ECG & Specimen Collection

Electrocardiography (ECG/EKG) and specimen collection (venipuncture, capillary puncture) are critical clinical skills tested extensively on the RMA exam.

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Electrocardiography (ECG/EKG)

12-Lead ECG Overview

A standard 12-lead ECG records the electrical activity of the heart from 12 different views using 10 electrodes (4 limb + 6 chest).

Limb Lead Placement

Memory aid: "White on right, smoke (black) over fire (red), and green (ground) on the right leg"

Precordial (Chest) Lead Placement

Normal ECG Waveforms

Common ECG Artifacts

Preparing the Patient for ECG

1. Explain the procedure (painless, no electrical shock)
2. Have patient remove clothing from waist up; provide gown
3. Position patient supine on exam table
4. Clean electrode sites with alcohol if needed (remove oil, hair as necessary)
5. Apply electrodes with proper skin contact (good adhesion, no air bubbles)
6. Attach lead wires to correct electrodes
7. Instruct patient to lie still, breathe normally, and not talk
8. Run the 12-lead ECG tracing
9. Check quality -- re-run if artifacts are present
10. Remove electrodes, clean skin, document

Venipuncture (Phlebotomy)

Order of Draw (Tube Colors)

The order of draw prevents cross-contamination of additives between tubes:

Memory aid for order: "Boys Love Really Gorgeous Ladies Globally" (Blood cultures, Light blue, Red/Gold, Green, Lavender, Gray)

Venipuncture Procedure

1. Verify the physician's order and confirm patient identity (two identifiers)
2. Assemble supplies (tubes, tourniquet, alcohol wipes, needle/holder or butterfly, gauze, bandage)
3. Position patient with arm extended and supported on a flat surface
4. Apply tourniquet 3-4 inches above the antecubital space (do not leave on >1 minute)
5. Have patient make a fist (do NOT pump the fist vigorously)
6. Palpate and select a vein (preferred: median cubital > cephalic > basilic)
7. Cleanse the site with alcohol in a circular motion from center outward; allow to air dry
8. Anchor the vein by pulling skin taut below the puncture site
9. Insert needle bevel up at a 15-30 degree angle
10. Collect tubes in the correct order of draw
11. Release tourniquet before removing the needle
12. Remove needle, apply gauze with pressure for 3-5 minutes
13. Label tubes at the bedside immediately after collection
14. Apply bandage and provide post-care instructions

Preferred Veins (Antecubital Fossa)

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Capillary Puncture (Fingerstick/Heelstick)

Indications

• Small sample volumes needed (glucose, hemoglobin, hematocrit)
• Difficult venous access (veins are damaged, fragile, or inaccessible)
• Infant/pediatric specimen collection (heelstick)
• Point-of-care testing (POCT)

Procedure

1. Select the site: 3rd (middle) or 4th (ring) finger, slightly off-center on the fingertip
2. Warm the site to increase blood flow (warm cloth or warming device)
3. Cleanse with alcohol, allow to air dry
4. Puncture with a sterile lancet perpendicular to the fingerprint lines
5. Wipe away the first drop (contaminated with tissue fluid)
6. Collect subsequent drops into microtainer tubes or onto test strips
7. Do NOT squeeze or "milk" the finger (dilutes specimen with tissue fluid)
8. Apply pressure with gauze until bleeding stops

Capillary Order of Draw

1. EDTA (lavender) -- always first to prevent platelet clumping
2. Other additive tubes (heparinized, etc.)
3. Non-additive tubes (serum)

Note: This is different from the venipuncture order of draw!