well. The door to EKG time has improved from 20 minutes three months ago to 8 minutes. That's great.

In fact, yesterday one of the nurses pointed me to a sign on the window that notified us of this great improvement, and the nurse said, "Kudos to you."

I said, "No! Kudos to you and your boss."

I meant that. Now that the ER staf page us RTs STAT for procedures that should be done STAT, we know that when we get paged STAT it means STAT.

Of course it took money for the change to finally be implemented. Six months ago the head RN boss noticed that insurance companies will pay for any EKG on patients over 29 complaining of atraumatic chest pain. She also noticed that they weren't paying for most of our EKGs because the door to EKG times were way too often greater than 10 minutes.

So, she got one member from each department together at a meeting to determine what could be done to speed up the time from door to EKGs.

I was picked by the RT boss to represent the RT Cave. My suggestion was simple: "Call us STAT only for ACLC EKGs. In other words, call us STAT for Atraumatic Chest Pains."

The idea was implemented. And, no surprise, it works. We RTs are happy because we know exactly when we need to rush, the nurses are happy because they no longer have to complain we took too long, and the RT Bosses are happy because they get paid."

So, kudo's to the bosses at Shoreline Medical Center. You've earned it.

5 Common myths about performing EKGs

Since I'm the fastest and best EKG technician in the world (yes I'm arrogant. Just call my Ricky Henderson). I thought I'd take this moment to clarify some myths about doing EKGs that slow some of my fellow EKG techs down.

Yes, that's right, if you eliminate the following myths from your EKG routine, you should be able to speed up your time:

Fallacy: I have to set the machine on the left side of the patient.

Truth: The machine does not have to be on the left side of the bed. In fact, I usually set it at the back of the bed so it's out of the way.

Fallacy: The patient has to be flat

Truth: The patient does not need to be flat. You can get the same good EKG whether the patient is supine or sitting on the edge of the bed (although while sitting it's sometimes a challenge keeping the leads from falling off)

Fallacy: No one can be touching the patient when you are performing the test

Truth: I do the EKG test while lab is drawing blood or the nurse is inserting the IV all the time, and this never effects the results. There is no reason you can't share the patient with other technicians while performing this test.

Fallacy: For males, you have to shave the patient.

Truth: I rarely shave patients to do this procedure, and rarely have a poor EKG as a result. So long as you can move enough hair aside to get the stickers to stick, you're good to go.

Fallacy: For females, you have to expose breasts.

Truth: I usually cover the patient with a blanket up to her belly button, and pull up the gown so it's just under the breaths. I rarely ever see breasts. This method works very well for anxious females, and especially young sensitive ones. Some guys who pull the gown down from the top use a towel to cover the breast. Either method will work great, and your patient may appreciate your special care.

Fallacy: You have to prep the skin before doing the test.

Truth: I can honestly say I have never prepped the skin in all my years doing EKGs. The only time I prep skin is when I want the leads to stay on long term, such as when I set up Holter Monitors.

Fallacy: You can't do an EKG when the patients legs are crossed.

Truth: Yes you can.

A vampire, a ghost, or deep brain stimilation

I'd say I'm pretty fast at doing EKGs. I can start and finish an EKG in less than 2 minutes, and provide the Dr. with a quality EKG.

Yet, after I was in the room of Mrs. Leed for over 10 minutes and the machine wasn't picking up any signals, I was getting a bit vexed.

"Are you sure you're not a vampire," I said to the patient with a smile.

"It's possible," she said.

"Sorry, I'll be right back," I said to the patient, and I rushed upstairs to get a new machine. "This one must be broken."

I set up the second machine... nothing. I double checked the leads... nothing. Gosh! This can't be happening. There's no way 2 machines could be broken. Then it occurred to me. Maybe something in her was causing interference. "Do you have a pacer?" I said.

"No!" she said. "But I do have deep brain stimulation." She tapped her chest, and there was a scar covering the device. She said she had it for therapy for MS. She said it helped her with the shaking.

