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ELECTROCARDIOGRAPHY
FOR HEALTHCARE PROFESSIONALS
Fourth Edition
Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS

Total Care Programming, Inc.
Palm Coast, Florida
Thomas O’Brien, AS, CCT, CRAT, RMA

Remington College
Allied Health Programs Chair
ELECTROCARDIOGRAPHY FOR HEALTHCARE PROFESSIONALS, FOURTH EDITION
Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2016 by
McGraw-Hill Education. All rights reserved. Printed in the United States of America. Previous
editions © 2012, 2008, and 2004. No part of this publication may be reproduced or distributed in
any form or by any means, or stored in a database or retrieval system, without the prior written
consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic
storage or transmission, or broadcast for distance learning.
Some ancillaries, including electronic and print components, may not be available to customers
outside the United States.
This book is printed on acid-free paper.
1 2 3 4 5 6 7 8 9 0 RMN/RMN 1 0 9 8 7 6 5
ISBN 978-0-07-802067-4
MHID 0-07-802067-0
Senior Vice President, Products & Markets: Kurt L. Strand

Vice President, General Manager, Products & Markets: Marty Lange
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Compositor: Laserwords Private Limited
Printer: R. R. Donnelley
All credits appearing on page or at the end of the book are considered to be an extension of the
copyright page.
Library of Congress Cataloging-in-Publication Data
Booth, Kathryn A., 1957- author.

Electrocardiography for healthcare professionals / Kathryn A. Booth, Thomas
E. O’Brien. — Fourth edition.
p. ; cm.
Includes index.
ISBN 978-0-07-802067-4 (alk. paper) — ISBN 0-07-802067-0 (alk. paper)
I. O’Brien, Thomas E. (Thomas Edward), 1959- author. II. Title.
[DNLM: 1. Electrocardiography—methods—Problems and Exercises.
2. Arrhythmias, Cardiac—diagnosis—Problems and Exercises. WG 18.2]
RC683.5.E5
616.1’207547—dc23
2014019157
The Internet addresses listed in the text were accurate at the time of publication. The inclusion
of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and
McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites.
www.mhhe.com
Dedication
To the individuals using this book, you have chosen a worthwhile and
rewarding career. Thank you; your skills and services are truly needed.
To my youngest grandaughter, Harper Kathryn, so happy you are in my life.
Kathryn Booth
I want to thank my beautiful wife, Michele, and our wonderful children,
Thomas, Robert, and Kathryn. Without their love and support, I would have
nothing. They inspire me every day to make a difference in people’s lives. I
also want to express my sincere thanks to the faculty, staff, and students of
Remington College for their encouragement and guidance. Today’s students
are the difference makers of tomorrow!
Thomas O’Brien
About the Author
Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS, is a registered
nurse (RN) with CPR and ACLS training as well as a master’s degree in educa-
tion and certifications in phlebotomy, pharmacy tech, and medical assisting.
She is an author, educator, and consultant for Total Care Programming, Inc.
She has over 30 years of teaching, nursing, and healthcare work experience
that spans five states. As an educator, Kathy has been awarded the teacher of
the year in three states where she taught various health sciences. She serves
on the American Medical Technologists registered Phlebotomy Technician
Examinations, Qualifications, and Standards Committee. She stays current in
the field by practicing her skills in various settings as well as by maintaining
and obtaining certifications. In addition, Kathy volunteers at a free healthcare
clinic and teaches online. She is a member of advisory boards at two educa-
tional institutions. Her larger goal is to develop up-to-date, dynamic health-
care educational materials to assist other educators as well as to promote the
healthcare professions. In addition, Kathy enjoys presenting innovative new
learning solutions for the changing healthcare and educational landscape to
her fellow professionals nationwide.
Thomas E. O’Brien, AS, CCT, CRAT, RMA, is the Allied Health Program chair-
person at Remington College, Fort Worth, Texas. Tom also works as an author
of CME activities and editor with Practical Clinical Skills (www.practical
clinicalskills.com). He is also on the Board of Trustees and Exam Chair for the
Certified Cardiographic Technician and Certified Rhythm Analysis Technician
Registry Examinations working with Cardiovascular Credentialing Interna-
tional (CCI). His background includes over 24 years in the U.S. Air Force and
U.S. Army Medical Corps. Tom’s medical career as an Air Force Independent
Duty Medical Technician (IDMT) has taken him all over the United States and
the world. He has several years’ experience working in the Emergency Ser-
vices and Critical Care arena (Cardiothoracic Surgery and Cardiac Cath Lab).
He was awarded Master Instructor status by the U.S. Air Force in 1994 upon
completion of his teaching practicum. He now has over 15 years of teaching
experience; subjects include Emergency Medicine, Cardiovascular Nursing,
Fundamentals of Nursing, Dysrhythmias, and 12-Lead ECG Interpretation. His
current position provides challenges to meet the ever-changing needs of the
medical community and to provide first-rate education to a diverse adult edu-
cation population.
iv
Brief Contents
Preface xi
CHAPTER 1 Electrocardiography 1
CHAPTER 2 The Cardiovascular System 28
CHAPTER 3 The Electrocardiograph 54
CHAPTER 4 Performing an ECG 82
CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121
CHAPTER 6 Atrial Dysrhythmias 147
CHAPTER 7 Junctional Dysrhythmias 166
CHAPTER 8 Heart Block Dysrhythmias 186
CHAPTER 9 Ventricular Dysrhythmias 204
C H A P T E R 10 Pacemaker Rhythms and Bundle Branch Block 234
C H A P T E R 11 Exercise Electrocardiography 253
C H A P T E R 12 Ambulatory Monitoring 282
C H A P T E R 13 Clinical Presentation and Management of the
Cardiac Patient 307
CHAPTER 14 Basic 12-Lead ECG Interpretation 334
APPENDIX A Cardiovascular Medications A-1
APPENDIX B Standard and Isolation Precautions B-1
v
APPENDIX C Medical Abbreviations, Acronyms, and Symbols C-1
APPENDIX D Anatomical Terms D-1
Glossary G-1
Photo Credits PC-1
Index I-1
vi Brief Contents
Contents
Preface xi
CHAPTER 1 Electrocardiography 1
1.1 The ECG and Its History 2

1.2 Uses of an ECG 3
1.3 Preparing for an ECG 11
1.4 Safety and Infection Control 15
1.5 Vital Signs 18
CHAPTER 2 The Cardiovascular System 28
2.1 Circulation and the ECG 29

2.2 Anatomy of the Heart 29
2.3 Principles of Circulation 34
2.4 The Cardiac Cycle 36
2.5 Conduction System of the Heart 38
2.6 Electrical Stimulation and the ECG Waveform 41
CHAPTER 3 The Electrocardiograph 54
3.1 Producing the ECG Waveform 54

3.2 ECG Machines 59
3.3 ECG Controls 64
3.4 Electrodes 67
3.5 ECG Graph Paper 69
3.6 Calculating Heart Rate 71
vii
CHAPTER 4 Performing an ECG 82
4.1 Preparation for the ECG Procedure 83

4.2 Communicating with the Patient 84
4.3 Identifying Anatomical Landmarks 86
4.4 Applying the Electrodes and Leads 88
4.5 Safety and Infection Control 91
4.6 Operating the ECG Machine 94
4.7 Checking the ECG Tracing 95
4.8 Reporting ECG Results 100
4.9 Equipment Maintenance 101
4.10 Pediatric ECG 102
4.11 Cardiac Monitoring 103
4.12 Special Patient Considerations 104
4.13 Handling Emergencies 107
CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121
5.1 Rhythm Interpretation 121

5.2 Identifying the Components of the Rhythm 122
5.3 Rhythms Originating from the Sinus Node 129
5.4 Sinus Bradycardia 132
5.5 Sinus Tachycardia 134
5.6 Sinus Dysrhythmia 135
5.7 Sinus Arrest 137
CHAPTER 6 Atrial Dysrhythmias 147
6.1 Introduction to Atrial Dysrhythmias 147

6.2 Premature Atrial Complexes 148
6.3 Wandering Atrial Pacemaker 150
6.4 Multifocal Atrial Tachycardia 152
6.5 Atrial Flutter 153
6.6 Atrial Fibrillation 155
CHAPTER 7 Junctional Dysrhythmias 166
7.1 Introduction to Junctional Dysrhythmias 166

7.2 Premature Junctional Complex (PJC) 168
7.3 Junctional Escape Rhythm 169
viii Contents
7.4 Accelerated Junctional Rhythm 171
7.5 Junctional Tachycardia 173
7.6 Supraventricular Tachycardia (SVT) 175
CHAPTER 8 Heart Block Dysrhythmias 186
8.1 Introduction to Heart Block Dysrhythmias 186

8.2 First Degree Atrioventricular (AV) Block 187
8.3 Second Degree Atrioventricular (AV) Block, Type I (Mobitz or
Wenckebach) 188
8.4 Second Degree Atrioventricular (AV) Block, Type II (Mobitz II) 191
8.5 Third Degree Atrioventricular (AV) Block (Complete) 193
CHAPTER 9 Ventricular Dysrhythmias 204
9.1 Introduction to Ventricular Dysrhythmias 205

