Rites of Passage

February 15

Ask any prospective paramedic student what they worry about trying to learn and you will likely get an answer that contains at least one of these words: Cardiology or Pharmacology. For some students – myself included the answer contained them both. Adding to my level of anxiety is the fact that the program I am attending is all but legendary locally for its program – and more legendary then the program is the exam – 200 questions – 100 multiple choice and 100 short answer questions relating to 14 different rhythm strips, with roughly a four hour time limit – Highest score ever on the test was a 98.

Interesting to me was the number of practicing medics sitting in the back of the room to “refresh” their knowledge base. The program allows it’s employees to sit in on Paramedic School lectures for CE’s – typical classes have one or two medics back there – Pharmacology had 5 or 6 – Cardiology had 15 – 20 easily EVERY NIGHT for the entire section.

We were told to purchase calipers – as there was no way we could pass the exam without them… Granted most medics don’t even carry them let alone use them in the field – but they wanted to be sure we knew how to break a strip – even the most complicated strip down.

The exam lived up to its reputation – it was EASILY the most difficult test I have ever taken – memorization wouldn’t have helped – the exam required a genuine understanding – after we took the test they told us that as far as they were concerned anyone who got a 70 on that exam was an expert in the field of pre-hospital ECG interpretation – I got a 92 – but I certainly don’t FEEL like an expert…


If only it was this easy


Cardiology started with the warning that the instructors goal for us was if someone ever asked us where we learned cardiology we didn’t embarrass them when we gave their names. Both of the instructors are captains at the division I want to work at and one of them is instrumental in the hiring process – cause you know the standard student anxiety over cardiology wasn’t enough for me – I had to ramp it up a little.

I have heard many times so far during school we don’t use a certain book for this because a good one doesn’t exist to teach you what we want you to learn (More experienced providers that write – take notice) Cardiology was an exception – they did have a book for that – but it’s interesting the one they choose.


Practical Guide to ECG Interpretation By: Ken Grauer MD FAAFP


Available from Amazon here if you are interested.

What makes Dr. Grauer’s book so interesting is that it is out of print – The program actually contacted Dr Grauer (he includes his contact information in the book in case you want to contact him about the book or cardiology in general – wow) to ask his permission to copy the book for their students – all 500 pages of it.

The process they taught us for breaking down a strip was methodical but lengthy – in fact it takes me 10 to 15 minutes to go through each step and wrote the findings out –

  • Rate
  • Rhythm
    • P- Are p waves present in lead II
    • Q – is the QRS wide or narrow – (if wide examine for BBB)
    • R- Regular or irregular
    • S – Single or married – are the wave complexes married to each other or separate
  • Intervals
    • PRI
    • QRS
    • QT
  • Axis (fasicular blocks?)
  • Hypertrophy
    • Right or Left atrial abnormality
    • Left Ventricular Hypertrophy
    • Pulmonary Disease pattern
  • Infarction – any signs of infarction, strain or ischemia?
    • Q – are Q waves present in any lead? are they pathological? are they expected in that lead?
    • R – Is the R wave progression normal? where is the zone of transition?
    • S – ST segment changes – Elevation, depression, strain pattern?  Are the changes related to a vessel or global? What area of the heart is affected?
    • T – Are there T wave changes? what do they indicate?

The answers to all of these questions only give you HALF of the information you need to interpret the strip – This just gives you the descriptive analysis of the strip – you have to take the patients presentation and past medical history into account or the “clinical impression” as the book calls it.

Dr. Grauer also says that to get the most accurate information possible from a strip you should try to have a prior strip available for comparison – and our instructors took that one step further – if you can actually get a prior strip (unlikely in our setting – but stranger things have happened) was it the patients strip on admission or on discharge ?

My head has been spinning with all the information contained in this module – Brugada’s Syndrome, Ashman’s Phenomenon, WPW (Type A & B),  Default Vs. Usurping rhythms, differentiating between V-Tach and SVT with aberrant conduction, Fib-Flutter, the potential causes of a tall R wave in V1, the causes of QT prolongation…To the point where I have to run through the steps I listed above mentally or I end up staring at the strip with a blank look on my face.

