Introduction to Pacing

Exams are over, coursework is in, and I’ve FINALLY got some time to devote to TSP, so I’ll endeavour to post updates with the same level of regularity as I did a few moths ago. It’s been a while since I added anything other than study pages, so it’s proving difficult to get back into the swing of reflective writing. I shall try to be clear, however.

The first week of my 15 week placement has been an interesting and challenging one. I’ve been in pacing clinics (the third of which allowed me to have some hands-on experience), tape clinics and have analysed my first full 24 hour ECG recording, so the amount of information I’ve absorbed has been of a high volume in a short space of time.

I’m not going to comment on tape analysis or clinics just yet, as I’m yet to have my completed work assessed, so I’ll wait until I’ve gained some feedback on my current performance. Pacing, however, is extracurricular, so I’ll glady share my experience.

Pacing checks were very fun; during eight or so hours of lingering/observation, I was gradually allowed to do a bit more with regards to clinical practice; analysing lead outputs and EGM readings, setting up programming equipment and learning my way around each box-specific bit of software, etc.

The majority of patients that came into the clinic were annual follow-ups, and six week post-insertion assessments, wherein the overestimated pacing parameters are altered so as to preserve battery life, and due to their nature, each was simply a case of checking each value and adjusting accordingly, meaning each 15 or 20 minute consult went off without a hitch, and I got a feel for the regular procedure and could have some of the physics explained to me. It also allowed my tutors to ask me questions and test me a bit.

The third and final clinic, however, allowed me to assume the role of primary (under strict supervision, of course) and perform threshold tests on my patient. It’s amazing how quickly it’s possible to forget everything you’ve spent the last few days learning, when it comes to actually doing it; the sudden pressure of being thrown into practical learning caused my mind to go completely blank, but with a bit of time, I settled into the role and things started to make sense as I was doing them. There’s a really overwhelming feeling of resposibility when you’re charged with manually increasing or decreasing your patient’s heart rate during threshold tests, and in addition, spotting the loss of atrial capture is, in most cases, far more difficult that that of ventricular capture. It was an exillerating experience, though, and I really felt like I had accomlished something at the end of the clinic. In three days I felt like I could quantify my progression, so the first week has left me feeling excited for the rest of the placement block.

Until this week, I’d never considered pacing as a future specialism – I was focussed on echo –  but getting some real exposure has shown me how much I could enjoy a future in the discipline. I can’t wait to do more.

I’ll write more about my own research into pacing as I do it, so keep an eye out for that.



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Review: Acadoodle


Price: $99/ £66 per annum (approx)

Authors: Dr John Ryan, Dr John Seery

Acadoodle is a subscription-based online resource for ECG training that boasts a large selection of video tutorials which can be viewed individually, or as part of a tested course. The ECG Teacher sections are the primary focus of this review, but other courses such as blood gas analysis are available, however.

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Produced by Drs John Seery and John Ryan, I found these courses to compliment my study, and even when I wasn’t watching them directly, I found myself letting them play in the background as I read a textbook, or went over my lecture notes.

The videos themselves are well produced and make understanding the ECG and its subsequent analysis much easier. The animations are slick and the narration is clear, concise and full of all the pertinent diagnostic information you will require.

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Each area of study is tailored to a specific area of electrocardiogram diagnostics, so each playlist/module flows from one video to the next. In addition, the flow of the modules themselves makes sense, and the learning curve increases in a logical order and as such, each section follows on from the one that precedes it in a manner that doesn’t overload you with information before you’re ready.

A small selection of the videos are available on YouTube, so if you wished to try before you buy, then searching for “Acadoodle” would throw up some of the more basic tutorials for you to have a look at. I noticed that these YouTube videos are also embedded in the Acadoodle site proper, giving rise to a sometimes noticeable drop in picture quality, on occasion.