9.2 Premature Ventricular Complexes (PVCs) 205
9.3 Agonal Rhythm 210
9.4 Idioventricular Rhythm 211
9.5 Accelerated Idioventricular Rhythm 213
9.6 Ventricular Tachycardia 215
9.7 Ventricular Fibrillation 217
9.8 Asystole 220
CHAPTER 10 Pacemaker Rhythms and Bundle Branch Block 234
10.1 Introduction to Pacemaker Rhythms 234

10.2 Evaluating Pacemaker Function 236
10.3 Pacemaker Complications Relative to the ECG Tracing 241
10.4 Introduction to Bundle Branch Block Dysrhythmias 243
CHAPTER 11 Exercise Electrocardiography 253
11.1 What Is Exercise Electrocardiography? 253

11.2 Why Is Exercise Electrocardiography Used? 255
11.3 Variations of Exercise Electrocardiography 257
11.4 Preparing the Patient for Exercise Electrocardiography 260
11.5 Providing Safety 264
11.6 Performing Exercise Electrocardiography 265
11.7 Common Protocols 267
11.8 After Exercise Electrocardiography 270
Contents ix
CHAPTER 12 Ambulatory Monitoring 282
12.1 What Is Ambulatory Monitoring? 282

12.2 How Is Ambulatory Monitoring Used? 284
12.3 Functions and Variations 285
12.4 Educating the Patient 290
12.5 Preparing the Patient 292
12.6 Applying an Ambulatory Monitor 293
12.7 Removing an Ambulatory Monitor and Reporting Results 296
CHAPTER 13 Clinical Presentation and Management

of the Cardiac Patient 307
13.1 Coronary Arteries 308

13.2 Cardiac Symptoms 310
13.3 Atypical Patient Presentation 312
13.4 Acute Coronary Syndrome 314
13.5 Heart Failure 316
13.6 Cardiac Patient Assessment and Immediate Treatment 318
13.7 Treatment Modalities for the Cardiac Patient 324
CHAPTER 14 Basic 12-Lead ECG Interpretation 334
14.1 The Views of a Standard 12-Lead ECG and Major Vessels 334
14.2 Ischemia, Injury, and Infarction 339
14.3 Electrical Axis 343
14.4 Bundle Branch Block 345
14.5 Left Ventricular Hypertrophy 347
Appendix A Cardiovascular Medications A-1

Appendix B Standard and Isolation Precautions B-1
Appendix C Medical Abbreviations, Acronyms, and Symbols C-1
Appendix D Anatomical Terms D-1
Glossary G-1
Photo Credits PC-1
Index I-1
x Contents
Preface
Healthcare is an ever-changing and growing field that needs well-trained indi-
viduals who can adapt to change. Flexibility is key to obtaining, maintain-
ing, and improving a career in electrocardiography. Obtaining ECG training
and certification, whether it be in addition to your current career or as your
career, will make you employable or a more-valued employee. This fourth edi-
tion of Electrocardiography for Healthcare Professionals will prepare
users for a national ECG certification examination, but most importantly
provides comprehensive training and practice for individuals in the field of
electrocardiography.
The fact that you are currently reading this book means that you are
willing to acquire new skills or improve the skills you already possess. This
willingness translates into your enhanced value, job security, marketability,
and mobility. Once you complete this program, taking a certification exami-
nation is a great next step for advancing your career.
This fourth edition of Electrocardiography for Healthcare Profes-
sionals can be used in a classroom as well as for distance learning. Check-
point Questions and Connect exercises correlated to the Learning Outcomes
make the learning process interactive and promote increased comprehension.
The variety of materials included with the program provides for multiple
learning styles and ensured success.
Text Organization
The text is divided into 14 chapters:
● Chapter 1 Electrocardiography includes introductory information about
the field as well as legal, ethical, communication, safety, and patient edu-
cation information. In addition, basic vital signs and troubleshooting are
addressed.
● Chapter 2 The Cardiovascular System provides a complete introduction
and review of the heart and its electrical system. The information focuses
on what you need to know to understand and perform an ECG. Specific top-
ics include anatomy of the heart, principles of circulation, cardiac cycle,
conduction system and electrical stimulation, and the ECG waveform.
● Chapter 3 The Electrocardiograph creates a basic understanding of the
ECG, including producing the ECG waveform, the ECG machine, elec-
trodes, and ECG graph paper.
● Chapter 4 Performing an ECG describes the procedure for performing
an ECG in a simple step-by-step fashion. Each part of the procedure is
explained in detail, taking into consideration the latest guidelines. The
chapter is divided into the following topics: preparation, communica-
tion, anatomical landmarks, applying the electrodes and leads, safety
xi
and infection control, operating the ECG machine, checking the trac-
ing, reporting results, and equipment maintenance. Extra sections are
included regarding pediatric ECG, cardiac monitoring, special patient
circumstances, and emergencies. Procedure checklists are included to
practice performing both an ECG and continuous monitoring.
● Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms introduces
the five-step criteria for classification approach to rhythm interpretation
that will be utilized throughout Chapters 5 to 10. With updated, realistic
rhythm strip figures, explanations, and Checkpoint Questions, the user
learns to interpret the sinus rhythms, including criteria for classification,
how the patient may be affected, basic patient care, and treatment.
● Chapter 6 Atrial Dysrhythmias provides an introduction to and inter-
pretation of the atrial dysrhythmias, including criteria for classification,
how the patient may be affected, basic patient care, and treatment.
● Chapter 7 Junctional Dysrhythmias provides an introduction to and inter-
pretation of the junctional dysrhythmias, including criteria for classifica-
tion, how the patient may be affected, basic patient care, and treatment.
● Chapter 8 Heart Block Dysrhythmias provides an introduction to and
interpretation of the heart block dysrhythmias, including criteria for
classification, how the patient may be affected, basic patient care, and
treatment.
● Chapter 9 Ventricular Dysrhythmias provides an introduction to and inter-
pretation of the ventricular dysrhythmias, including criteria for classifica-
tion, how the patient may be affected, basic patient care, and treatment.
● Chapter 10 Pacemaker Rhythms and Bundle Branch Block provides an
introduction to pacemaker rhythms, evaluation of pacemaker function,
and complications related to the ECG tracing. An introduction to bundle
branch block dysrhythmias, including criteria for classification, how the
patient may be affected, basic patient care, and treatment, is also included.
● Chapter 11 Exercise Electrocardiography provides the information nec-
essary to assist with the exercise electrocardiography procedure. The
competency checklist provides the step-by-step procedure for practice
and developing proficiency at the skill.
● Chapter 12 Ambulatory Monitoring includes the latest information
about various types of ambulatory monitors and includes what you need
to know to apply and remove a monitor. A procedure checklist is also
provided for this skill.
● Chapter 13 Clinical Presentation and Management of the Cardiac
Patient expands on the anatomy of the coronary arteries and relates them
to typical and atypical cardiac symptoms. STEMI, non-STEMI, and heart
failure are introduced. The chapter includes a section about sudden car-
diac death as compared to myocardial infarction and finishes with assess-
ment, immediate care, and continued treatment of the cardiac patient.
● Chapter 14 Basic 12-Lead ECG Interpretation provides an introduction
to 12-lead ECG interpretation. It includes anatomic views of the coronary
arteries and correlates the arteries with the leads and views obtained
on a 12-lead ECG. It also identifies the morphologic changes in the trac-
ing that occur as a result of ischemia, injury, and infarction. Axis devia-
tion, bundle branch block, and left ventricular hypertrophy round out the
chapter concepts. The last section helps users put all of these concepts
together for 12-lead interpretation.
xii Preface
These chapters can be utilized in various careers and training programs. Fol-
lowing are some suggested examples:
● Telemetry technicians (Chapters 1–12, depending on requirements)
● EKG/ECG technicians (the entire book, depending on requirements)
● Medical assistants (the entire book, depending on where they work)
● Cardiovascular technicians working in any number of specialty clinics,
such as cardiology or internal medicine (the entire book)
● Remote monitoring facilities personnel (transtelephonic medicine) (Chap-
ters 1–10, 12–14)
● Emergency medical technicians (Chapters 2, 5–10, 14, possibly more depend-
ing on where they work)
● Paramedics (Chapters 2–14)
● Nursing, especially for cross-training or specialty training (Chapters 2–14)
● Patient care tech or nursing assistant (Chapters 2–4, 12, perhaps more de-
pending on job requirements)
● Polysomnography technologist (Chapters 2–10)
● Echocardiography technologist (Chapters 2, 5–11)
● Cardiac cath lab technologist (Chapters 2–10, 14)
New to the Fourth Edition

● Over 25 new photos and revised figures for an improved, up-to-date, and
realistic look that also provides additional student practice.
● Complete revision of Chapter 1 including new and expanded sections on
safety and infection control and basic vital signs.
● Modified Bloom’s specific learning outcomes providing one learning out-
come per level 1 heading and corresponding questions to ensure student
understanding and success.
● Added and updated content about the following essential topics: cardiac
anatomy, lead descriptions, law and ethics, cardiac output, vagal tone,
stroke volume, premature complexes, Wolff-Parkinson-White syndrome,
Torsades de Pointes, pacemakers, exercise electrocardiography (includ-
ing a new table for common stress test chemicals), and ambulatory
monitoring.
● Modified and simplified descriptions of arrhythmias; changed the term
configuration to morphology when appropriate for accuracy.
Features of the Text