Still, she said the battery has been dead for a year. Just then the nurse came in, and I showed her how I couldn't get an EKG on this patient. She started to say, "Well, we have to have one," but then she looked up at the monitor, where the rhythm strip was flat line.

She checked the leads. They were all fine. "Don't even bother replacing the leads," I said. "She's a vampire."

The patient laughed, and said, "I'm not a vampire, I'm a ghost."

Deep Brain Stimulation was originally approved for depression, but has been approved for other disorders, like OCD. It's a device that requires brain surgery.

According to the Mayo Clinic: "Deep brain stimulation works much like a pacemaker for your brain. With deep brain stimulation, a neurostimulator device is implanted in your chest and electrodes are implanted in your brain. Wires under your skin connect the electrodes to the neurostimulator. The neurostimulator sends electrical signals to your brain, affecting mood centers and possibly improving depression symptoms."

Regardless, one of the disadvantages of the device is it impedes the ability to get a rhythm strip or an EKG. And I learned that the hard way today. I had never heard of deep brain stimulation before.

Now we know.

3 types of lethal arryhthmias

Dear RT Cave readers:

I promise I will write something useful soon. It has been extremely "swamped" where I work each of the past six days. We have one vent right now, but we have had up to two on many of the past several days.

And, if I am not mistaken, I have had at least one BiPAP ongoing all 6 of those days, and have set-up at least one BiPAP each of those nights. And add to this ten regular patients on bronchodilator treatments (perhaps three of which actually need them).

And then you have to add constant calls to the ER. And, of course, you have to note that I am the humble night shift RT here at Shoreline medical, so that means I did this all by myself.

Oh, and you also have to add to that some one in in my department has been a god awful something that rhymes with twitch and starts with a b minus the tw. You can figure that one out. I swear you can have a million more important things to do, and
this person still finds something to nag about.

Whoops, I'm not supposed to complain anymore. Oh, and I forgot that we (I)had an RT student last night too for the first four hours of my shift. And since I love to teach, this kind of added another responsibility to my long list of things to do.

We RTs here at Shoreline like to share our RT humor with our students. Albeit they often aren't sure if we are joking or not. Last night the day shift RT (The sagacious Jane Sage) educated them on the three basic types of lethal arrhythmia's you should be able to recognize on a rhythm strip or EKG.

These Lethal Arrhythmia's are:

1. Too fast

2. Too slow

3. Oh shit

Have a great weekend. And, oh, as soon as my energy level returns to, say, the 50% level, I will write something useful on this blog. So bare with me.

Sincerely:

Rick.

Creed updated to account for EKGs

The Real Physician's creed (not the one taught by Hippocrates and adjusted by science for modern medical professionals, but the one taught only to medical students and kept hidden from nurses and especially RTs) has been updated to account for ER EKGs.

From now on, all of the following should be treated as cardiac in origin and should be indications for STAT or ASAP EKG

The obvious: chest pain, arm pain, jaw pain, nausea, vomiting, dizzy, syncopal episode, light headed, cardiac history, palpitations, electrolyte abnormalities

Could be: fell, stroke, trauma, malaise, vomiting, poverty, homeless, maggots on body, PE, COPD, bloody nose, headache, mental changes, diarrhea

The one's RTs will cringe about but we know are needed: Hang nail, bloody nose, lice, scabies, smelly patient, sore toe, patient stinks, bloody nose, rotten odor in room, rickets, any respiratory illness, over90, stress, anxiety, sore toe, lice, blurred vision, abscess on bottom, cirrhosis, or just because the nurse felt like it.

Note #1: All EKGs MUST be completed within ten minutes whether RT thinks they are indicated or not, and whether RT has "priority" therapies or not. Non-compliance in any way, or late EKGs, will result in a write-up.

Note #2: To allay rumors, this new policy has nothing to do with the fact the hospital is guaranteed reimbursement for all EKGs. Likewise, it has nothing to do with the fact the interpreting doctor gets paid $40 a pop for basically doing nothing (or is it $60 now?).