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It’s nearly impossible to fault the content and structure, as these videos have helped me immeasurably throughout the last six or seven months, but it is an expensive purchase for anyone, let alone students, especially when you consider that almost all of the content is in some way available via lectures or found in other, similar video courses on YouTube. In that respect, despite the quality of the content, I find it hard to recommend Acadoodle to physiology students who are considering purchasing a personal subscription, but for lecturers or professional bodies and universities, it should prove to be a valuable asset when clarifying concepts to a class full of students.

That isn’t to say that a student purchasing a subscription wouldn’t get a lot out of Acadoodle; it’s certainly worth it, it’s just expensive at a time when disposeable income is generally spent on textbooks or… food and shelter. If splitting £66 is something that you and a few peers feel is possible, then I highly recommend it, as the website can be used from multiple PCs with little to no issue.

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Being A Patient: Part I

(or “what I learned when the tests I have done to others, were done to me”)

The tests presented in this post are intentionally not explained thoroughly here. I have focussed, currently, on patient experience. If you wish to learn more about the things presented here, and the interpretation of the possible results, wait for them to be explained in your lectures, or, perform a quick Google search.

Before the new semester began proper, I was asked to assist with some physiology practicals on my campus. I agreed because I felt (much in the same way a chef will sample his/her food before selling it to the masses) that it would be good for my overall learning to experience the same anxieties and physical exertions -if applicable- that a patient may endure when they undergo physiological testing. When one repeatedly performs tests day in, day out, it’s easy to forget that the patient likely does not have anywhere near the same levels of familiarity with the procedure and proficiency with them as that of you, the practitioner, so to gain an insight into the emotional and physical aspects from the other side would, I felt, be good practice.

Day one was one of a cardio nature, in that I performed lots of exercise tests at a physiologist’s disposal. (Some of these tests are reserved for respiratory physiologists, but if you’re studying and are not yet at the point of choosing which PTP pathway to follow, you’ll experience these, too).

I discovered upon entry, that I would be performing the following:

  • YMCA step test
  • Bleep test
  • Treadmill test: ramp protocol (similar to the Bruce Protocol)

The wait to enter the lab was, (obviously not the same in terms of anxiety levels, but regardless) akin to a patient’s wait to enter a clinic testing room; knowing that I was going to have to perform tests, but not knowing exactly what they were was rather nerve-jangling (especially considering my then-unknown weight gain after the obligatory food-filled, sedentary lifestyle commonly experienced over the festive break).

The real difficulties stemmed from trying to comprehend the techniques required for each test. Explaining, or writing about them is one thing, but actually doing them is another thing entirely.

The YMCA step test itself wasn’t particularly challenging, given that it only involved 3 minutes of steady box steps. The difficulty came in not influencing heart rate on recovery. Knowing that my HR was being documented every minute meant I kept looking at the oximeter, and as has been documented (a quick google search will give you confirmation of this), it is relatively easy to change your HR on command.

For a patient, this last point may not be of particular issue, given that they might not be particularly aware of the potential influence they can have on their HR, but I can easily see how repeatedly stepping onto and off of a box could be difficult task for a patient of advanced age.

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Bonus Clinical Perspective: In this test the Heart Rate Recovery and VO2 max doesn’t appear to be particularly accurate, when using normal values, especially when compared with the VO2 max displayed through the other tests, either. The values are based on age, as oppose to individual physiological characteristics, so assume a physical ideal that doesn’t necessarily transcend to real life.  

The bleep test wasn’t like ones I have previously attempted in the gym, or what have you; rather, it was more about timing, ensuring there were no stops. This involved slowing down so as to reach the end of the designated track in time with the beep, then speeding up to repeat, meaning that pacing yourself was a must. The resulting strain on my legs caused them to become incredibly painful, incredibly quickly..! (I’m aware that bleep test procedure differs between fitness centres, so forgive my whinging if you use this format regularly).

Encouraging a patient to exhaust themselves doing this test would take a great deal of commitment from both parties; I’m not particularly unfit, but I had nothing tangible to aim for, with regards to an end point, so with no time to “beat”, I didn’t have anything to work towards and as a result, I gave up after 10 or so minutes, despite the fact I could have carried on for a while longer.  For the average patient that would frequent clinics to perform this test, achieving maximal exertion may not be something that can be coaxed out of them, especially if they had already endured other tests in the same day.

