NIMS COLLEGE OF PARAMEDICAL TECHNOLOGY

Nims University Medical College & Hospital

JAIPUR-DELHI HIGHWAY 11C, JAIPUR-303121

JAIPUR (RAJASTHAN)

Hospital Training
LOG BOOK2023

Diploma
Batch:-2019-20
DIPLOMA IN ECG TECHNOLOGY

DEPARTMENT Medicine

PERSONALDETAILS
1. Full Name

2. Date of Birth

3. Enrollment
number

4. Father’s
Name

5. Permanent
Address

6. Phone No.

7. E-mail ID

8. Date of
Joining
9. Date of
Completion
 Nims University Medical College & Hospital
Rajasthan
SHOBHA NAGAR, JAIPUR-DELHI HIGHWAY, JAIPUR-303121

DEPARTMENT: Medicine (ECG)

Certificate

This is to certify that Mr. -------------------------was registered as a under Diploma student for the Diploma in
the subject of Diploma in ECG Technology at Nims College of Paramedical Technology, Jaipur. The
procedures and the academic activities recorded in the log book have been checked and authenticated and are
as per the hospital records and have been carried out under the guidance of the faculty members of the Nims
College of Paramedical Technology, Jaipur

Technical Supervisor HOD

Dept:-Medicine (ECG) Dept of Medicine
Nims Hospital, Jaipur Nims University, Jaipur

Principal
NIMS College of Paramedical Technology

CLINICAL POSTING SCHEDULE

(To be filled before training commencement by HOD/Training Coordinator)

Sr. MONTH LOCATION OF POSTING MENTOR CONTRACT NUMBER

no.
1

3
4

10

11

12

Technical Supervisor HOD

Dept:-Medicine (ECG) Dept of Medicine
Nims Hospital, Jaipur Nims University, Jaipur

Principal
NIMS College of Paramedical Technology

Overallperformance
(To be filled Clinical Supervisor at the Completion of internship)

YES NO Comments

Would you supervise this

intern again?

Would you recommend this

student to other organizations?

Overall performance of this intern:-

Unsatisfactory Poor Average Good Outstanding

Comments :-

Technical Supervisor HOD

Dept:-Medicine (ECG) Dept of Medicine
Nims Hospital, Jaipur Nims University, Jaipur

Principal
NIMS College of Paramedical Technology

Paramedic Skills Log

Book
The following skills log book is to provide evidence:
1. that the skills have performed often enough to have developed the required
knowledge and dexterity
2. that the feedback indicates development toward independent capability in the
student
3. a record for skill usage to assist in seeking employment and right of practice

Notes to supervisors Please date and initial and grade occasions where the
appropriate skill has been performed by the student
Gradings
I Independent The student is able to recall the associated facts and complete the skill
to a high standard with no assistance
SSupervised The student is able to recall essential facts and requires minimal
supervision to complete the skill to a high standard

MMarginal The student requires prompts and assistance to complete the skill to an
adequate standard
DDependant The student cannot recall essential facts or perform essential elements
of the skill
 Examples
1. You attend a cardiac chest pain. The student suggests at the appropriate time
that an ECG is appropriate. You agree and Bob completes the skill, problem
solving as he goes. The finished product is good and you rate this skill as an I as
you were not required to prompt or give any assistance to the student to
achieve this standard
2. You ask the student to place an LMA in a cardiac arrest patient. The student
sets up and places the LMA and completes the safety checks. You note that the
student put the maximum amount of air into the LMA on the first opportunity
and later you discuss why this is not always the best practice. You rate the skill
attempt as S (supervised) as no safety issues were raised and the skill was
performed to a high standard.
3. The student is asked to place an intravenous cannula. You note that the aseptic
technique is good but the he hasn’t organised a sharps container at hand. You
supply this and the student goes on to complete the IVC with no further issues.
Because the student needed a prompt for a safety issue you grade this attempt
as M (marginal)
4. You ask the student to prepare some Morphine for IV administration. The
student is unable to identify the correct amounts of morphine and saline for
this task and when you ask the student later to identify this they are unable to.
You mark this
attempt as D (dependant) because the student could not recall essential or complete the skill
without direct intervention