● Key Terms and Glossary: Key terms are identified at the beginning of
each chapter. These terms are in bold, color type within the chapter and
are defined both in the chapter and in the glossary at the end of the book.
● Checkpoint Questions: At the end of each main heading in the chapter
are short-answer Checkpoint Questions. Answer these questions to make
sure you have learned the basic concepts presented.
● Troubleshooting: The Troubleshooting feature identifies problems and
situations that may arise when you are caring for patients or perform-
ing a procedure. At the end of this feature, you are asked a question to
answer in your own words.
Preface xiii
● Safety & Infection Control: You are responsible for providing safe
care and preventing the spread of infection. This feature presents tips
and techniques to help you practice these important skills relative to
electrocardiography.
● Patient Education & Communication: Patient interaction and educa-
tion and intrateam communication are integral parts of healthcare. As
part of your daily duties, you must communicate effectively, both orally
and in writing, and you must provide patient education. Use this feature
to learn ways to perform these tasks.
● Law & Ethics: When working in healthcare, you must be conscious of
the regulations of HIPAA (Health Insurance Portability and Accountabil-
ity Act) and understand your legal responsibilities and the implications
of your actions. You must perform duties within established ethical prac-
tices. This feature helps you gain insight into how HIPAA, law, and ethics
relate to the performance of your duties.
● Real ECG Tracings: Actual ECG tracings, or rhythm strips, have been
provided for easy viewing and to make the task of learning the various
dysrhythmias easier and more realistic. Use of these ECG rhythm strips
for activities and exercises throughout the program improves compre-
hension and accommodates visual learners.
● Chapter Summary: Once you have completed each chapter, take time
to read and review the summary table. It has been correlated to key con-
cepts and learning outcomes within each chapter and includes handy
page number references.
● Chapter Review: Complete the chapter review questions, which are pre-
sented in a variety of formats. These questions help you understand the
content presented in each chapter. Chapters 4, 11, and 12 also include Pro-
cedure Checklists for you to use to practice and apply your knowledge.
Resources
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xiv Preface
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Preface xv
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rience, but an engaging and dynamic one in which students are more likely
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Valuable reports provide instructors with insight on how students are pro-
gressing through textbook content, and are useful for shaping in-class time
or assessment. As a result of the adaptive reading experience found in Smart-
Book, students are more likely to retain knowledge, stay in class, and get bet-
ter grades. This revolutionary technology is available only from McGraw-Hill
Education and for hundreds of courses—including Electrocardiography for
Healthcare Professionals—as part of the LearnSmart Advantage series.
xvi Preface
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Preface xvii
Guided Tour
Features to Help You Study and Learn
The
Electrocardiograph
Learning Outcomes and Key Terms, and an Learning Outcomes 3.1 Explain the three types of leads and how each is recorded.
3.2 Identify the functions of common ECG machines.
Introduction begin each chapter to introduce 3.3
3.4
Explain how each ECG machine control is used.
Recognize common electrodes.
you to the chapter and help prepare you for the 3.5
3.6
Describe the ECG graph paper.
Calculate heart rates using an ECG tracing.
information that will be presented. Key Terms artifact

augmented lead
millimeter (mm)
millivolt (mV)
bipolar lead multichannel recorder
bradycardia output display
Einthoven triangle precordial lead
electrodes serial ECG comparison
gain signal processing
hertz (Hz) speed control
input tachycardia
lead unipolar lead
limb lead
3.1 Producing the ECG Waveform

In this chapter, we discuss the electrocardiograph and the equipment needed
Copyright © 2016 by McGraw-Hill Education

to perform an ECG and record the ECG waveform. You will discover how the
12-lead system works and how to read the measurements on the ECG graph
paper. Learning the equipment and lead system thoroughly and correctly will
prepare you to record your first ECG.
The electrical impulse that is produced by the heart’s conduction system
is measured with the ECG machine. The ECG machine interprets the impulse
and produces the ECG waveform. The waveform indicates how the heart is
functioning electrically.
A single heart rhythm tracing views the heart from one angle. Because
the heart is three-dimensional, it is necessary to view the electrical impulse
from different sides to obtain a complete assessment of its electrical activity.
A 12-lead ECG provides a complete picture, not of the heart’s structure, but of
its electrical activity. It records the heart’s electrical activity from 12 different
54
boo20670_ch03_054-081.indd 54 02/09/14 3:43 pm
Sinus Arrest
Troubleshooting exercises identify problems A patient is in sinus arrest that lasts longer than 6 seconds. This indicates
that no electrical current is traveling through the cardiac conduction system
and situations that may arise on the job. You asystole When no rhythm
or electrical current is
traveling through the cardiac
and is known as asystole. What should you do?
conduction system.
may be asked to answer a question about the
situation.
Check Point 1. Using the criteria for classification, select the rhythm that most
Question closely resembles sinus arrest.
(LO 5.7)
A.
Checkpoint Questions are provided at the end of B.
each section in the chapter to help you understand

the information you just read.
Which distinguishing feature(s) led you to make the selection?
Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 139
boo20670_ch05_121-146.indd 139 02/09/14 4:26 pm
xviii
“I have been examining textbooks for approximately 4.1 Preparation for the ECG Procedure
eight years now and this ECG text provides students Now that you understand how the ECG is used, the anatomy of the heart, and
the electrocardiograph, the next step is to record an ECG. The ECG experi-
ence should be pleasant for the patient and not produce anxiety. The ECG
with the most complete and accurate information procedure must be done correctly, and the tracing must be accurate.
Prior to performing the ECG, you will need to prepare the room. Cer-
tain conditions in the room where the ECG is to be performed should be con-
without overwhelming them.” sidered. For example, electrical currents in the room can interfere with the
tracing. If possible, choose a room away from other electrical equipment and
x-ray machines. Turn off any nonessential electrical equipment that is in the
Donna Folmar, Belmont Technical College room during the tracing. The ECG machine should be placed away from other
sources of electrical currents, such as wires or cords.
An ECG must be ordered by a physician or other authorized personnel,
and an order form must be completed prior to the procedure. This form may
be called a requisition or consult and should be placed in the patient’s record.
It should include why the ECG was ordered and the following identifying
Patient Education & Communication boxes information:
● Patient name, identification number or medical record number, and birth
give you helpful information for communicating ●

date
Location, date, and time of recording
● Patient age, sex, race, and cardiac and other medications the patient is
effectively—both orally and written—with patients. ●
currently taking
Weight and height
● Any special condition or position of the patient during the recording
If this information is not included on the requisition or consult, you should
ask the patient or find the information in the patient’s record.
Most facilities now have computerized systems. The ECG order is fre-
quently entered through this system. Entering the patient’s identifying infor-
mation into the computer will produce the order form and generate patient
charges. Without a computer system, the information should be handwritten
on the order form, consult, or requisition, whichever your facility uses.
Cardiac Medications
Certain cardiac medications can change the ECG tracing. Prior to the ECG

procedure, determine if your patient is on any cardiac medications and, if
so, inform the physician and write the names of the medications on the ECG
report. See the appendix Cardiovascular Medications for examples of com-
mon cardiac medications.
The patient’s identifying information should also be entered through the

LCD panel on the ECG machine prior to the recording. If the ECG machine
does not allow you to enter the information or there isn’t time due to an emer-
gency situation, you should write it on the completed ECG. Most importantly,
all information should be written or entered accurately no matter what type
of ECG machine or order system you are using.
Figure 9-7 Ventricular fibrillation.
Interpret-TIP features throughout boo20670_ch04_082-120.indd 83 02/09/14 4:20 pm
Chapters 5–10 provide simple and easy

guidelines to help you recognize each of Interpret-TIP Ventricular Fibrillation
the ECG rhythms presented. Ventricular fibrillation is the absence of organized electrical activity. The
tracing is disorganized or chaotic in appearance.
How the Patient Is Affected and What You Should Know

What appears to be ventricular fibrillation on the monitor may not be ventric-
Safety & Infection Control boxes ular tachycardia at all. Remember to always check your patient first. Fibril-
latory waveforms may be caused by a variety of different things, like poorly
attached or dried out electrodes, broken lead wires, and excessive patient
movement. If your patient is talking to you, the patient is not in ventricular
present tips and techniques for you to apply apnea The absence of
breathing.
fibrillation.
In true ventricular defibrillation, patients will be unresponsive when the
on the job. advanced cardiac life sup-

port (ACLS) A set of clinical
interventions for the urgent
ventricles are quivering without contracting. This will always be an emer-
gency situation. Check your patient first, then initiate CPR and activate EMS
or in a healthcare institution follow the protocol for the emergency. Every
treatment of cardiac arrest patient experiencing ventricular fibrillation will be unconscious, apneic
and other life-threatening (apnea means not breathing), and pulseless. CPR and emergency measures
medical emergencies, as should begin immediately. It is recommended that appropriate personnel
well as the knowledge begin the advanced cardiac life support (ACLS) to regain normal cardiac
and skills to deploy those function. Rhythm strips are maintained and used as documentation in the
interventions. patient’s medical record.