Already I was beginning to understand the plight of the patient, when it comes to tests that require their full participation, and I still had the hardest one to come… I was not looking forward to the post-lunchbreak activities.

It turns out, the Ramp Protocol test was actually the most enjoyable of the day. Perhaps this was simply because I was growing used to being fatigued/dehydrated, or perhaps it was the setup of the test itself, but I could have happily continued running on the treadmill for a great deal longer than I did, time allowing.

The ramp protocol treadmill test involves the face mask setup presented in the pictures, and a steady speed and incline increase on the treadmill for as long as it takes for the patient to reach their VO2 max, but it is up to the patient when they stop. Unlike the bleep test, which involved travelling at an uncomfortably slow rate at times, the ramp protocol was a fairly rapid journey to a pace similar to that of a distance runner. It was far from comfortable, so would still require a great deal of coaxing and encouragement in order to get the patient to work hard to complete the test, but it was certainly more comfortable than the test that had preceded it.

The whole day not only reminded me of tests and theory that I had almost forgotten, but it really helped me to understand what a patient has to go through when they visit a hospital. The feelings and tests that I personally experienced were, on the whole, not pleasant, but I wanted to be there. For a patient, this will most likely not be the case. When your clinic list is seemingly never-ending and you don’t have time for restarts, it’s easy for the fact that patients don’t know the requirements and procedures as well as you might, to slip your mind, but thanks to this experience, it’s something that I’ll never forget, and I feel it solidifies a vital skill that students require to be able to operate efficiently and fairly: empathy.

Tomorrow brings a different kind of discomfort, in that I will be having my first echocardiogram. I’ll add that experience to part II

The ramp protocol will also get the full write up treatment, as it was by far the most complex and in addition, I have a detailed set of results.

Thanks for reading.


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Holiday-Only Arrhythmias

During the festive season, its easy to indulge in excess; too many sprouts, an increase in afternoon napping, festive drinks… You know the score. It isn’t all smiles and sunshine, though, as we shall see.

One particular result of all the festive excess relevant to cardiac professionals, has been reported across the globe, but particularly in Entirely Fictitious Primary Care Centres (EFPCCs); Bacardi Branch Blocks, or BacBBs

BacBBs are thought to affect the heart as a whole, but it can be seen that they have a particularly odd effect on the ventricles, and cause an odd, never-seen-in-real-life depolarisation wave on the ECG, that actually defies physics and medical science by going back in time!

Symptom sheets compared with the compiled ambulatory data have shown unanimously that BacBBs are present sporadically within sinus rhythms, but coincide with that one-drink-too-many during a family game of Monopoly (Mr Moneybags isn’t thought to be an underlying cause, so the activity isn’t seen as a risk factor).

Atrial activity stops altogether, presumably because the SA node just forgets what it’s doing, as it’s seen enough crepe paper hats and screwdriver sets fly from crackers to last it a lifetime.

After an episode of BacBB, sinus rhythm resumes, and the patient will return to whatever their festive-norm may be until the next instance.

This phenomenon seems to disappear entirely during the first couple of weeks of January, when normal working hours begin again, hence, I feel that it is triggered by the holidays themselves.

None of this is being researched, or is even disputed, because it is both totally false, and invented entirely by me.

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Bacardi Branch Block

  • Common holiday rhythm abnormality only found during the festive season, and even then, only in fictitious settings
  • HR between 80-120bpm
    • Depends entirely on board game leader-board position
  • No P waves
  • Abnormal ventricular action
    • Resembles upturned cocktail glass
  • Is thought to only contribute to familial tolerance levels during prolonged exposure to each other



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Review: AliveCor Mobile ECG Monitor (3rd gen)

Download the android app: Free

Purchase the monitor: £75 approx.