ECG Basics
Introduction to ECG
An electrocardiogram is a picture of the electrical conduction of the heart. By examining changes from normal on
the ECG, clinicians can identify a multitude of cardiac disease processes.
There are two ways to learn ECG interpretation — pattern recognition (the most common) and understanding the
exact electrical vectors recorded by an ECG as they relate to cardiac electrophysiology — and most people learn a
combination of both. This tutorial pairs the approaches, as basing ECG interpretation on pattern recognition alone is
often not sufficient.
Parts of an ECG
The standard ECG has 12 leads. Six of the leads are considered “limb leads” because they are placed on the arms
and/or legs of the individual. The other six leads are considered “precordial leads” because they are placed on the
torso (precordium).
The six limb leads are called lead I, II, III, aVL, aVR and aVF. The letter “a” stands for “augmented,” as these leads
are calculated as a combination of leads I, II and III.
The six precordial leads are called leads V1, V2, V3, V4, V5 and V6.
Below is a normal 12-lead ECG tracing. The different parts of the ECG will be described in the following sections.
E

The Normal ECG

A normal ECG contains waves, intervals, segments and one complex, as defined below.
Wave: A positive or negative deflection from baseline that indicates a specific electrical event. The waves on an
ECG include the P wave, Q wave, R wave, S wave, T wave and U wave.
Interval: The time between two specific ECG events. The intervals commonly measured on an ECG include the PR
interval, QRS interval (also called QRS duration), QT interval and RR interval.
Segment: The length between two specific points on an ECG that are supposed to be at the baseline amplitude (not
negative or positive). The segments on an ECG include the PR segment, ST segment and TP segment.
Complex: The combination of multiple waves grouped together. The only main complex on an ECG is the QRS
complex.
Point: There is only one point on an ECG termed the J point, which is where the QRS complex ends and the ST
segment begins.
The main part of an ECG contains a P wave, QRS complex and T wave. Each will be explained individually in this
tutorial, as will each segment and interval.
The P wave indicates atrial depolarization. The QRS complex consists of a Q wave, R wave and S wave and
represents ventricular depolarization. The T wave comes after the QRS complex and indicates ventricular
repolarization.
Note that right-sided ECGs and posterior ECGs can be helpful and are described elsewhere.

10 Steps to Learn ECG Interpretation

Learning the art of ECG interpretation requires intellect, commitment, effort and — perhaps most importantly — an
organized approach.
I have spent thousands of hours (yes, thousands) looking at 12-lead ECG tracings, studying ECGs for the cardiology
boards, interpreting ECGs for direct patient care, and developing ECG tutorials and quizzes for Learn the Heart.
Assuming that most of you reading this blog do not have that much time, allow me to share what I have discovered
in my years teaching ECGs to make the process simpler — and maybe even enjoyable.
ECGs Made Easy?
Learning all of ECG interpretation is going to take time and it is not quite so easy. To be proficient, it will take
effort. Some memorization and pattern recognition will be required. The more you see, the more you will remember.
Having a pair of calipers is helpful.
Step 1. Learn the Basics of a 12-lead ECG Tracing
Knowing the basic parts of an ECG tracing will lay a good foundation for everything else that is to come. The
different waves, complexes and intervals need to be ingrained in your brain. How many seconds is a full ECG
tracing? How much time does each big box and each little box represent?
This is not the time to learn about the different P-wave morphologies that occur with atrial enlargements and ectopic
atrial rhythms — but rather, it is the time to learn what the normal P wave looks like and what it represents. It’s a
similar concept for the other parts of the ECG.
The Learn the Heart ECG Basics module contains detailed articles on various waves, segments, intervals and more.
Step 2. Determine Heart Rate on the ECG
To determine whether bradycardia, a normal heart rate or tachycardia is present requires the knowledge to calculate
the heart rate on the ECG. Remember to apply these techniques to both the atrial rate, which is measured by the rate
of the P wave, and the ventricular rate, which is measured by the rate of the QRS complex.
Read Determining Rate.
Step 3. Determine Axis on the ECG
The axis on the ECG can give a clue to many different pathologic states. Unless you are going into
electrophysiology as a career, the only axis that you need to measure is that of the QRS complex.
Know the causes of left axis deviation, right axis deviation and when the axis is indeterminate (northwestern). Also,
know the quick shortcuts to determine the axis.
Read Determining Axis.
Step 4. Learn Abnormal Heart Rhythms
Learning a normal sinus rhythm was taken care of in Step 1. Now, it is time to learn the below rhythms. Review
multiple examples of each in the individual ECG Reviews sections below.

