Instructors Teach ECG Interpretation in 3 Phases

Early in my EMS career, while I was an undergraduate student just getting my feet wet, I remember being mesmerized the first time I saw a portable monitor/defibrillator. I can still picture my chief at that time showing me the monitor and telling me that this machine was capable of ECG monitoring and transmitting 12-lead ECGs to the local hospitals. My mouth hung open in pure amazement. Ever since those early days, I’ve attributed prehospital ALS to that of a “curbside cardiologist.”

I still hold fast to this notion of a curb-side, dynamic, life-changing care model outside of the emergency department (ED). EMS providers have the ability, and responsibility, to bring the ED, and even the ICU, to the patient. The gold standard and foundation of this ability is the acquisition, interpretation and treatment of ECG rhythms and other pathologies related to ECG interpretation. This very cornerstone of EMS requires a high degree of expertise that can only be achieved with a strong educational framework.

However, in EMS education we struggle with the ability to blend accelerated and inexpensive training with that of a foundations-backed, well-rounded education. Additionally, the nature of EMS and its training has relied on the ability to quickly and efficiently disseminate information without the reliance of a strong didactic or liberal arts-like component.

We’re quickly learning this model will no longer work. The work of the National Registry of Emergency Medical Technicians, National Association of Emergency Medical Technicians, Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions and many others are proving that a balanced and well-rounded approach to prehospital medicine and its education is crucial to achieving the goals set forth by the EMS Education Agenda of the Future published by the National Highway Traffic Safety Administration.1

So where does the ECG training come in to play with all of this? Well, it’s generally reserved for ALS providers in the initial education for certification. The instruction is almost exclusively via traditional, in-classroom and lecture-based with a modest amount of repetition-type practice. However, this model often leaves EMS students with a one-sided view on electrocardiography, and prehospital medicine is anything but one-sided.

The Theory

The small-group model of education modified to be effective with the adult learner will serve students and instructors well for teaching ECG education.2 First and foremost, a sturdy foundation of anatomy and physiology must be presented by the instructors and mastered by the students.3 Next is the acquisition phase of ECG. This is the only psychomotor component of ECG education and is generally picked up quickest by the students. The third phase is the analysis of ECG data. This phase will often take the most time, as the learner needs to perfect the ability to extrapolate all of the detailed anatomy and physiology previously mastered, followed by the ability to then apply the anatomy and physiology foundation and lastly critically think to achieve an informed, guided and correct diagnosis. The final phase of ECG education using this approach is the treatment of patients with particular ECG presentations. Little of this article will cover education of treatments; however, a strong foundation in A&P will serve the students best and should generally make treatment modalities a fairly simple concept for the learner.

Because all ALS provider course work is completed by adult learners, special attention should be drawn to this area of education. The adult learner brings a host of experiences that dramatically shape their ability to obtain, understand, retain and apply information. The educators’ responsibility will be to include the student’s experiences and point of view into the education model.

It’s important to remember that adult learners don’t respond well to the traditional, paternalistic approach to education. Paternalistic education is a rigid, structured type of instruction that demands students learn material in a certain way, while instilling the teacher’s all-encompassing authority in regard to values and everyday social norms. The ability for the educator to come from behind the lectern and engage the students will be paramount. The students need to understand the reason they must learn this particular information. This process then needs to be included as an active part of their education. This entire process will entail the educator being flexible with lesson planning and partnering with the students during the instruction.4

Again, a lecture-only education style isn’t ideal for ECG education. The students will gain a great deal of information and appreciation for subject matter if they’re afforded the opportunity to learn in groups. This allows the students to teach others and be taught by their peers. This combination affords the EMS student the opportunity of learning from an instructor and learning on their own level with the fellow students.

The Practice
The education should initially focus on a clear and detailed presentation of anatomy and physiology material as it relates to ECG, including electrical anatomy of the heart, cardiac blood flow, cardiac cycle and cardiac muscle cell contraction (e.g., sodium/potassium pumps, action potential, propagation, and intercalated discs). EMS instructors should thoroughly cover this important material, and the student should be evaluated regularly for comprehension during this initial phase.