Developer: AliveCor, David Albert

Thus far, my reviews have been mostly confined to apps, with the only exception being Windows/Linux software, simECG. This review is quite exciting for me, as it involves a physical monitor as well as a companion app. I picked up the now world-famous AliveCor Mobile ECG Monitor a couple of days ago to road test it, and I’m pleased to say that for patients, it’s fantastic, and for students, it’s just as good.

As far as functionality goes, this app serves as a personal event monitor with a particular focus on atrial fibrillation, and it has a ton of nice features that make it a worthwhile investment for patients regular to cardiac departments.


Out of the box, the dual-electrode plate can be attached to the back of your mobile device via an adhesive strip, or kept separate; AliveCor works either way, and if you do attach the monitor and change your phone, you can pick up additional attachment plates for around £6.

Obtaining a trace is a very quick process; it only took me a few seconds to open the app and begin recording, and the trace is saved automatically after 15 seconds, with the limit set at 30. The user is then presented with a series of tick-able boxes such as hand or chest ECG, and a notes section to document any symptoms. These are then stored with the trace.

In this video, you can see that AliveCor jumps straight into recording once fired up.

Heart rate and beat fluctuation are tracked and graphed automatically to allow patients to relate multiple recordings in conjunction with the particular activity being performed during monitor operation.


In addition to this, the app comes with an algorithm that determines the presence of atrial fibrillation and keeps track of how many instances this occurs.

AliveCor offers a great deal of options when it comes to sharing data and to physical useage: once the trace has been recorded, the user can email it, save it as a fully notated PDF and print either from the app or a different program.


Holding the device in your hands, as shown in the app instructions gives you a trace in lead I, and it’s possible to obtain leads II and III by placing the two electrodes in different areas of the body (I have provided these instructions at the bottom of the page). Handily, AliveCor doesn’t just measure biopotentials in the peripherals, but also in the chest. A Lewis lead configuration is possible to view atrial activity with more clarity.

I experienced a minor issue with artefact at the start of recording, but this was almost definitely user error, as AliveCor ‘steadies’ itself pretty quickly if you remain relaxed and support you arms. This learning curve is honestly the only problem I had with the product, and after 10 or so minutes, it wasn’t a problem at all. I don’t want to speak for everyone, but I feel it’s fairly easy to get to grips with, so I doubt that your average patient would have too much trouble with it after a short while.

Traces themselves look very clean and, thanks to the standard calibration and the inclusion of a regular ECG paper grid, various amplitudes, intervals and waveforms can be measured manually. The trace screen also gives the option to invert the recording, and filter enhancement is selectable for each one.

As an event monitor, this device is invaluable. It comes with its own built-in symptom sheet and it’s incredibly quick and easy to record a good quality trace. AliveCor has been given the thumbs up from the FDA and NICE, so it’ll be interesting to see how the SCST view the monitor; I’ve reached out to them, but haven’t heard anything yet. If I do, I shall update accordingly.

I assume that in the U.S. this app allows patients to forgo some of the high cost of continued medical care by way of allowing the trace to be sent directly to a clinician for review. The UK version gives the option to send the trace to a Cardiac Physiologist for £5 and provides the analysis results within 24 hours, allowing the patient to present an official ECG report to their GP, should they need to.

As an added bonus, the AliveCor app has an educational area that features breakdowns of common arrhythmias and cardiac anatomy. The illustrations are aesthetically very pleasing and straightforward. The information contained within it is not as comprehensive as the information you’ll find in your lectures or textbooks, but it isn’t designed for the use of practitioners, so what is there is entirely sufficient.

All in all, AliveCor truly is a technical feat and not only does exactly what it sets out to do, but gives a glimpse of the future of ECG technology. This is an extremely good way for patients to become actively involved in their own heart health, with a relatively small price tag. The app provides a simple, intuitive UI and doesn’t require any Bluetooth connectivity between monitor and phone: it works right out of the box so that any patient can use it with ease. There’s a reason this product has garnered praise around the globe.