 Atrial Fibrillation ECG Review

 Atrial Flutter ECG Review
 Atrioventricular Nodal Reentrant Tachycardia (AVNRT) ECG Review
 Atrioventricular Reentrant Tachycardia (AVRT) ECG Review
 Ectopic Atrial Rhythms ECG Review
 First-Degree Atrioventricular (AV) Block ECG Review
 Idioventricular Rhythms ECG Review
 Junctional Rhythms ECG Review
 Multifocal Atrial Tachycardia (MAT) ECG Review
 Second-Degree Atrioventricular (AV) Block Type I (Wenkebach) ECG Review
 Second-Degree Atrioventricular (AV) Block Type II ECG Review
 Sinus Arrhythmia ECG Review
 Sinus Bradycardia ECG Review
 Sinus Tachycardia ECG Review
 Third-Degree Atrioventricular (AV) Block ECG Review
 Ventricular Tachycardia (VT) ECG Review
 Wandering Atrial Pacemaker (WAP) ECG Review
Step 5. Learn Chamber Hypertrophies and Bundle Blocks
Learning chamber hypertrophies and bundle blocks can be difficult. Atrial enlargements are not too difficult, but the
criteria for left ventricular hypertrophy can be overwhelming. In my opinion, there is no need to memorize them all,
but rather just the main two or three.
With left and right bundle branchs, the “bunny ears” are easy to spot in right bundle branch blocks, although not
always present. Don’t forget to learn what a non-specific interventricular conduction delay looks like, as well.

 Bifascicular Block ECG Review

 Left Anterior Fascicular Block (LAFB) ECG Review
 Left Atrial Enlargement (LAE) ECG Review
 Left Bundle Branch Block (LBBB) ECG Review
 Left Posterior Fascicular Block (LPFB) ECG Review
  Left Ventricular Hypertrophy (LVH) ECG Review
 Poor R Wave Progression ECG Review
 Right Atrial Enlargement (RAE) ECG Review
 Right Bundle Branch Block (RBBB) ECG Review
 Right Ventricular Hypertrophy (RVH) ECG Review
 Trifascicular Block ECG Review
Step 6. Learn Acute MI and Ischemic ECG Findings
This is the fun part of ECG interpretation. Some of the acute MI ECG findings, such as anterior ST segment
elevations and inferior ST segment elevation MIs, are obvious. The tough part is identifying the more subtle ECG
changes.
Know when ST segment elevation is due to ischemia and when it is due to other causes, including left ventricular
aneurysm or left ventricular hypertrophy. Likewise, know when ST segment depression is due to digoxin ECG
changes.

 Anterior Wall ST Segment Elevation Myocardial Infarction (MI) ECG Review

 Inferior Wall ST Segment Elevation Myocardial Infarction (MI) ECG Review
 Posterior Wall Myocardial Infarction (MI) ECG Review
Step 7. Learn the Everything Else Including Atypical ECG Findings
Some repetition and memorization is required. The list of things that go into this category is long. Review the list
below.

 Arrhythmogenic Right Ventricular Dysplasia (ARVD) ECG Review

 Atrial Septal Defect (ASD) ECG Review
 Brugada Syndrome ECG Review
 Dextrocardia ECG Review
 Digoxin Effect ECG Review
 Early Repolarization ECG Review
 Hypercalcemia ECG Review
 Hyperkalemia ECG Review
 Hypertrophic Obstructive Cardiomyopathy (HOCM) ECG Review
 Hypocalcemia ECG Review
 Hypokalemia ECG Review
 Hypothermia ECG Review
 Left Ventricular (LV) Aneurysm ECG Review
 Limb Lead Reversal ECG Review
 Lown-Ganong-Levine Syndrome ECG Review
 Low Voltage ECG Review
 Neurologic Insult ECG Review
 Pericarditis ECG Review
 Prolonged QT Interval ECG Review
 Pulmonary Embolism ECG Review
 Wellens’ Syndrome ECG Review
 Wolff-Parkinson-White (WPW) ECG Review
Step 8. Quiz, Quiz, Quiz and Review, Review, Review
Take the Learn the Heart ECG Quizzes and Cases, then review once again, or as many times as you’d like, when
you identify a gap in your knowledge. You can never look at too many 12-lead ECG tracings. In real life, you see
full 12-lead ECG tracings — so that is how you need to test yourself.
Step 9. Review ECGs in Real Patient Case Scenarios
Whether you are a medical student in clinical rotations, an EMT or an internist in practice, or another health care
professional, looking at the ECGs that you will encounter in everyday practice is important. See how the ECG fits
the clinical scenario. Sometimes the best way to remember an ECG finding is to associate it with an interesting case
that you experienced personally.
Alternatively, you can practice with ECG Cases, like the examples in the Learn the Heart ECG Library — online or
in a textbook — in which a patient scenario is presented and the ECG that goes along with it is revealed.
Step 10. Teach Others How to Read an ECG
I have learned the most about ECG interpretation by developing content for Learn the Heart and teaching ECG
courses in person. If you can put yourself in a position to teach students or your colleagues about ECGs, you will
solidify your skills tremendously.
The Practice of Medicine – Never Stop Learning
Keep reviewing. One day, you will stop and think, “Wow, I think I get it.” Follow Learn the Heart and read the
articles regularly. This will keep things fresh in your mind and will even introduce you to rare ECG tracings. – by
Steven Lome, DO, RVT
Related Content:
 Atrial Arrhythmias ECG Quiz
 Beginner ECG Quiz
 Chamber Enlargements and Axis ECG Quiz
 Comprehensive ECG Quiz
 Expert ECG Quiz
 Heart Blocks ECG Quiz
 Infarcts and Ischemia ECG Quiz
 Miscellaneous ECG Quiz
 Ventricular Arrhythmias ECG Quiz
 ECG Cases
. The ECG Library features hundreds of 12-lead ECG tracings on common and rare cardiac abnormalities. Challenge
yourself with these ECG examples.
Junctional Rhythms ECG Review