Another doctor sees things my way

When I started out as an RT, I was told when I did an EKG to take it directly to the doctor, even if you have to hunt the doctor down. That was when I was a student.

Then, after I was hired here at Shoreline, and I continued to hunt doctors down, I was lectured by one doctor about how I didn't need to do that. So, for the next five years I did the EKG and put it on the chart, unless it was one that needed to be seen right away.

Ultimately, however, we had a massive Dr. turnover in the ER, and now we have two doctors who require that we RTs hunt them down, Dr. Krane, of whom I work with most often, is one of them. So here I am after doing an EKG, running around like a little kid hunting the doctor down to show him an EKG I know is normal.

However, last week a new doctor (Dr. Click) and the nurses kept ordering EKGs, and I kept handing them to the doc. Then, as I was handing her the 6th EKG in an hour, I observed she had a whole stack of EKGs on the table next to her. And she said, "Rick, you don't need to hunt me down every time you do an EKG. I trust you to know when a person is having a heart attack."

Wow. I was so impressed I thought I could shout with joy. After ten years in this profession, and five years of hunting doctor Krane down, this doctor confirms that I am smart enough to know what an MI looks like.

I would like Dr. Click to have a word with Dr. Krane and knock some sense into her.

Finally a doctor who sees things my way

For years my RT co-workers and I have been trying to change the EKG policy in the ER so that EKGs are only ordered on people who need them, as opposed to every person who walks into the door with CP, stomach pain, back pain, toe pain, etc.

However, our boss doesn't like to rock the boat, and he didn't want to have to go out of his way to try to convince the ER RNs and doctors that they need to be more specific on who they order EKGs on. Or, better yet, it's all about money, and the more EKGs we do, the more money we make.

And our medical director did a review of the EKGs ordered in ER, and the reasons why they were ordered, and he agreed that there were many frivolous reasons for EKGs being ordered, however he was also reluctant to overrule the ER EKG policy where the nurses get to order the EKG on any patients they think one is needed on.

Yet today I went to ER to do an EKG on a 24-year-old female with CP. To me it sounded like she had a little chest cold or something, but considering I was overruled on my attempt to get rid of these frivolous EKGs, I had no choice but to complete the procedure.

Yet this time, as I handed the EKG to Dr. Honk, he said, "I don't think we need to do an EKG on every 24 year old with CP."

"I just do what I'm told," I said. "The nurses order the procedure, and I do the test."

"Well, Ill have to have a talk with them, because I wouldn't have ordered this EKG."

Awesome, I thought. Finally a doctor who's anti-useless therapies. And now that I think of it, he doesn't order breathing treatments on every patient who comes through the ER doors complaining of a common cold either.

Wow. If Dr. Krane, of whom usually works my nights, was working, not only would I be doing the EKG, but I'd be doing a breathing treatment "to ease that chest pressure." And I'd be coming up with a new name for a new 'olin for the bottom of this blog.

I'll have to have this Dr. Honk talk with Dr. Krane and have him knock some sense into her.

RT saves life and then gets no respect from RT boss

One of my day shift co-workers did an EKG on an out-patient and it was normal. Then the patient told him that she was fine when she was just sitting there, but got SOB and her heart felt funny every time he walked.

"Well, go run up and down the hall and come back and we'll do another EKG," my co-worker said.

The patient did, and my co-worker did the second EKG, which turned out to be abnormal.

So said co-worker called the patient's doctor and the doctor said, "Excellent job of thinking off the cuff there." The patient is currently admitted in the critical care.

Said co-worker told the head RT boss about this situation, and RT boss said, "WHAT! YOU DID WHAT?"

"I had him run up and down the hall, and then I got this EKG." My co-worker showed the boss the abnormal one. "If I wouldn't have done that, the only EKG I would have got was this one, and it looks normal. Would you feel comfortable sending this patient home with this normal EKG on file, when every time he moves he gets this abnormal EKG?"