I will add that the device’s creator, Dr David Albert, is one of the nicest individuals with whom I have ever had the pleasure of conversing. His instructions for getting the most out of AliveCor for the purposes of this review have been invaluable, and even though he really didn’t have to, he answered every question I asked him, swiftly too. I’d like to thank David for being kind enough to help me get to grips with the product all the way from his residence in Oklahoma. Students need input such as this; it cements that we are valued and encourages learning outside of regular studies.

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Positioning data:

Lead I: LH – RH

Lead II: LL (knee) – RH

Lead III: LL – LH

Lewis: Electrode 1 on V1, device angled vertically

Is Mobile Echocardiography On The Horizon?

Smartphone and tablet technology is advancing at a rapid rate, so it should come as no surprise that it is being used for a variety of different purposes. Healthcare companies are finding novel ways to encourage patients to take charge of their own health; peripherals allow for BP measurement and three lead ECG monitoring in one’s own home, and it’s possible to measure your heart rate at rest and during exercise now, with software that comes as a pre-installed fitness suite on most modern devices.

It stands to reason, then, that these same companies would create clinical grade applications and device extensions that would benefit practitioners, also. I covered the use of Google Glass in revascularisation, already, but another device is making its way to the market at the moment, too; mobile ultrasound.

After unveiling it in 2014, Philips were granted FDA approval of their Luimfy system only a couple of weeks ago and have announced that it is now available for purchase in the US.

A $199 per month subscription, an Android phone/tablet and a micro USB probe are all you need, as the app and it’s peripheral are designed to work with compatible devices off-the-shelf.

In its current form, the scanning app allows practitioners to examine the gall bladder, abdomen and lungs, in addition to having obstetric, vascular, superficial, musculoskeletal and soft tissue functionality, so the device isn’t suitable for echocardiography, but I’m certain that in the future, given the power already available in modern devices, it’s a real possibility.

In UK hospitals, where space is a deciding factor for treatment options, having an ultrasound monitor that can fit in a small case would be a real boon. Emergency and critical care ultrasound is actually what the system was designed for, so it makes sense that the most obvious impact relates to time and accessibility.

Streamlining the healthcare process is paramount, and the fact that this system is based around an app could be a real advantage. The images gained by the practitioner can be shared via the cloud, so the network of professionals involved with one patient can have near instant access to the relevant materials needed for diagnosis. Philips could also provide continued software support and provide updates based on user feedback, without the need for engineer call outs.

Now, I’m no app developer (I’m trying. It’s rather complex…), but I do use them, so I can identify some common problems in cloud storage and functionality.

Firstly, as this is an Android app, it may present issues in performance across devices. There are a number of latency issues with apps for this OS and further issues regarding app performance in general from one device to another, especially if the base OS differs slightly between manufacturers (if you’ve tried to compare performance between Samsung and Google Nexus, you’ll know what I mean). In this case, Philips would have to be fairly on the ball with their customer support, especially given the subscription costs for practitioners.

I guess the issue with cloud storage brings us to patient confidentiality, as the last couple of years have seen some high profile cloud hacks leak “sensitive” data to the public, but many hospitals are already digital, so surely it’s a case of ensuring the level of security is appropriate.

As far as echo goes, the advantage of switchable probes and live, cloud updating comes into its own; echo features could be added with an update, in theory. It’s a case of making it happen. It’s unlikely, but if I ever get a chance to try one, I’ll make sure to tell you of my experience.

For more information, go here:

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Virtual Reality In The Cath Lab

If you’ve kept abreast of tech news in the last few years, specifically with regard to Google Glass, you’ll probably be aware of two things: 1. it has been met with scepticism and apprehension, and 2. at present it’s largely pointless.

I’ll admit that the second point is subjective, but now, this (my) subjective view is likely to change. A team of cardiologists from Warsaw have used Glass’ virtual reality capabilities to tackle what is referred to as the “final frontier in interventional cardiology” by repairing a total occlusion of the right coronary artery.

An effective visualisation of the coronary arteries is often lacking using normal angiography radiology techniques, but by employing coronary computed tomography angiography (CTA), a smartphone app and a headset based on Google Glass, the team at the Institute of Cardiology have successfully restored blood flow in the right coronary artery of a 49y/o male, with two drug- eluting stents.