Crash Cart
Emergency equipment found on the crash cart must be ready when a code
situation occurs. It is important that the cart be well stocked and the emer-
crash cart A cart or tray gency equipment functioning properly. Each facility has a policy that
containing emergency medi- requires regular checking and documentation of all emergency equipment
cation and equipment that and crash carts.
can be easily transported to
the location of an emergency
for life support.
Interpret
p TIP Supraventricular
Supravent
tricular Dysrhythmias
Supraventricular
Supraventrricular tachycardia describes a group of dysrhythmias
d that
218
present with a normal-to-narrow QRS compl
complex rate of greater than
lex and a ra
150 beats per
per minute.
boo20670_ch09_204-233.indd 218 29/08/14 10:01 am

How the Patient Is Affected and What You Should Know
There are various supraventricular dysrhythmias, all of which may cause the
patient to exhibit the same signs and symptoms. The patient may be in either
a stable or an unstable condition. The stable patient (one without signs and
Law & Ethics boxes help you gain insight into symptoms of decreased cardiac output) may complain only of palpitations and
state, “I’m just not feeling right” or “My heart is fluttering.” When the patient’s
condition is unstable, he or she may experience any symptom of low cardiac
necessary information related to the performance of output because the heart is not pumping effectively to other body systems.
Many patients may present initially with a stable condition and then a few min-
utes later experience unstable symptoms.
your duties.
Observe the patient for signs and symptoms of low cardiac output.
Signs, symptoms, and rhythm changes need to be communicated quickly to a
licensed practitioner for appropriate medical treatment. Because tachycardia
significantly increases myocardial oxygen demand, treatment should begin
as early as possible. It is difficult to predict how long a patient’s heart can
beat at a rapid rate before it begins to affect the other body systems.
Scope of Practice
Your role regarding evaluation of the rhythm strip and assessment of the
patient will depend on your training and place of employment. Working out-
side your scope of practice is illegal, and you could be held liable for per-
forming tasks that are not part of your role as a healthcare professional.
Chapter 7 Junctional Dysrhythmias 177
boo20670_ch07_166-185.indd 177 28/08/14 9:28 pm
xix
Criteria for Classification
● Rhythm: P-P interval cannot be determined; the R-R interval is regular.
ECG Rhythm Strips make the task of learning the ● Rate: Atrial rate cannot be determined due to the absence of atrial depo-
larization. The ventricular rate is 40 to 100 beats per minute.
● P wave morphology: The P wave is usually absent; therefore, no analy-
various dysrhythmias easier and more realistic. Over ●
sis of the P wave can be done.
PR interval: The PR interval cannot be measured because the P wave
200 strips are included within the textbook. ●

cannot be identified.
QRS duration and morphology: The QRS duration and morphology
measure 0.12 second or greater and have the classic ventricular wide and
bizarre appearance.
Interpret-TIP Accelerated Idioventricular Rhythm
“Practice ECG rhythm strips are key tools for prac- The accelerated idioventricular rhythm has an absence of P waves, a
ventricular rate of 40 to 100 beats per minute, and wide and bizarre QRS

ticing rhythm recognition. An excellent comprehen- complexes.
sive textbook for the Electrocardiography student.” Figure 9-4 Accelerated idioventricular rhythm.
Stephen Nardozzi, Westchester Community College
Chapter 9 Ventricular Dysrhythmias 213
Key Points correlated to the learning

outcomes in each Chapter Summary help you Second
ond degree type II
boo20670_ch09_204-233.indd 213
Missing QRS
RS
S Complex
Co
C omplex Missing QRS
Mi
Missing QRS
Third degree (Complete)
29/08/14 10:01 am
Missing QRS
Mi
Missing QRS Missing QRS
Mi
Missing QRS Mi
M ssing QRS
Missing QRS Mi
Missing QRS
Missing QRS
review what was just learned.

PRI remains PRI remains PRI remains PRI remains P wave is partialy P wave is partialy P wave is partialy
the same the same the same the same buried within the T wave buried within the QRS buried within the T wave
Chapter Summary
Learning Outcomes Summary Pages
8.1 Describe the various heart block In heart block rhythms, the electrical current has difficulty 186
dysrhythmias. traveling along the normal conduction pathway, causing
a delay in or absence of ventricular depolarization. The
degree of blockage depends on the area affected and the
cause of the delay or blockage. The P-P interval is regular
with all heart blocks. There are three levels of heart blocks.
8.2 Identify first degree atrioventricular (AV) First degree AV block is a delay in electrical conduction 187–188
block using the criteria for classification, and from the SA node to the AV node, usually around the AV
explain how the rhythm may affect the patient, node, which slows the electrical impulses as they travel to
including basic patient care and treatment. the ventricular conduction system.
8.3 Identify second degree atrioventricular Second degree heart block type I has some blocked or 188–190
(AV) block, Mobitz I, using the criteria for nonconducted electrical impulses from the SA node to
classification, and explain how the rhythm the ventricles at the atrioventricular junction. The impulses

may affect the patient, including basic patient coming from the atria are regular, but the conduction
care and treatment. through the AV node gets delayed.
8.4 Identify second degree atrioventricular Second degree atrioventricular block, Mobitz II, is 191–193
(AV) block, Mobitz II, using the criteria for often referred to as the “classical” heart block. The
classification, and explain how the rhythm atrioventricular node selects which electrical impulses
may affect the patient, including basic patient it will block. No pattern or reason for the dropping of
care and treatment. the QRS complex exists. Frequently this dysrhythmia
progresses to third degree atrioventricular block.
8.5 Identify third degree atrioventricular (AV) Third degree atrioventricular block is also known as third 193–196
block using the criteria for classification, and degree heart block or complete heart block (CHB). All
explain how the rhythm may affect the patient, electrical impulses originating above the ventricles are
including basic patient care and treatment. blocked and prevented from reaching the ventricles. There is
no correlation between atrial and ventricular depolarization.
In third degree atrioventricular block, the P-P and R-R
intervals are regular (constant) but firing at different rates.
196 Chapter 8 Heart Block Dysrhythmias
Chapter Review
boo20670_ch08_186-203.indd 196 28/08/14 10:12 pm
Multiple Choice
Circle the correct answer.
1. Which heart block rhythm is the one with the distinguishing feature of a PR interval that measures
greater than 0.20 second and measures the same duration each time? (LO 8.2)
a. First degree heart block
b. Second degree type I
c. Second degree type II
d. Third degree heart block
2. Which of the following heart block dysrhythmias is identified by a repetitious prolonging PR interval
Chapter Reviews consist of various methods of pattern after each blocked QRS complex? (LO 8.3)
quizzing you. True/false, multiple choice, matching, c. Second degree type II

and critical thinking questions, among others, appeal 3. Which of the following heart block dysrhythmias is identified by missing QRS complexes and a
consistent PR interval measurement? (LO 8.4)
to all types of learners. b. Second degree type I

4. Which of the following heart block dysrhythmias is identified by regular P-P and R-R intervals that
are firing at two distinctly different rates? (LO 8.5)
At the end of each chapter, you will be directed to visit a. First degree heart block
the Internet to experience more interactive activities

5. P-P intervals are with all heart block dysrhythmias. (LO 8.2–8.5)
about the information you just learned. a. irregular
b. absent
c. regular
d. progressively prolonged
6. QRS complexes that measure 0.12 second or greater with a rate between 20 and 40 beats
per minute indicate that the impulses causing ventricular depolarization are coming from
the . (LO 8.5)
a. SA node
b. interatrial pathways
c. AV node
d. Purkinje fibers (ventricles)
Chapter 8 Heart Block Dysrhythmias 197
boo20670_ch08_186-203.indd 197 28/08/14 10:12 pm
xx
Procedure Checklists help you learn and apply the PROCEDURES CHECKLIST 12-1
Applying and Removing an Ambulatory (Holter) Monitor
knowledge presented. Practice Practice Performed Mastered
Procedure Steps (Rationale) Yes No Yes No Yes No Date Initials
Preprocedure
1. Gather supplies and equipment.
• Prep razor
• Alcohol
• Electrodes
• Gauze pads
• Skin rasp
• Tape
• Holter unit with strap and case
• Fresh batteries
• Digital disk (SD card)
• Pen and patient diary
2. Review patient instructions per facility policy

(to ensure accuracy and prevent problems
during the testing procedure).
• Documentation (diary), activities of daily living

(ADLs), when symptoms occur.
• Medications.
• Physical restrictions such as new activities

(should maintain normal routine), bathing,
showers, swimming while wearing the device.
• How to operate the event marker.