A junctional rhythm occurs when the electrical activation of the heart originates near or within the
atrioventricular node, rather than from the sinoatrial node.Because the normal ventricular conduction
system (His-Purkinje) is used, the QRS complex is frequently narrow. A junctional rhythm is normally slow —
less than 60 beats per minute. When faster, it is referred to as an accelerated junctional rhythm.Because the
electrical activation originates at or near the AV node, the P wave is frequently not seen; it can be buried
within the QRS complex, slightly before the QRS complex or slightly after the QRS complex. The morphology
of the P wave will not be similar to the sinus P wave, which is normally upright in lead II and biphasic in lead
V1. Often, the P wave is inverted in lead II, if it can be seen at all. A pacemaker may be needed to relieve
symptoms when no reversible cause — i.e. AV blocking medications or electrolyte disturbances — is
found.The strip below shows a junctional rhythm with retrograde P waves seen just before the QRS complex.
The second rhythm strip shows retrograde P waves just after the QRS complex.

Atrial Arrhythmias ECG 1

1. Atrial fibrillation with an uncontrolled ventricular response

There are three common heart rhythm disorders that cause an irregularly irregular rhythm: Atrial fibrillation

1. Atrial flutter with variable conduction

2. Multifocal atrial tachycardia (MAT).
With atrial fibrillation, no descrete P waves can be seen, however sometimes coarse "fibrillitory waves" are
present. In atrial flutter a "sawtooth" pattern is seen. In MAT there are at least 3 distinct P wave
morphologies present.

Atrial Fibrillation with Rapid Ventricular Rate ECG (Example 5)

ENLARGE

ECG Findings:
1. Atrial Fibrillation with a rapid ventricular response (RVR)
2. Premature Ventricular Contraction (PVC)

CARDIOLOGY

The common anatomical site/s where diseases occur are listed in a box and so are the common
etiologies of disease and the pathophysiological syndromes encounter

SYNDROMES OF
SITE OF DISEASE DYSFUNCTION
When the heart is not working pro
Pericardium
Congestive Heart Failure
Myocardium
Cardiac Asthma
Endocardium: Valvular
Low output Syndrome or Shock
Pancardium: Rheumatic
Arrhythmia
Fever, Trauma
Bacterial Endocarditis supervening
Vascular: Artery
 CARDIOLOGY – THE COMMON PLAN

A. HISTORY: As in the common, this part will answer questions A1-5.

SYMPTOMS SUGGESTING CARDIO VASCULAR INVOLVEMENT

-- Central chest pain esp. on exertion

-- Dyspnea on exertion
-- Nocturnal Dyspnea
-- Palpitation
-- Swelling over dependent parts

Symptoms suggesting PATHOPHYSIOLOGICAL EFFECTS

Most of the above symptoms occur because of the effects of primary disease on circulation. The
symptoms of the disease per se may be few or none and the symptoms due to the consequent
pathophysiological changes predominate or even predate.

CAUSE OF DISEASE

One has to consider the onset, course duration and the response to treatment in totality to reach
the probable cause of disease. A chart depicting these will help as a guideline in the history. It needs to be
re- emphasized that all these points have to be taken together to arrive at a decision.