“This case demonstrates the novel application of wearable devices for display of CTA data sets in the catheterization laboratory that can be used for better planning and guidance of interventional procedures, and provides proof of concept that wearable devices can improve operator comfort and procedure efficiency in interventional cardiology,” says lead investigator Maksymilian P. Opolski, of the Department of Interventional Cardiology and Angiology at the Institute of Cardiology, Warsaw.

The set up itself projects the three- dimensional CTA images onto the Glass-based head mounted display via a mobile app featuring voice command and a zoom function. The combination allows for digital viewing of the coronary artery, the occlusion and the placement of the guide wire for stent implantation. Thanks to its basis in Google Glass, the device can record video, view images and also allow the practitioner to see the surrounding environment, simultaneously. The possibility for the lenses to be fitted with filters that protect the user from x-rays only cement this technology as one that cardiologists will look to use increasingly, after this first success.

A. Surgeon using the Glass-based monitor to view CTA images on the lens. B & C. 3D images on lens show trajectory of distal right coronary and occlusion.


Virtual Reality might not be having the impact on video games that the industry had hoped, but it would appear to be having a profound impact on healthcare.


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Ref: Canadian Journal of Cardiology, Elsevier Health Sciences

SCST National Update

Yesterday, on the 20th of November, Oli and I attended the SCST annual update meeting. It’s the first physiology conference I’ve attended that wasn’t tied to one specific trust (the last one I attended was the Royal United Hospital’s respiratory medicine conference), rather, it was applicable to and attended by cardiac scientists from across the four home nations. The day was packed with talks, networking opportunities and insight into the future of the science. Speakers hailed from a variety of professions and organisations, but all were entrenched in the science of cardiology and education.

Due to the long distance travel and Birmingham’s seemingly city-wide roadworks, Oli and I missed the introduction, but we were present for the rest of the day and we recorded and annotated everything else, so whilst I’ll provide an overview here, detailed breakdowns of everything relevant to PTP study will be supplied separately, as and when time and my coursework volume allows.

Of particular note is the information on preceptorship qualification, delivered by Sophie Blackman of SCST and Boston Scientific. I collared her after the event proper, and she kindly agreed to provide the literature pertaining to this, so as soon as it’s available, I’ll add it for you all to have a mosey over. It seems like a great opportunity for newly- qualified practitioners to become super confident in all aspects of their job, so I highly recommend that you read the contents when they’re available.

Dr Patricia Oakley of King’s College outlined the plans for a new variety of health clinic: the centre that isn’t home and isn’t a hospital, but the “place in the middle”. These will be networked, multidisciplinary centres, featuring social workers, scientists, psychiatrists, GP’s, etc, so cardiac physiologists will most likely be a necessity in their implementation. The whole session really drove home the emerging importance of this profession, but also the requirement of all of us, student and qualified, to ensure that the cardiac physiologist is recognised as being at the forefront of innovation so as not to be overlooked. It was mentioned more than once, that if we don’t put ourselves forward for emerging structures, someone else will.

Dr Oakley told of the need to reduce treatment variability by region. Her example was the treatment of amputation as a result of diabetes; Devon has, by far, the highest number of below-hip amputations when compared with the rest of the UK, due to the fact that the majority of Devonian surgeons trained under a surgeon who has a penchant for this level of removal. The advent of these networked clinics will reduce this level of variability and promote consistency across the home nations.

The president of the AHCS, Dr Brendan Cooper delivered the final talk of the day, discussing the future role of the healthcare scientist in wider healthcare and medicine, and the need for physiologist prescribing. I’ll provide  a detailed breakdown of this talk next, and shall hopefully post it in this coming week.



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Mental Health

This post is something of a departure from the usual fayre, in that it is far more personal, and, for a number of reasons, much more difficult to write.