• How to reapply an electrode if one comes
loose or falls off.
• Must return with the Holter and diary to

complete the test.
• Must wear loose-fitting garments on the

upper body to reduce artifact.
• Provide facility phone number, copy of

instructions, and “point of contact” if the
patient has questions, problems, or concerns.
• Provide picture of electrode locations,

extra electrodes, and adhesive tape per
clinic policy.
(Continued)
Chapter 12 Ambulatory Monitoring 303
boo20670_ch12_282-306.indd 303 30/08/14 8:48 pm
Critical Thinking Application Rhythm Identification

Review the dysrhythmias pictured here and, using the criteria for classification provided in the chapter as
clues, identify each rhythm and explain what criteria you used to make your decision. (LO 5.3 to 5.7)
Review and Practice Rhythm 23.
Identification throughout textbook

activities provide ample practice
opportunities.
Rhythm (regular or irregular): PR interval:
Rate: QRS:
P wave: Interpretation:
24.
Rhythm (regular or irregular): PR interval:

Rate: QRS:
P wave: Interpretation:
Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 143
boo20670_ch05_121-146.indd 143 02/09/14 4:27 pm
xxi
Acknowledgments
Authors
Kathryn Booth: Thanks to all the reviewers who have spent time helping to
make sure this fourth edition is up-to-date. In addition, I would like to acknowl-
edge McGraw-Hill for supporting this book into its fourth edition and Jody
James for being my right hand through the process.
Additionally, I would like to acknowledge Patricia Dei Tos and the members
of the Inova Health system, who help to create and support the development
of this textbook, and the Inova Learning Network, which provided encourage-
ment and lab space for photo opportunities. Also, I would like to acknowledge
the members of the Inova Heart and Vascular Institute and Inova eICU for
their assistance in obtaining photographs and video selections.
Thomas O’Brien: I would like to acknowledge Mr. David Rubin, president
& CEO of Aerotel Medical Systems (1998) Ltd., 5 Hazoref St., Holon 58856,
Israel. I would like to express my sincere appreciation to a pair of former
students and Central Florida Institute graduates: Rebecca Walton, CCT, for
her contribution of Interpret-Tips and Jamie Merritt, CCT, for “bunny branch
block.” I would also like to give a special thank-you to the staff members of
the Non-Invasive Cardiology Departments at the Pepin Heart Hospital, Mor-
ton Plant Hospital, All Children’s Hospital, and Palms of Pasadena Hospital for
their inputs and generous donation of their time and expertise.
Additionally I would like to thank my co-workers and the leadership at CFI:
Rose Lynn Greene, Director; Susan Burnell, DOE; Steve Coleman, NCMA, Edu-
cation Supervisor; Amanda L. Jones, MBA, NR-CMA, NCPT, CPC, Medical Assis-
tant Program Director (CFI); and Nicholas R. Senger, RMA, Medical Assistant
Program Instructor (CFI). Additionally I would like to thank my former col-
leagues at Central Florida Institute: Mr. Jimmy Smith, DOE; Mr. John Michael
Maloney, RCIS; Mrs. Kathy Hellums, RCS; and Mr. Steve Coleman, NCMA.
Finally, a very special thank-you to my son Rob for his hours devoted to
scanning many of the cardiac rhythms in this text.
Consultants
Cynthia T. Vincent, MMS, PA-C
Alderson Broaddus College, Philippi, WV
Jennifer Childers, MS PAC
Alderson Broaddus College, Philippi, WV
Susan Hurley Findley, RN, MSN
Houston, TX
Lynn M. Egler, RMA, AHI, CPhT
St. Clair Shores, MI
Kimberly Speiring, MA
St. Clair Shores, MI
xxii
Reviewers
Stephanie Bernard, BA, NCMA David Martinez, Medical Assistant/
Sanford–Brown Institute EMT
Jacksonville, FL Vista College
Gayle Carr, CPFT, RRT, MS Richardson, TX
Illinois Central College John McBryde, Nationally
East Peoria, IL Registered Paramedic
Cyndi Caviness, CRT, CMA East Mississippi Community College
(AAMA), AHI Mayhew, MS
Montgomery Community College Cheryl McQuay, CPT, CMA, CPI, CEKG
Troy, NC Star Career Academy
Harvey Conner, NRP, AHA Brick, NJ
Oklahoma City Community College Sheri Melton, PhD, ACSM Certified
Oklahoma City, OK Exercise Specialist, ACSM
Mary Hewett, BSEMS, MEd, Certified Health Fitness Specialist
NREMTP West Chester University
University of New Mexico West Chester, PA
Albuquerque, NM Bharat Mody, MD
Charles Hill, Paramedic Star Career Academy
North Georgia Technical College Clifton, NJ
Clarksville, GA Nicole Palmieri, RN, AHI
Cynthia Hill, MBA, CPT, CEHRS, Advantage Career Institute
CMA Eatontown, NJ
NewBridge Cleveland Center for Arts Stephen Smith, MPA, RT, RRT
& Technology Stony Brook University
Cleveland, OH Stony Brook, NY
Scott Jones, BS, MBA, EMT-P Scott Tomek, Paramedic
Victor Valley College Century College
Apple Valley, CA White Bear Lake, MN
Konnie King Briggs, CCT, CCI; PBT, Suzanne Wambold, RN, PhD
ASCP; CPCI, ACA The University of Toledo
Houston Community College Toledo, OH
Houston, TX Andrew Wood, MS, NREMT-P
Joyce Lockwood, NREMTP Emergency Medical Training
Prince George’s Community College Professionals, LLC
Largo, MD Lexington, KY
Previous Edition Reviewers

Emil P. Asdurian, MD Nia Bullock, PhD
Bramson ORT College Miller-Motte Technical College
Forest Hills, NY Cary, NC
Vanessa J. Austin, RMA, CAHI Jesse A. Coale, PA-C
Clarian Health Sciences Center, Philadelphia University
Medical Assistant Philadelphia, PA
Indianapolis, IN
Stephen Coleman
Rhonda J. Beck, NREMT-P
Central Florida Institute
Central Georgia Technical College
Palm Harbor, FL
Macon, GA
Acknowledgments xxiii
Harvey Conner, AS, REMT-P Elizabeth Laurenz
Oklahoma City Community College National College
Oklahoma City, OK Columbus, OH
Barbara S. Desch, LVN, CPC, AHI Sheri A. Melton, PhD
San Joaquin Valley College Inc. West Chester University
Visalia/Hanford Campus West Chester, PA
Visalia, CA
Stephen J. Nardozzi
Melissa L. Dulaney Westchester Community College
MedVance Institute of Baton Rouge Valhalla, NY
Baton Rouge, LA
David James Newton, NREMT-P
Mary Patricia English Dalton State College
Howard Community College Dalton, GA
Columbia, MD
R. Keith Owens
Michael Fisher, Program AB-Tech Community College
Director Asheville, NC
Greenville Technical College
Greenville, SC Douglas A. Paris, BS,
NREMT-P
Donna L. Folmar Greenville Technical College
Belmont Technical College Department of Emergency Medical
St. Clairsville, OH Technology
Anne Fox Greenville, SC
Maric College
David Rice, AA, BA, MA
Carson, CA
Career College of Northern Nevada
James R. Fry, MS, PA-C Reno, NV
Marietta College
Marietta, OH Dana M. Roessler, RN, BSN
Southeastern Technical College
Michael Gallucci, MS, PT
Glennville, GA
Assistant Professor of Practice,
Program in Physical Therapy Wayne A. Rummings, Sr.
School of Public Health, New York Lenoir Community College
Medical College Kingston, NC
New York, NY David Lee Sessoms, Jr., MEd, CMA
Jonathan I. Greenwald Miller-Motte Technical College
Arapahoe Community College Cary, NC
Littleton, CO Mark A. Simpson, NREMT-P, RN,
Grace Haines CCEMTP
National College Director of EMS
Dayton, OH Northwest-Shoals Community College
Linda Karp Muscle Shoals, AL
Atlantic Cape Community College Linda M. Thompson, MS, RRT
Mays Landing, NJ Madison Area Technical College
Deborah Kufs, MS, BSN, CEN, Madison, WI
EMT-P Dyan Whitlow Underhill, MHA, BS
Hudson Valley Community College Miller-Motte Technical College
Troy, NY Cary, NC
Susie Laughter, BSN, RN Eddy van Hunnik, PhD
Cambridge Institute of Allied Health Gibbs College Boston
Longwood, FL Boston, MA
xxiv Acknowledgments
Suzanne Wambold, PhD, RN First Edition
RDCS, FASE Civita Allard
The University of Toledo Mohawk Valley Community College
Toledo, OH Utica, NY
Danny Webb Vicki Barclay
Milan Institute West Kentucky Technical College
Visalia, CA Paducah, KY
Danielle Schortzmann Wilken Nina Beaman
Goodwin College Bryant and Stratton College
East Hartford, CT Richmond, VA
Stacey F. Wilson, MT/PBT Cheryl Bell
(ASCP), CMA Sanz School
Cabarrus College of Health Washington, DC
Sciences Lucy Della Rosa
Concord, NC Concorde Career Institute
Fran Wojculewicz, RN, BSN, MS Lauderdale Lakes, FL
Maricopa Community College Myrna Lanier
Glendale, AZ Tulsa Community College
Roger G. Wootten Tulsa, OK
Northeast Alabama Community Debra Shafer
College Blair College
Rainsville, AL Colorado Springs, CO
Acknowledgments xxv
Electrocardiography
Learning Outcomes 1.1 Describe the history and the importance of the ECG.
1.2 Identify the uses of an ECG and opportunities for an electro-
cardiographer.
1.3 Troubleshoot legal, ethical, patient education, and communication
issues related to the ECG.
1.4 Perform safety and infection control measures required for the ECG.
1.5 Compare basic vital sign measurements related to the ECG.
Key Terms auscultated blood pressure ethics