Following the successful comprehension of cardiovascular A&P, the students should be taught the skill of ECG acquisition in a laboratory setting. Generally, this hands-on material is easily ascertained by students. In the lab setting, the EMS instructor should divide students into groups with a fairly low ratio of students to instructors (e.g., 4:1). The students should be shown and required to practice monitor operation, electrode style/selection, lead placement, skin prep and electrode removal.

The students should practice on each other whenever possible. Here, the students should also learn how to read blocks on ECG paper, understand the fundamentals of Einthoven’s Triangle and be exposed to vectors.

Following the completion of this phase, the students should be able to calculate time and voltage using ECG paper, discuss the principles of vectors as they relate to the ECG and properly acquire an ECG.

The third and most critical phase of ECG education is interpretation. Because this tends to be the most difficult and abstract phase, EMS instructors should pay special attention to how the information is presented and received by students. In this phase, the small-group model for adult learners will prove most beneficial. The class should be split into several groups of four to six students per group. The ratio of instructors to students isn’t as important here as in the lab setting. One to two instructors per 10 students will suffice.

Once the students are divided into groups, the instructor should begin to methodically teach ECG interpretation. The instructor should start with waveform definition and recognition.

The correlation between the concepts of electrophysiology taught in phase I and that of actual schematic representation on an ECG tracing will be paramount to the student’s ability to grasp the information. Following each concept covered, the students should be given the opportunity to explain the information presented by the instructor to one another and apply it to practice as a group. Worksheets will work well here.

Have the students circle waveforms of different morphologies and calculate rate. As the students learn the information, they’ll be able to share it with their group in an open-ended dialogue, and they’ll be able to strengthen their understanding of the material during this process.

When one student is struggling, the other group members will be able to better explain how they have comprehended the material on the level of the student, rather than the educator simply re-covering the material. During this process, the instructor(s) should continually walk around between groups helping to guide the students in the correct direction so they arrive at the correct conclusions.

This style and format should be continued throughout the remaining ECG education, including such topics as wave intervals, sinus rhythms, atrial rhythms, junctional rhythms, ventricular rhythms and even 12-lead ECG analysis.

Many EMS instructors will find that as the students use their own language and styles for conveying information, the other students in the groups and in the class benefit. As one student excels, so should the others.

This method will generally ensure that no single student silently falls behind. Additionally, the small-group model is only strengthened synergistically when supplemented by laboratory exercises, simulation practice, clinical education and other experiential practice.

This educational model will take some practice on the part of the educator, but it should prove beneficial to both the educator and the student in the long run. It should also create longevity in the competency and retention of ECG interpretation in EMS students. The adult learner responds well to this model, and the entire class will grasp the material as an entity, not just the chronic achievers.

The ability of the EMS educator to be flexible and willing to practice new techniques such as these, which better educate and prepare EMS students for the ever-changing healthcare field, is what’s needed to set prehospital medicine apart from other traditional healthcare and launch it into the future. JEMS

1. National Highway Transportation Safety Administration. Emergency Medical Services Education Agenda for the Future: A Systems Approach. Retrieved December 1, 2011, from
2. Springer L, Stanne M, Donovan S. Effects of small-group learning on undergraduates in science, mathematics, engineering and technology: A meta-analysis. Rev Educ Res. 1999;69(1):21—51.
3. Dubin D. Rapid Interpretation of EKG’s, Sixth Edition. Cover Pub Co.: New York, 2000.
4. Newman P, Peile E. Valuing learners’ experience and supporting further growth: Educational models to help experience adult learning in medicine. BMJ. 2002;325(7357):200—202.

This article originally appeared in February 2012 JEMS as “Easy as E-C-G: Teach 12-lead interpretation in 3 easy phases.”

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