"Well, you better chart the hell out of this," the head RT boss said.

Here you go out of your way to save a patient's life, and not even that is good enough to please the RT bosses. This is another example of how they have lost touch with everyday RTing.

I'm going to be written up -- I hope

I'm going to be written up, and I'm happy about it.

About seven hours into my shift I had a patient with a bad heart of whom the ER doc had already decided to ship. I had a bad feeling about this patient, so I decided to hang out in ER until the patient was secured into the ambulance, and the ambulance was gone.

Leaning against the wall, being cool, I casually looked down at the counter and saw that someone had written something on a note pad. This is what it said: "Respiratory did not respond to do an EKG after 2 pages."

I smiled, stood by coolly, and pretended I didn't see it. Most ER nurses understand that I am the only RT on duty, and that my other patients are just as important as ER patients, but this new nurse, her name is Mary, hasn't figured that out yet.

During my recent stay in the hospital, she was the only nurse who didn't treat me like royalty. In fact, when she was my ER nurse, that was the first time I had met her. Now I'm quite certain that not only is she a bitch from the patient POV, she is also a bitch from this side too. She is a rare and unfortunate scar on an otherwise awesome staff here at Shoreline.

Despite my opinion, which is subject to change once I get to know her, I continued to treat her with respect, and I continued to coolly smile at her each time I passed her. And, to my surprise, she was quite nice to me the rest of the night. She even smiled once.

As you guys know from a previous post, I have a proposal for ER EKGs that I have yet to take to the powers that be here at Shoreline. If I get written up here, I am going to use this as a prime opportunity to state my case for STAT reform.

Instead of paging me "EKG in ER" I think I should be paged "STAT EKG in ER" or "Just because EKG in ER" so that I can prioritize appropriately. However, I did tell this to a nurse once, and she paged me STAT for every EKG, because, as she said, "All ER EKGs are STAT."

"No they are not," I said.

"Everything ordered down here is STAT."

"That's not necessarily true." And I proceeded to give her many examples: Treatment for sputum induction, treatment on a not SOB patient, pre-op EKGs, etc.

I said, "If you start paging me STAT to all EKGs, then I'm going to get numb to the word STAT. It's not fair to my patients on the floor if I drop what I'm doing every time I get a STAT page, especially when the EKG in ER isn't needed."

When this nurse I do not like paged me the first time, and to my defense, I was with another patient. I did get the page. I was tied up in another room. And, since about 80% of ER EKGs are done just because, I figured I'd finish up what I was doing before going down to ER. And, lo and behold, I received a second page three minutes later, and still decided to finish up what I was doing.

I was swamped all night.

Okay, yes I could have called. I am at fault there. However, most of the time I call to say I'm going to be a while getting down there, I get down there 20 minutes later to find the EKG is still not done, so why bother calling.

Now, you might be thinking, "If they thought to page you a second time, didn't you think that perhaps they thought the EKG needed to be done urgent?"

No. The reason I didn't think that was because ER always pages me three minutes after the initial page, especially if I don't get down there right away. I get tired of it, especially when I drop what I'm doing and the patient has an EKG ordered for a hang nail or something stupid like that.

I'm the kind of RT who gets along with everybody for the most part. I never complain. In fact, just last night I walked into a room to do a STAT EKG on a patient who was being packed up to be shipped to the CCU, and I observed the patient's NC was hooked up to a tank.

"Is that tank even on," I said while hooking up my leads.

"Yeah, I'm sure of it," the young nurses aid reassured me.

I casually unplugged the tubing from the tank and hooked it to the flowmeter, and turned the flowmeter on. Then I checked the O2 tank. Yes, it was on to 2lpm, but there was something she didn't notice: the tank was empty.

Now, instead of jumping all over her and telling her she was a stupid ass like some people might do, I used this as a teaching opportunity. She probably thinks I'm going to write her up. I won't.

Why won't I write her up? Because I know that some day I'm going to do something stupid. We are a team. We need to stand up for one another.