automatic external healthcare providers
defibrillator (AED) hypertension
body mechanics hypotension
cardiac output isolation precautions
cardiopulmonary law
resuscitation (CPR) libel
cardiovascular disease (CVD) medical professional liability
cardiovascular technologist myocardial infarction (MI)
Code Blue personal protective equipment
coronary artery disease (CAD) (PPE)
defibrillator slander
diastolic blood pressure standard precautions
dysrhythmia stat
ECG monitor technician systolic blood pressure
electrocardiogram (ECG) telemedicine
electrocardiograph vital signs
electrocardiograph (ECG)
technician
1
cardiovascular disease 1.1 The ECG and Its History
(CVD) Disease related to
The number one cause of death in the United States every year since 1918 is
the heart and blood vessels
cardiovascular disease (CVD), or a disease of the heart and blood vessels.
(veins and arteries).
Approximately 2,500 Americans die every day because of coronary artery
coronary artery disease disease (CAD), which is narrowing of the arteries of the heart, which causes
(CAD) Narrowing of the a reduction of blood flow. Unbelievably, one out of every three American
arteries around the heart, adults has some form of CAD. You may know someone who has hypertension
causing a reduction of blood (high blood pressure) or other heart conditions. Maybe someone you know
flow. has had a myocardial infarction (MI) or heart attack.
myocardial infarction An instrument known as an electrocardiograph allows the heart’s
(MI; heart attack) Damage electrical activity to be recorded and studied. It is used to produce an electri-
to the heart muscle caused cal (electro) tracing (graph) of the heart (cardio). This tracing is known as an
by lack of oxygen due to a electrocardiogram (ECG).
blockage of one or more of Scientists have known since 1887 that electrical currents are produced
the coronary arteries. during the beating of the human heart and can be recorded. An English physi-
cian, Dr. Augustus D. Waller (1856–1922), showed that electrical currents are
electrocardiograph An
produced during the beating of the human heart and can be recorded. Willem
instrument used to record
Einthoven (1860–1927) invented the first electrocardiograph, which resulted
the electrical activity of the
in a Nobel Prize in Physiology or Medicine in 1924. Advancements in this tech-
heart.
nology have brought about today’s modern ECG machines (see Figure 1-1).
electrocardiogram Computer technology continues to improve the availability and speed of com-
(ECG) A tracing of puter interpretation and quickly communicates this information to a health-
the heart’s electrical care professional. Digital communication allows healthcare professionals to
activity recorded by an monitor patients from remote locations miles away.
electrocardiograph.
Figure 1-1 Today’s 12-lead ECG machine

is attached to the patient’s chest, arms,
and legs using electrodes and lead wires.
It records a tracing of the electrical activity
of the heart.
2 Chapter 1 Electrocardiography
Performing the actual ECG procedure is not difficult; however, it must
be performed competently. The tracing of the electrical current of the heart
must be accurate because it is used to make decisions about a patient’s care.
An inaccurate tracing could result in a wrong decision about the patient’s
medication or treatment. These decisions could result in a negative outcome
for the patient.
Checkpoint 1. What is the leading cause of death in the United States?

Questions
(LO 1.1)
2. Who is credited with determining that the human heart produces
electrical currents that can be recorded?
1.2 Uses of an ECG

healthcare providers Healthcare providers study the ECG tracing to determine many things
Physicians and other about the patient’s heart. They look for changes from the normal ECG tracing
medically trained personnel or from a previous ECG tracing. The American Heart Association (AHA) rec-
who are licensed by ommends that individuals over the age of 40 have an ECG done annually as
individual states to provide part of a complete physical. This baseline tracing assists the physician in
healthcare to patients. The diagnosing abnormalities of the heart. A sample of a normal tracing is shown
scope of practice for each in Figure 1-2. Normal and abnormal ECG tracings are discussed in the chap-
type of healthcare provider ters The Cardiovascular System and Rhythm Strip Interpretation and Sinus
is determined by the state Rhythms.
license. Electrocardiography can be performed in a number of healthcare set-
tings. The type of ECG tracing produced depends on the setting and the type
of ECG machine used.
Figure 1-2 A normal ECG tracing is a

horizontal line with upward and downward

spikes or deflections that indicate electrical
activity within the heart.
P S-T T
P-R QRS
Q-T
Chapter 1 Electrocardiography 3
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COLLEGE AND UNIVERSITY.[2]
Touching the theme of higher education, inquiries were sent to a

large number of universities, colleges, and secondary schools. The
first two questions related to the work of secondary education, and
were as follows: (1) What should the high-school graduate be when
entering college? (2) What does he lack of an ideal education when
he enters? Considering the general character of the questions, the
answers were all that might be expected, and they are valuable for
the limit of their range, as well as for what they express, since they
show that, concerning the main purpose of education, there is
nothing new to be said.
The following are opinions that represent the majority or appear
important as individual views: (1) The high-school graduate, when
entering college, should possess a mind educated by methods that
create interest and make power to think and generalize—power to
do original work. (2) He should have an acquaintance with each field
of knowledge, and should show a symmetrical development of his
mental activities. (3) As tending to produce greater interest,
knowledge, and power, he should have been trained in only a limited
number of subjects in each field; in these subjects the work should
have been continuous and intensive. (4) He should have good
command of English. (5) He should be well-grounded in right habits
and moral principles—the practice of self-control.
While this inquiry is not strictly upon the subject, it shows that the
difficult problems of university life are to be solved in part by the
secondary schools, and that some of the failures in higher education
are due to the imperfections of earlier training. It also introduces part
of the discussion that follows.
The third question pertained to higher education: What should the
college or university do for the high-school graduate? Some of the
more important opinions received may be expressed as follows:
(a) It should supplement the failures of his earlier training. There
should be no chasm between secondary and higher education.
(b) It should give him a liberal education; it should offer him a
course that has unity and harmony. It should cultivate the power of
research. It should teach him to bring all his knowledge and all his
power to bear on the problems of life.
(c) It should make him broad, and then deep in some subject. It
should start him in lines of study leading to his life work.
(d) It should give him high ideals of private and civic conduct; it
should make a man of him.
To consider merely the subject of college ideals would be trite and
unprofitable, and some latitude will be used in the discussion.
The influence of the college should be felt in the work of

preparation. That the college should be closely articulated with the
high schools is an idea of modern date, but one that now is received
with growing favor. An examination of the admission requirements of
the colleges still shows a variety of demands, having no common
basis in principles of education, in the standard courses of high
schools, or in uniform agreement. The requirements of some
colleges are imperative for specific subjects that are not
fundamental, but merely rank with a series of allied subjects in a
given field of knowledge. Often a method of work acceptable to one
college would be rejected by another. Among reputable institutions
the height of the standard varies by two years.
The dissatisfaction of the high schools with these evils is deep-
seated and wide-spread. The fault rests mainly with the colleges and
universities, and the reasons that maintain unessential distinctions
are absurd in the eyes of secondary-school men. If absolute
uniformity in college admission is not feasible, a reasonable choice
of equivalents within a given department of knowledge may be
allowed. At least a plan of admission may be “organized without
uniformity.” A college has been known to refuse four years’ excellent
work in science as a substitute for some chapters in a particular
book on physical geography. In another instance a certain scientific
school, requiring two years of preparation in Latin, refused a four
years’ course in Latin in lieu of the prescribed number of books in
Cæsar. A joint committee has recently been appointed by the
Department of Higher Education and the Department of Secondary
Education, of the National Educational Association, to consider
further the basis of connection between the high schools and the
colleges. This committee consists of eminent and able men, who will
accomplish important results, if given proper encouragement and aid
by the National Association, and if the various local associations
coöperate, instead of fostering organized differences.[3] The report of
the Committee of Ten did much to prepare the way for a more
complete and satisfactory connection between the colleges and the
high schools, but much remains to be done which may well be
undertaken by this joint committee. It is interesting to note that one of
the longest sections in the report of the Royal Commission on
Secondary Education is on the “Relation of the University to
Secondary Education,” and that the importance of a close
connection is emphasized and the means of securing it is suggested.
The work of secondary education must be based on pedagogical
principles and adapted to the stage of development which it
represents, and the colleges must take up the work where the high
schools leave it. Whatever is best for a given period of growth is also
good preparation for what follows. There should be no saltus in the
process of general education. We do not mean that the colleges are
not to help determine the preparatory courses of study; but they
must regard the natural order of development in grades below the
college as well as ideal college standards.
By a closer union with the high schools, the colleges may help to
fashion their courses, improve their methods, and may suggest the
importance of placing college-educated men and women in charge
of the various departments of high-school work. The report of the
Royal Commission previously referred to, discussing the preparation
of teachers for the secondary schools, says: “So far as regards
general education, they will obtain it, and, in our opinion, ought to
obtain it, not in special seminaries, but in the same schools and
universities as are resorted to by persons desiring to enter the other
professions. The more attractive the profession becomes, the larger
will be the number of teachers who will feel that they ought to fit
themselves for it by a university course.” The report further says:
“Whatever professional education is provided for teachers ought to
have both a theoretical and a practical side.... Freedom and variety
would, in our opinion, be best secured, if the universities were to
take up the task; ... and, if the science of education is to make good
the claims put forward in its behalf, it ought to be studied where other
branches of mental and moral philosophy are fully handled by the
ablest professors.”
Many colleges are doing much to increase laboratory practice in
the high schools, to cultivate the spirit of investigation, to limit the
number of subjects and secure good results. In one of the new
States, Colorado, the principle is generally recognized that a good
preparatory education is also a good general education, and that
every high school is, therefore, a preparatory school. The secondary-
school period is maintained at four years, laboratories are provided
in all the schools, and Latin and German, if not Greek, are found in
all. These results are largely due to the close relation in that State
between secondary and higher education.
In the second group of opinions quoted, the philosophy is Platonic