CAUSE ONSET COURSE DURATION OUTCOME

Rapidly
VASCULAR Sudden Progressive or Few days Good/ Bad
regressive
Episodes of
RHEUMATIC Acute fever + Years Variable
Prophylaxis
Good with
TUBERCULAR Sub- Acute Progressive Months treatment

CARDIOMYOPA - Slowly
Sub- Acute Progressive Months/ years Bad
THY

Good in
CONGENITAL Since birth Progressive Variable milder forms

ARRYTHMIA Acute Episodic Years Variable

Slowly Acute
JOINT DISEASE Sub- Acute Progressive Years exacerbation
problematic
 A. 4BACKGROUND HISTORY: NATURE OF DISEASE CAN BE ELUCIDATED

· Congenital disease : There may be an antenatal history of

-- Disease in the mother like Rubella
-- Birth trauma
-- Delayed milestones
-- Squatting, crying spells
-- History of other anomalies
· Rheumatic disease
-- Chorea
-- Fleeting arthritis
· Atherosclerosis
-- Family history of diabetes, premature deaths in the family
-- Past history of other organ involvement by atherosclerosis
-- Diabetes mellitus
-- Smoking
-- Blood pressure
· Syphilis
-- Past, family or personal history pointers to syphilis
-- Present history of primary chancre
-- Past history of primary chancre or signs of secondary syphilis
-- Signs of Syphilis in the sexual partner and in congenital syphilishistory of
still births/abortions of siblings
· Tuberculosis
-- Family history of Tuberculosis
· Hypertension
-- Past history of other organ involvement
-- Family history
-- History of renal diseases
-- History of Endocrinal diseases

A.5 PATHOPHYSIOLOGICAL ABNORMALITIES AND DYSFUNCTION MEASUREMENT

~ Edema may suggest CHF

~ Nocturnal dyspnea suggests cardiac asthma
~ Episodes of unconsciousness may suggest arrythymias
~ Prolonged fever may indicate bacterial endocarditis
~ Cold extremities and muscle fatigue may suggest low output syndrome

In assessing dysfunction, the degree of breathlessness is to be noted, keeping in mind

his job requirement and personal situation which includes details of his residence,how
many stairs he has to climb, what are his hobbies & other recreational activities and the
disturbance of function should be measured against these parameters.
The NYHA grade of dyspnoea must be recorded.

LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY

3 Lead ECG Acquisition

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HOD /Medicine Dept .Supervisor

Nims Hospital ECG Dept.

LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY

3 Lead ECG Acquisition

LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY

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Nims Hospital ECG Dept.

Posting w.e.f. to Date of Reporting:

Signature of Staff:

LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY

 WORK DONE STATEMENT
Numbers Performed,
Activity with Numbers Date and Signature
Assisted and Observed
Recommended of Staff
as the case may be

1. OPD Cases to be seen (50)

2. Case sheets to be written (50)

3. Number of follow ups to be written (100)

4. Number of Discharge summaries to be written

(50)

5. Monitoring of critically ill patients (20)

6. Basic lab investigations to be Done (20) Hb, TC, DC,

ESR, Urine Exam etc.

7. Blood samples to be drawn (10)

8. Injections to I.V. to be given

(10) I.M.
S.C.

9. I.V. Cannulas to be inserted (10)

10. Ryle’s to be inserted (2)

11. Catheterization to be done (2)

12. Pleural/Ascitic fluid aspirations to be done (2)

13. Liver biopsy/Bone marrow Aspirations/CSF

tap (any 2) to be done

LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY

14. Nebulizations to be given (10)

15. Oxygen delivery (10)

16. Cardiac monitoring to be Observed (5)

17. Assisted in
CPR (2)
Intubation (2)
Defibrillation (2)

18. Resuscitation of patients in shock (2)

19. Revealing bad news to relatives (4)

20. Recording of ECGs to be done (2)

21. Emergencies to be attended to (20)

22. Blood Transfusions to be given and

monitored (10)

23. Bone Marrow Aspiration and Liver Biopsy

to be assisted (2)

24. Attending and participating in

Health Education Programmes (2)

TRAINEE ATTENDANCE RECORD

P-Pesent ,A-Absent , L-Leave ,H- Holiday
LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY
MONTH:-
Date Pesent ,A-Absent , L-Leave ,H- Holiday Date Pesent ,A-Absent , L-Leave ,H- Holiday

1 16
2 47
3 18
4 19
5 20
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10 25
11 26
12 27
13 28
14 29
15 30
31
Dept:-ECG
NIMS Hospital, Jaipur Principal
NIMS College of Paramedical Technology

TRAINEE ATTENDANCE RECORD

P-Pesent ,A-Absent , L-Leave ,H- Holiday
LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY
MONTH:-
Date Pesent ,A-Absent , L-Leave ,H- Holiday Date Pesent ,A-Absent , L-Leave ,H- Holiday

1
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Dept:-ECG
NIMS Hospital, Jaipur Principal
NIMS College of Paramedical Technology

LOG BOOK PARAMEDICAL Batch 2019-20 ECG TECHNOLOGY