I know more than a couple of people who decided against a career in healthcare due to their mental health issues, with depression and bipolar being cited as the chief afflictions. They felt they would be judged by colleagues and potential employers, perhaps being overlooked for postgraduate positions or being seen as an inferior member of staff.

The very nature of mental health conditions such as these means that every day is a struggle in and of itself regardless, and this is only exacerbated when depression is at a particularly debilitating level. Often, once the sufferer has climbed the seemingly impossible mountain that is just getting out of bed, having to face an interview wherein the disclose or discussion of one’s pertinent medical history would be a requirement, is akin to reaching the top of Everest, only to find that it’s doubled in size. It’s overwhelming. The fear of being judged and viewed as damaged can stop a person for whom depression is an issue, from doing a multitude of things.

I know this, because I suffer with these things.

I was diagnosed as being bipolar when I was 16. Since then I’ve overheard colleagues in various places say (not about or directed at me, I’ll add)“it’s just the grumps- get over it”, “everyone has bad days and THEY manage to pull themselves together without attention-seeking” or that they “don’t believe in rubbish like [depression]”.

I’ll just add, that I’ve been slightly misleading: these three comments weren’t from a variety of places. They were from the staff in a hospital. One hospital ward, to be more specific.

These comments emanated from people who deal with and treat illness on a daily basis, and often these illnesses aren’t directly visible. Why, then, is a mental health illness less credible than a physiological one, even if it also, can’t be seen?

Hospitals have upped their game when it comes to mental health training, so I’d assume that due to the increased awareness, opinions such as these are slightly less commonplace, but there is still a lot more that can be done; subjects like this are still difficult to discuss and there still exists a fear upon doing so.

I have no doubts in my abilities as a healthcare scientist. I’m confident in everything I have learned thus far, and have proved as such through testing and assessment. I’m not frightened of learning everything else that I have to in order to qualify and more, either; I relish the challenge. My issues lie in the everyday tasks that my colleagues seem to be able to do, that I cannot. For example, I have of late, found it incredibly difficult to climb the aforementioned first mountain, and get out of bed, and I hate how weak I feel it makes me. I have a crippling fear of failure, despite enjoying challenge and I sometimes loathe that one is quite often more powerful than the other despite my best efforts.

The thing is, when I’m happy, I’m REALLY happy. I’m enthusiastic, talkative, and willing to do anything, but in the back of my mind, there’s always the knowledge that it isn’t going to last; I’m going to come crashing down and revert back to a miserable person to be around. It’s these days that I can’t face leaving the house unless I absolutely have to. It’s these days that I’d rather complete lectures from home, in solitude.

I haven’t missed a day’s work in my life, without good reason (case in point: nearly losing the end of an index finger in a professional kitchen blender, getting it stitched and, despite everyone but my boss telling me how moronic it was, returning to work on the same day), so it isn’t as though I choose to stay home and work because I’m lazy or work shy, or that I simply can’t be bothered, I think it’s because of the fact that because the work material is provided online, it means I can if I need to. I take some solace in the fact that my mental health issues have never stopped me from going to work, so I know that they won’t stop me from doing my job in the future, just that I might be less exuberant sometimes, as I do so.

The one thing I took on board from my ex-colleagues was that everyone does indeed, have bad days. The majority of people get through these bad days, too. I’m going to do the same. I won’t quit, no matter how difficult it may be, because I’ve worked very hard to get here. I’ve been in a battle with my own brain for a long time, and I’ve been winning, so there’s no way I’m going to stop now.

The more people that speak up about issues like this, the less taboo it will become, and the less room for stigmatism there will be. It isn’t something that falls squarely at the feet of sufferers, either, it’s something that everyone has to recognise and talk about. It isn’t easy, but it’s necessary. Mental health issues aren’t going to go away, but the ability to manage them has moved forward tenfold in recent years. Attitudes towards the subject now need to catch up.

If you, like some of my friends, are put off pursuing a career in healthcare because of mental health issues, don’t! You’ll be surprised at just how strong you can be. You’ll have bad days and good days, sure, but you’d have them anyway, wouldn’t you? Your good days will feel so much better if you’re doing something you want to do.