rather than materialistic or utilitarian. It makes a student a man of
ideal powers, possibilities, and aspirations. He possesses a nature
whose development is an end in itself, whose well-being is of prime
consideration. Liberal education aims to give the student a conscious
realization of his powers, without reference to material advantage
through their use in a given occupation or profession. Through liberal
education the student acquires ideas of universal interest and
essential character. He gains a comprehensive view that enables
him to estimate things at their relative value, to learn the place, use,
and end of each.
That liberal education should remain the ideal of at least a large
part of the college course, most educators agree. Were this function
of the college not a distinctive and essential one, that department of
learning would of necessity be abandoned, and the direct road to
practical business would be pursued. Recent addresses,
representing three of the greatest American universities, agree that
the function of the college is to be maintained, and that acquaintance
with the several fields of knowledge is necessary to the very idea of
liberal education. They agree to include the field of the languages
and literature, the field of the sciences and mathematics, the
subjective field, that of philosophy and psychology. In a late report of
the Commissioner of Education appears a German criticism of
American education, which mentions the lack of linguistic training.
The writer says: “The consequences are seen in the defective
linguistic-logical discipline of the mind, which perhaps more than the
discipline in the mathematical forms of thought is a requisite of all
profound intellectual progress, be that in linguistic or in mathematical
and scientific branches.” In the University of Berlin, philosophy is a
required subject for all degrees.
The conservation of the ideals of the race is largely the work of
liberally educated men. Some one has argued that not through
education, but through a higher standard of society and politics, will
the youth of the land be reached; but society and politics depend
upon ideal education and the church for their own purification.
The power of research is characteristic of modern university
training and is essential to a liberal education, as giving one the
mastery of his powers. Carlyle was not far from the right when he
said that the true university is a library. The ability to use a library is
one criterion of successful college work. Here the student gathers his
own material, uses his own discrimination, formulates his opinions in
the light of numerous facts and opinions, and gains self-reliance. It is
the scientific method, as taught by Socrates, applied to all fields of
study. This is the kind of work that prepares the student to grapple
with the practical problems of the day.
The opinion that some portion of the college work should be
prescribed appears to be well founded. This view is strengthened by
the fact that many high schools are weak in one or more
departments of preparation. A minimum of required work in leading
departments of the college will tend to supply the deficiencies of
previous training. From an inspection of the latest college catalogues
it appears that all colleges exercise some kind of supervision over
the choice of studies, and many of them prescribe and determine the
order of more than half the curriculum. In choice of electives many
require the group system, in order that consistency may be
maintained and that a definite result in some line of work may be
reached.
The line of demarcation between college and university work is a
variable, and the problem of definitely locating it is perplexing in the
extreme. Many believe they see signs of segmentation at the end of
the junior year and predict that the senior year will adhere to the
graduate school. There are many evidences that somewhere along
the line the period of general education will be shortened, and the
tendency to specialize before the end of the college course is one
proof that the change is demanded. Historically the college in
America stands as a whole for liberal education, but in its later
development the standard has been advanced and the period of
professional education has been lengthened until the problem
presents new phases demanding important readjustments. Replies
recently received from many institutions of higher learning, touching
this question, show a variety of opinions. One correspondent pithily
says, “Verily, we are a smattering folk. I believe both the college and
the professional course should be lengthened.” President Eliot
advocates “a three years’ course for the A.B., without disguises or
complications.” Estimating the replies already received numerically,
something more than half favor some kind of time readjustment, to
the end that the period covered by the college and the professional
school may be shortened one year.
While defending liberal education, it may be held that, especially
while a four years’ college course is maintained, it should also look
toward the world of active influence, and the filling of some vocation
therein. The student’s duties toward society must take on the
modern aspect, as contrasted with the self-centred interest of the
mediæval recluse. That education should aim at mere serene
enjoyment of the True, the Beautiful, and the Good is an idea of the
past. The mere recluse to-day has no meaning and no use in the
world. Educated men must join the march of progress; they must
take part in the solution of ethical problems, in the bettering of
government and society. The world demands of them altruism, public
spirit, high ideals. They should mass the forces of the past for an
onward movement in the present. Old knowledge should reach out
toward new and useful applications.
To these ends the college should provide for a deeper knowledge
of some subject or group of related subjects. This is an essential
element of general education, and also has a practical aim. The
principles of the philosophical and social sciences should find
concrete illustration in the present. And above all, student life should
be inspired with ideas of the duties and responsibilities of citizenship.
A public statement has been made that the seniors of a well-

known university have less intellectual vigor and less moral power
than the average man they might meet on the streets. If the charge
be true, it is a matter for serious thought, but the statement should
be swallowed with a large grain of salt. It may, however, serve as a
text. The college must assume an amount of responsibility for the
character of the undergraduate student. There has been a natural
reaction against some of the unwise requirements of twenty-five
years ago, but the reaction may have gone too far. One of our
famous universities ten years ago adopted the policy of leaving the
student to his own devices and the moral restraint of the policeman,
but the plan was condemned by the patrons of the institution, and to-
day it exercises a wise and friendly care over the student’s choice of
studies, his attendance upon lectures, and his daily walk and
conversation. Entire freedom in student life belongs only to the
graduate schools, and to place both undergraduate and graduate
students under one system can but prove harmful.
The ethical problems of college life are not to be solved wholly by
perfunctory religious exercises, but by the spirit that pervades the
whole teaching and student body, and by the many ways and means
that the united efforts of earnest and devoted faculties may employ.
It is a favorable circumstance that the student to an extent can
choose subjects in accord with his tastes; that his powers may reach
out toward some great intellectual interest. That the spirit of
education is broader, more liberal, and scientific is significant; the
fact makes for truth and honesty. The historical method succeeds the
dogmatic in history, social science, philosophy, and ethics. Men are
better because they are broader and wiser and are coming to a
higher realization of truth.
No doubt the ethical life has the deepest significance for man. The
great Fichte was right in claiming that, if this is merely a subjectively
phenomenal world, it is a necessary creation of mind that we may
have it wherein to work and ethically develop. That institution will
turn out the best men where the Baconian philosophy is combined
with the Platonic, the scientific with the ideal. By some means the
student should constantly come in contact with strong manhood and
high ideals. It makes a practical difference whether the student
believes in his transcendent nature and possibilities or in mere
materialism and utilitarianism, whether his ethics is ideal or
hedonistic, his view of life optimistic or pessimistic.
If the question is made distinct, What should the university do for

the student?—there are some additional considerations.
It is enough to say of graduate courses that they should be a
warrant for extended and thorough knowledge of a group of related
subjects, and for original power to grasp and deal with difficult
problems. The candidate’s knowledge and power should be publicly
tested by a good old-fashioned examination and defence of thesis.
The university should refuse to admit the student to the
professional schools until he has received at least the equivalent of a
complete high-school education. The faculties of the University of
Colorado have made an investigation of the standard of admission to
the professional schools, the length of professional courses, and the
relation of the professional courses to the college. The results are of
interest.[4] Very few schools of applied science in the universities
require four years of preparation. Only three or four universities
require that standard for their law or medical schools. Most
catalogues read after this fashion: Admission to law or medical
school—a college diploma, or a high-school diploma, or a second-
grade teacher’s certificate, or evidence of fitness to pursue the
subject. Less than half of the law schools require entrance
qualifications, and only twenty of them require a three years’ course.
All medical schools advocate a thorough scientific foundation, many
of them in a very ideal way, and urge extensive laboratory practice in
many special subjects. The most of them think the first two years of
a medical course could well be spent without clinical work. Many
colleges and collegiate departments of universities provide electives
that are accepted by some schools of theology, law, or medicine for
their regular first-year work. In rare instances, studies covering two
years are made common to the college and the professional schools.
But only a few universities have within their own organization a plan
for shortening the period of college and professional study.
The “Report on Legal Education,” 1893, issued by the United
States Bureau of Education, says: “Admission to the bar in all
Continental (European) countries is obtained through the universities
which are professional schools for the four learned professions—
theology, medicine, law, and philosophy. In England and America the
colleges and universities are chiefly schools for general culture; only
a few offer provision for thorough professional studies. While in
England and America the erroneous idea is still predominant that a
collegiate education need not necessarily precede professional
study, in Continental Europe it is made a conditio sine qua non. No
one more needs than the lawyer the power of general education to
grasp all the facts relating to a subject, to weigh their value, discard
the unessential, and give prominence to the determining factors; no
one more needs the power to avoid fallacies and to argue
intelligently scientific points which may be involved in litigation. No
one more than the physician needs an acquaintance with psychology
and philosophy, with the various sciences and the modern
languages; no one more needs the power of judgment in view of
seemingly contradictory facts and symptoms; no one more needs the
ethical quality of the noble and honorable gentleman. Let the
American universities maintain the standards which in theory they all
are ready to advocate.”
FOOTNOTES:
[2] Read before the National Association of City
Superintendents, at Jacksonville, Florida, in 1896.
[3] This committee made its report in 1899. The committee
recommend that any study, included in a given list regarded as
suitable for the secondary-school period, and pursued under
approved conditions one year of four periods a week, be regarded
as worthy to count toward admission to college; they recognize
that not all secondary schools are equipped to offer all the
subjects, and that the colleges will make their own selections for
admission; they recognize the principle of large liberty to the
student in secondary schools, but do not believe in unlimited
election, and they emphasize the importance of certain constants
in all secondary schools and in all requirements for admission to
college; they recommend that these constants be recognized in
the following proportion: Four units in foreign languages (no
language accepted in less than two units), two units in
mathematics, two in English, one in history, and one in science.
The thirteenth annual convention (1900) of the Association of
Colleges and Preparatory Schools of the Middle States and
Maryland passed resolutions urging the establishment of a joint
college-admission examination board to bring about an
agreement upon a uniform statement as to each subject required
by two or more colleges for admission, to hold examinations, and
to issue certificates to be accepted by the Middle-State Colleges.
At the Charleston meeting of the N. E. A. (1900) the following
resolution was passed: “Resolved, That the Department of
Secondary Education and the Department of Higher Education of
the National Educational Association commend the Report of the
Special Committee on College-Entrance Requirements, as
affording a basis for the practical solution of the problem of
college admission, and recommend the Report to the attention of
the colleges of the country.”
[4] During the four years (1896-1900) since this investigation
was made, there has been great progress throughout the country.
The standard universities now require at least a high-school
education for admission to professional schools, and offer four
years in medicine and three years in law.
UNIVERSITY IDEALS.[5]
To an extent a university must represent the philosophy of a