This ER nurse however. I am very confident that once I get her trained I will get along with her just fine, so long as there is any humanity in her. In the meantime...

I hope she writes me up.

Need STAT reform STAT

Aside from the need for bronchodilator reform, I've been thinking lately that we also need some major STAT reform. It's getting the the point that the word STAT has lost all credibility.

"RT STAT to ER," wailed overhead. I had a SOB patient in need of a treatment, but what was I to do? I rushed down to ER to find a kid in no respiratory distress. He didn't even need a treatment. I rushed back up to care for my SOB patient.

When I hear that word "STAT" that's what I think: drop what I'm doing and go (with a few exceptions.)

RT Rule #6: STAT means that you need to get to the patient's side right now. We are talking about a life and death situation.

I've been called to a room stat to do an EKG, only to find out the doctor wanted it done so he could go home. I consider that abuse of the STAT system.

I've been called to pre-op STAT to do an EKG prior to surgery on a scheduled surgery. Those EKGs should be completed way before the surgery so they can be inerpreted.

I've been called STAT to induce a sputum. Once I was called to STAT NT suction patient for this.

After I very reluctantly performed this not indicated and traumatic procedure, the nurse cornered me. He said, "I called that STAT because of the pneumonia protocol, and we had to give the antibiotic within four hours."

"That's a silly reason to call me STAT," I said. And you're lucky I didn't have anything else to do, or I wouldn't have come down right away either. I'm not letting my SOB patients suffer for this.

I was even called to do a STAT Halter Monitor once, but that ended up being the ER staff fooling around with me because they knew I hated doing Halters in ER. I suppose I deserved that one.

The first thing you learn as an RT is that a page to ER is considered a STAT page. I was told that I should be down in ER in about 5 minutes.

When I first started working here I was told by the ER staff how impressed they were at how quickly I got down there to do EKGs and treatments. "You get down here almost twice as fast as any other RT."

I was perplexed. I thought we were supposed to be in ER within 5 minutes. I thought we were supposed to drop whatever we were doing and get down there.

Then I caught on. I realized that I was quitting in the middle of a breathing treatment, rushing down to ER, and doing an EKG on a patient who had leg pain, or abdominal pain, or bad fingernails or something stupid like that. Or I'd get called down there to do a treatment on a kid with a cold.

Either that or I'd get down there and the nurses were putting in a catheter and tell me I had to wait. After a few months of waiting 10-15 minutes each time this happened, I decided I could better utilize my time.

I tried to go to my boss, but they had more pressing issues to deal with. That was a dead end. I learned that other RTs had done the same thing when they first started as RTs. Now we are all slow. According to some ER RNs, we are slow getting to ER because we are lazy.

That's fine, call me lazy, but you guys need to learn how to use the word STAT. I would like a reform of the ER paging system. When I think of STAT I think of running. I think that if I don't get there right away the patinet might die or have prolonged suffering.

One day an ER nurse was blunt with me. "What took you so long to get down here?"

"I'm sorry, I'm swamped," I said. It was true.

"You should at least call so we could do it."

"I was at a code."

Twenty-minutes later I received another page to ER for an EKG, and this time I really was busy and called. An hour later I made it down to ER and the EKG was still not done.

To be fair, most ER staff at Shorline are very understanding that sometimes RT is busy, and that we have to prioritize. And, as it turned out in this case, the nurse that did complain was a rental nurse not familiar with our hospital.

And, even while ER procedures are considered STAT, the people who order them are simply following the current protocol and, thus, doing there jobs.

To correct this problem, we at the RT Cave wrote the following letter. It was signed by all my fellow RTs:

To whom it may concern:

To speed up time from door to EKG for critical patients in the ED, and to allow the respiratory therapy staff leeway in prioritizing EKGs with important therapies on the patient floors, we propose the following paging protocol be instituted for all EKGs ordered in the Emergency Department (ED).