Thank you for reading. This is far from my whole story and I apologise if it seems slightly disjointed in places, but this is the hardest thing I’ve ever had to write.

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How Is Your ECG Electrode Placement?

As a student cardiac physiologist it has been drilled into our heads from an early stage the importance of correct anatomical electrode placement in obtaining an accurate ECG recording. An ECG measures the electrical activity of a patient’s heart from many different angles, and is achieved by placing 10 sticky electrodes on the patient; four on the limbs and six on the chest. For correct electrode placement we follow the clinical body guidelines set out by the our governing body, the SCST. As specialists within the field, we have a duty to perform these tests in a standardised, methodical manner to produce reliable and accurate diagnostic information, as the ECG is the first port of call when assessing heart abnormality.

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Unfortunately, from my experience, and from that of my colleagues, the misplacement of these electrodes has become somewhat commonplace. To the unassuming operator this may seem superficial but incorrect placement of electrodes can alter the ECG patterns displayed simulating or concealing abnormalities, such as myocardial ischemia/infarction.

There is evidence that many health professionals who record ECG’s have not been suitably trained or assessed in the technique: A study by Kings College London into electrode misplacement highlighted that only 50% of nurses and less than 20% of cardiologists correctly place leads V1 and V2 during a standard 12-lead ECG. These numbers are quite shocking and highlight the widespread misunderstanding of this key diagnostic tool.

An example of how NOT to perform an ECG. V1 and 2 are incorrectly placed, as are 3 and 5.

I personally witnessed an example of this whilst on my first week of placement. I was performing an ECG on a patient within the cardiac ward under the supervision of an assistant technical officer who regularly performs ECGs. I correctly located the anatomical landmarks on the patient’s chest and applied the electrodes, as per the official guidelines. At this point, the ATO interrupted me and challenged the placement of my V1+V2 electrodes, stating they were too low. She then took over control of the procedure and removed the electrodes. She began to count the intercostal spaces, beginning from the clavicle. The guidelines state the operator should identify the manubriosternal joint, or angle of Louis, on the patient to locate the second intercostal space as their first anatomical landmark. This subsequently meant her V1 and V2 electrodes were placed too high and  my original placement was in fact correct. After the procedure I challenged my colleague about this explaining we were taught to follow the SCST guidelines in our electrode placement. The ATO responded by saying that this was “how they had always done it.” I discussed this with my clinical educator and the issue was later addressed with my colleague.

The consequence of incorrect ECG recording can lead to potentially incorrect diagnoses and inappropriate treatment leading to wasteful use of healthcare resources and even cause harm to patients. Evidence suggests that adequate training of operators reduces ECG recording errors. However as the SCST highlights in their guidelines, the indications there is little awareness in many practitioners of the need for training.

Clearly, the solution to this issue is to increase awareness in health professionals exposed to ECG practice about the importance of correct electrode placement.  This could be achieved by increased collaboration between cardiac physiologists and other healthcare professionals. As specialists within the field we have duty to share our expertise and knowledge to ensure our patients receive the best standard of care. As a profession we should be much more active in teaching and increasing awareness of what we do and why it is so important. Relevant staff should be confident in performing ECGs not because of experience, but due to high quality training and continual auditing.

To achieve this I feel our profession needs to embrace this responsibility and be far more active in the support and training of other health professionals.

Khunti, K. (2013) Accurate interpretation of the 12-lead ECG electrode placement: A systematic review. Health education journal . 73 (5) pp. 610-623.

Harrigan, H., Chan, TC., Brady, JW. (2012) Electrocardiographic Electrode Misplacement, Misconnection, and Artifact. The Journal of Emergency Medicine [online]. 43 (6), pp. 1038–1044.

Baxter, S, Blackman, S, Breen, C, Brown, C, Campbell, B, Cox, C, Eldridge, J, Hutchinso, J, Rees, E, Richley, D, Ross, C. Society for Cardiological Science and Technology (2014) Recording a standard 12-lead electrocardiogram. Available from:

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