scst – The Student Physiologist

SCST Diploma Day: A Reflection

Myself and OliGS recently sat the SCST Electrocardiography Diploma and Practical Examination, so I thought I’d jot down some of my experiences in the run up, and my retrospective thoughts on the day itself.

If you’re thinking of doing it, or have your PTP finals looming, then read on, as this will give you an idea of what to expect.

I’ll start by saying this: Oli and I have NEVER been so stressed in our entire lives.

This exam was a nightmare for which to prepare; I have extensive experience in taking exams, and it is my view that they’re 50% what you know, and 50% what the examiners want you to tell them. Without having met these examiners or seen a previous paper, it was very difficult to know what to really nail, in the revision stage. The syllabus was long, detailed, and contained what seemed like an entire career’s-worth of things to learn, so we already knew it was going to be a slog, but nothing prepared us for the written paper…

Read these. Lots.

We studied, sometimes sleeplessly, for weeks. Tested each other on rare arrhythmias, read textbooks cover-to-cover (repeatedly), and watched each other’s once sunny outlooks and youthful (ahem) features rapidly wither as the examination date draw closer. It consisted of 20 multiple choice questions, 10 arrhythmia analysis and knowledge questions, and 4 full ECG analysis recordings. Some of these were almost instantly recognisable, but others were brutally difficult to analyse. The MCQs (often the most looked-forward to section of any exam) were equally tough. Those 3 hours lasted a lifetime…

We left the exam battered and bruised, but glad it was over.

But it wasn’t over. It was far from over. As well as the written paper that had almost ruined us, we had the practical exam to do as well.

We had made sure that during our post-ECG placements we still got ourselves in the clinic so as to keep everything fresh, as performing a perfect ECG is not like riding a bicycle.

The last attempt before test day

It turns out that this was the correct call, as was practicing on one another in the hotel the evening before the exam; the margin for error in the exam is 2mm(!) Anyone who’s had an informal assessment, or had their Direct Observed Practice scrutinised whilst training knows that it’s very easy to second-guess when it comes to electrode placement, and despite having 20 minutes to complete the whole thing, this timeframe becomes devastatingly short once you’re in there. It’s a clinical assessment, so one needs to complete the necessary ID checks, explain the procedure to the patient AND to the examiners (i.e. in two different ways), perform it whist answering questions, and then complete a verbal examination.

Three hours after we had finished the written paper, we were called to attempt our practical exam. There were ashen faces all around. Some were on those still waiting for their number to be called as ours had just been, others had been told that their 2 attempts had been unsuccessful. Neither of us were looking forward to this. Now, given that I’ve already stated that each electrode is allowed to deviate only 2mm from the precise, gold standard location, the internet-purchased electrodes pictured in the above image would be somewhat unfair, right? It seems that the examination board concur, as they provide some rather cool, transparent electrodes complete with crosshairs. They doesn’t make it easier, per se, but they certainly go some way eliminate that lingering trepidation when it comes to deciding you’re happy with your placement and ready for judgement.

Crosshair emblazoned electrodes(!)

I opted for the “all at once” technique: I explained everything to the patient before I started, gained consent, then explained everything I was doing as I went along. Once was put simply to the patient, then once to the examiners, using correct terminology. I paid extra special attention to V1, V2 and V4, as my patient had a particularly wide sternum, so I wanted to be totally sure that I had the sternal border, especially given the electrodes were rather far apart when placed and looked slightly odd to me. After I took a step back and looked at my work, I was incredibly tempted to move the aforementioned electrodes, but either due to fear, fatigue, or a combination of the two, I decided to leave them as they were, opting to go with my initial judgement. After that, I waited.

I’m not entirely sure how the placements are measured, as candidates are asked to leave the room whilst they are checked by two examiners. I heard someone mentioning special rulers, but I didn’t get a look at them (it’s all very cloak and dagger), in any event, you’re called back into the room and, in my case at least, informed of your passing or failing grade. I’m pleased to report that I passed on the first attempt, which as I’m sure you can imagine, was a tremendous relief; I lost my cool somewhat, and expressed my joy rather loudly, as I was informed I wouldn’t have to do it again. Oli soon found me in the waiting area and, grinning wildly, slapped me on the back and hissed “YESSSSS!” before promptly throwing himself into a chair. It was over, and we were victorious.

We didn’t speak too much about it, on the way home, but in the couple of days that have passed since the exam, we both feel a tremendous sense of pride that we actually did it, and did it successfully. If I were to give you all some advice, it would be the following:

Be prepared for anything and everything, including waiting around for a long while
Practice analysing ECGs until you hate them
Practice performing ECGs until you hate them
Go with your gut as much as you can during the practical exam
Bring lunch
Don’t under ANY circumstances, stay at the Ibis Hotel in Birmingham’s Chinatown district (I can’t stress this enough because it backs onto a nightclub that doesn’t stop playing the most bass-heavy music until the wee hours of the morning)

Postgraduate Preceptorship

One of the SCST Annual Update sections most relevant to PTP students was based around postgraduate preceptorship. Delivered by Sophie Blackman, of Boston Scientific and the SCST, the talk went through the updates regarding the assessment and accreditation that a newly qualified physiologist can obtain, in conjunction with the council. Sophie stated that she has been quite heavily involved in the production of this framework, and proceeded to outline its intricacies.

The preceptorship programme is relevant to PTP students, because it is aimed specifically at us once we are “let loose”, as it were, into clinical practice. The SCST has received a great deal of feedback from around the country, pertaining to the varying levels at which new healthcare scientists are emerging from their academic study and also feedback from students themselves, on what they feel they need by way of support from the governing body. I for one, can appreciate this; I’m terrified of graduating. I’m confident in my own skills, thus far, and whilst I don’t think that fear will ever go away, I think it’s beneficial for newly qualified HCS to have someone outside of their department that can help them make that transition from student to professional. This nationwide initiative will help to provide this support for the individual, but will also ensure there is an equitable workforce in practice.

The programme itself is based around the individual, and is likely to take anywhere from six months, to two years, based on proficiency. Much like in your current degrees (if you’re a student), the programme features competencies and case based discussions, but in this case, they are undertaken as you perform a job at which you are already doing. Upon “qualification” (this may seem like an odd word to use, given the fact that the practitioner is already qualified, but bear with me…), the student will receive a certificate displaying their confidence in a particular discipline, and that can not only demonstrate a willingness on the practitioner’s part to be the best that they can be, but it will further cement that person’s knowledge and skills base to aid them in their position, thereby helping them, to a point, to leave the student role behind them.

The implication was that if you, as a new HSP, want to make that leap to the STP programme, or follow a different career framework, then this accreditation will assist in identifying your individual fortes, and allow you to perhaps see what pathway you would be best suited to.

The full texts relevant to students are given below:

Preceptorship Framework

Preceptorship guidance for HSPs

For more information, visit the SCST preceptorship page:

SCST National Update

Yesterday, on the 20^th 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.

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.

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.

Close0up — 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: http://www.scst.org.uk/resources/CAC_SCST_Recording_a_12-lead_ECG_final_version_2014_CS2v2.0.pdf

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