1.EKG Priority One: This page will be sent out for all EKGs ordered on highly critical patients such as obvious MI’s, life threatening arrhythmias, failing patients, etc. Upon receiving this page, the RT will drop what he is doing and run as fast as he can to the ED. If RT is unable to complete the EKG within 5 minutes, the ED will be called and the ED staff will complete the EKG.

2. EKG Priority Two: This page will be sent out for all EKGs that fit under the ACLS protocol where the EKG must be completed within 10 minutes of the patient’s arrival in the ED. Upon receiving this page, the RT should be in the ED within 10 minutes to complete the procedure. If RT is unable meet this time frame, the ED will be called and the ED staff will complete the EKG.

3. EKG Priority Three: This page will be sent out for all EKGs that do not fit under the ACLS protocol, the patient is stable, and a time frame from door to EKG is not essential. Upon receiving this page, the RT will have leeway to complete other
essential procedures prior to arrival in the ED. This page will also be utilized for all pre-op patients, and any patient currently unavailable due to use of commode, bathroom, gone for x-ray,CT, etc.

Ideally, priority three EKGs should be completed within 20 minutes from time of page. If RT is unable to meet this timeframe, the ED will be called with an estimated time of arrival. In some cases,the ED staff may decide to complete the EKG and, if this occurs, RT will be notified the procedure has been completed so they don't have to rush down when they finish the task at hand.

If the ER staff is called to do an EKG, and the EKG is not completed in a timely manner, the RN will have to order pizza for all the RTs on duty. If this is not possible, the total sum of $50 will be extracted from the RNs paycheck and set aside for an end of year RT party.

We believe the implementation of this protocol is essential to improving staff time management, and, more important, improving patient care.

Sincerely, The RT Staff

We understand it's a hell of a lot easier to be called lazy (we're used to that) than to try to change policies and procedures that make no sense. But we had to try with this letter.

If this works, we will tackle STAT ER treatments ordered on patients not having bronchospasm next.

Modest Men die and stupid people live

RT Cave Rule #2: Modest men feel stupid about coming to the ER, especially when they are perfectly fine, so make them feel like they did the right thing, even if you have to tell a white lie.

A man came into the ER tonight with obvious Atrial Fibrilation. Needless to say I was called to do an EKG on him.

"And, why are you here today?" I ask as I'm typing information into the computer.

"Oh," he said nonchalantly, "I've been feeling kind of funny all day, but I had to work." He smiled as he said the last part.

Dr. Krane came in. She said, "You mean you've been feeling crappy all day and you didn't go to the doctor?"

"Well," the patient smiled, "I took my blood pressure last night and it was normal, but when I woke up this morning it was high. But, you know, I had to work."

Hmm, so work's more important than your life. Talk about having your priorities straight.

I finish the EKG and hand DR. K a copy, who gives it a cursury glance and then looks at the patient. "So can you feel your heart beating fast?" she asked.

"No."

"Where do you work?"

"I'm a truck driver." Wow, that makes me feel better.

I do a lot of EKGs, and a lot of them aren't even indicated. Many times, when I tell the patient his EKG is normal, he says, "I knew I should have stayed home, but my wife made me come in."
"Hey, don't be thinking that way," I tell them, "You did the right thing by coming in."

Sure most of these chest pains are indegestion or some other abdominal ailment, but when that EKG shows something is wrong with the heart, especially when it's in its early stages, that man thanks his wife for saving his life, or at least he should.

But when he's had chest pain for two days, and nobody made him come in, and he really is having early signs of The BIG ONE, he'll be making a trip in here anyway, and he will be blue from the nipples up, with a tube in his throat, a bloated stomach from a botched CPR attempt, and a no hope for seeing the next day, let alone the next minute.

This happens more often with men than women, but Lord knows there are some modest women out there too.

So my man today with the AFIB has red eyes and smells of alchohol.

"When was the last time you had a drink," Dr. Krane asked.

"Oh, I had one last Wednesday."

The doctor shook her head. Like, this doesn't happen every day at Shoreline Hospital.