The most reassuring message came after the exam – you don’t have to be an expert at this stuff now – nor do you have to be an expert during your rides… or even during your Field Internship when you get a job as a Medic… You DO have to be an expert when you are cleared to independent duty and are making the interpretation “solo” – That’s a relief I have probably another year of practice then.

Our instructors recommended several books and a few blogs to take our studies further – I’ll share them here in case some of you may be interested

Practical Electrocardiogr aphy by Henry J. L. Marriott (Hardcover) - Called the bible of ECG by our instructors

Pathophysiology of Heart Disease 4th (Fourth) Edition by Lilly (Paperback)

Pure Practice For 12-Lead ECGs: A Practice Workbook by Robin Purdie RN MS (Paperback)


The blogs they recommend – Dr. Grauer’s Blog , , , Dr. Smith’s ECG Blog

Be good – get good – or give up


Posted by on February 15, 2012 in Cardiology, EMS, Paramedic School


Tags: , , , , , ,

8 responses to “Rites of Passage

  1. Brandon O

    February 15, 2012 at 14:58

    I am very impressed. Sounds like your instructors would fit in just fine around here. (Actually, it sounds like maybe they do!) Dr. Grauer posts regularly on the EKG Club ( and some other internet haunts; he’s a great resource and a great guy.

  2. Kevin

    February 15, 2012 at 15:01

    You can pick up a Marriott Bible dirt cheap if you search by the ISBN #. I got mine for 23c plus shipping. But get the early editions. He died after the 8th edition and it is written by someone else after that point.

  3. Ken Grauer, MD

    February 16, 2012 at 04:34

    Hello. Brandon Oto made me aware of your post. I am truly flattered and very happy that my material has been helpful for you. Unfortunately – as you note, my Mosby ECG Practical Guide book is out of print …. but I have been very active on my free on-line ECG Blog ( ) – and free ACLS COMMENTS site ( ). For anyone interested – I have written additional ECG/ACLS material (available in nook-kindle-ibooks) – and have also recently developed a detailed ECG-PDF Course for classes that takes my old Mosby book’s approach one step beyond. THANKS AGAIN for the very kind words – and I am truly happy that copying material from my prior book has been helpful to you! – Ken Grauer, MD (

    • hotlightsandcoldsteel

      February 16, 2012 at 13:44

      Dr. Grauer – Thank you for taking the time to visit the blog and leave a comment. I have several different books on electrocardiography and I must say the Mosby text is by far the most useful and easy to understand – you take an incredibly complex topic and make it easy for people to understand and implement in their practice. I will pass onto the school that you have a new program out that takes the old text one step beyond.

      THANK YOU for what you do!

  4. Too Old To Work

    March 12, 2012 at 15:56

    I’m not familiar with Dr. Grauer’s work, but Marriott is considered a standard. It’s not easy to get through, but it’s incredibly detailed.

    The best way to get good at ECG interpretation is to look at a lot of them. Some will be easy to interpret, some damned near impossible. Even cardiologists often disagree on interpretations.

    • Brandon O

      March 12, 2012 at 16:06

      You’re completely right, of course, but I do want to say one thing. I most often hear the “show this to ten cardiologists and you’ll hear ten interpretations” statement from medics trying to argue that they don’t need to be any better at reading ECGs — in other words, it’s the “knowing more than I do is just meaningless mumbo-jumbo” theory, and it’s nonsense. Certain topics in ECG interpretation are definitely academic at our level, and mainly discussed for the fun of it, but for the things we need to be good at (STEMI recognition, for instance), we should be among the very best — and the fact that it’s tough doesn’t mean it’s meaningless or impossible.

      I know you weren’t trying to pull one of these, TOTW — just a pet peeve I wanted to gripe about!


Leave a Reply to hotlightsandcoldsteel Cancel reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>