people at a given epoch, and their political, social, and industrial
tendencies. It symbolizes the stage of civilization and spiritual
insight. The ethical need of the time led to the study of philosophy in
Greece; the innate regard of the Roman people for justice and the
problems attending the development of the Empire emphasized the
study of law in Rome; Christianity and the influence of the Greek
philosophy made theology the ideal of the Middle Ages; the
development of the inductive method places emphasis on physical
science to-day; the industrial spirit of America gives a practical turn
to our higher education. It is no mere accident that the English
university is conservative and aristocratic and aims at general
culture, that the French faculties are practical, or that the German
universities are scientific and democratic. The differences in spirit
and method are determined by factors that belong to the history and
character of the different peoples.
The colleges of New England were founded on the traditions of
Oxford and Cambridge, and embodied their ideal and theological
aims and conservative method, although they naturally were more
liberal and democratic than the parent institutions. The history of the
early American colleges has been varied, but the more successful
ones have certainly become catholic and progressive. As the country
grew and men pushed westward, leaving tradition behind and
developing more freely the spirit of our advancing civilization, the
conception of a university, in touch with all the people, and scientific
and free, arose. Thus we have the state university. At the same time
the leading religious denominations have vied with each other in
founding in the new states colleges or universities that are more or
less denominational in spirit and aim.
The American university of to-day contains many elements.
Broadly speaking, it represents the ideals of the Platonic philosophy,
the direct inheritance from England, the character of the German
university, the modern scientific method, and the practical demands
of American civilization. All these elements are woven into the web
of our national life. There is, of course, much diversity. Each class of
universities contains something of all the ideals, but each
emphasizes certain ones. The older and larger denominational
school is more nearly the direct representative of English education,
but has made a great advance. The state universities represent the
people as such and the tendencies of our civilization, but in accord
with the highest ideals. They more readily accept the influence of the
German university. The denominational colleges scattered
throughout the West aim to perpetuate the denominational idea.
Almost from the foundation of our Government free elementary

schools have been regarded as an essential and characteristic part
of our American institutions. They became a logical necessity when
our forefathers abjured the caste and intolerance of the Old World,
and with prophetic insight proclaimed the era of a new civilization in
which the welfare of the state should mean the welfare of all the
people. While the idea of education at the expense of the state, and
under its control, was early accepted in that part of the country which
has gradually influenced the whole nation, we of to-day have
witnessed a part of the struggle to place on a permanent foundation
the modern system of high schools. These schools, especially in the
West, now have an assured position and command the confidence
of the people. The attempt to take the next step and establish state
universities was met with doubt and opposition. At a comparatively
recent date, however, many state universities have come into
prominence, and to-day they appear in the main to be the coming
institutions of university training from Ohio to Oregon, and from
Texas to Montana. Here is a development that is remarkable, and we
may well examine its significance.
In the first place the state university is the logical outcome of our
democratic ideal that made the public schools a necessity, an
outcome which naturally would be first realized in the newer states.
As America furnished new and favorable conditions for the
development of civilization, freed in part from the traditions of the Old
World, so the new states of the West became the field for a still more
liberal growth of the tendencies of the age. There is a recognized
tendency in our institutions toward a broader community of interests
in respect to many things that affect the common welfare, and in no
way does this tendency find a grander expression than in the means
for elevating the people at the expense of the people to a better
citizenship, higher usefulness, and wiser and nobler manhood. The
safety of the state depends upon giving the brightest and best of all
classes and conditions an opportunity to rise to the surface of affairs.
In Prussia, Switzerland, and Italy a healthy organization of society
is held to depend upon public control of both secondary and higher
education. England’s system of education tends to maintain social
distinctions and an intellectual conservatism that are harmful both to
the aristocracy and to the common people. Education in Germany
shows its superiority in that it reaches a larger number of the poor
classes and develops greater freedom of thought. The public control
of education makes it democratic and progressive, and strengthens
its influence with the people. It makes the scholar a leader in the line
of advance indicated by the ideals of the people. In the American
state university, men come together as a faculty, bringing with them
training and educational ideals gained in the best universities of the
world. They place themselves in touch with the public schools, the
press, and all the state agencies of influence and control. Knowing
the needs and demands of the people, they take the lead in the line
of natural progress. The state university is inseparably linked to the
state, and must carry with it the best influences of the state, and thus
extend its influence to the whole people.
The great denominational schools at first represented
homogeneous elements in the national life. Harvard was essentially
a state institution. It was founded in “accord with the fundamental
principles of the Commonwealth of Massachusetts.” The people of
Massachusetts, at that time, were largely homogeneous in race,
religion, and love of freedom. Yale was founded partly on the
conservative Congregationalism of Connecticut; hence it
represented the mass of people in that State. Princeton was founded
in the interest of the Scotch and Scotch-Irish political and religious
views in the Middle States, but was so far catholic as to enlist the
sympathy of the Dutch and the Quakers. However, it served a
comparatively homogeneous people. In later years each of these
universities, in order to reach large numbers of people maintaining
diverse views, has been obliged to subordinate specific sectarian or
denominational elements and emphasize only the highest ideals
common to its constituency. The newer states of the West have a
mixed population with heterogeneous interests. Hence it follows that
not a denominational school, but a state school, broad enough for all
the people, alone can satisfy the need of each state. Since it is
impossible to maintain a real university for each peculiar interest, all
must unite to support one institution, an institution maintaining the
highest ideals common to humanity, and specifically to our own
civilization. The ideals common to the American people are ample
enough for an ideal university, founded and maintained by the state.
Harvard or Princeton may say: “We have done for the state all that
the state university claims as its function.” Then let each state have a
Princeton which from the start is assured of an adequate foundation.
In our Western states the same reason that would create one
denominational college would create in each state fifteen or twenty.
The history of the world never has seen such a dissipation of
educational energy as is now seen in America, and a system of state
education which tends to correct the evil merits enthusiastic support.
It may be added that the state university exists in the West because
the majority of the people are coming to prefer that kind of institution.
We may say, then, that the state university represents (1) the
completion of the democratic ideal of public education; (2) the unity
of progress amidst diversity of view, and the mutual influence of the
knowledge and power of the scholar and the ideals of the people; (3)
the broad platform upon which the heterogeneous elements of the
state may unite in the interest of higher education. It is understood,
of course, that these three statements are not altogether mutually
exclusive.
These views of the raison d’être of the state university lead directly
to the presentation in detail of some facts in its history and some of
its aims, showing that its ideals are practicable.
The state university virtually, if not formally, is a part of the public-
school system. As such it holds a peculiar and influential relation
toward the public high schools. It furnishes teachers trained in the
university in regular and pedagogical courses. It scrutinizes the
courses of study and the character of the work, and formally
approves the schools of standard merit. It helps in every prudent way
the influence of the school with the community. By its friendly relation
it may present freely the advantages of higher education and thus
reach a large number who would otherwise rest at the goal of high-
school graduation. In every state, through the agency of the
university, the number of high schools is materially increased, and
their standards, plan of organization, and methods are improved.
Moreover, it gives the promise of something beyond that stimulates
the efforts of pupils in every grade of work.
The connection between the high school and the university still
gives rise to troublesome problems, not alone in this country. The
ideals of the older American university are often at variance with the
systematic development of education below the university and the
demands of the people. The state university has come nearer than
any other to the solution. While Harvard and Yale met the growing
demands of science by establishing separate schools, Michigan
introduced the scientific course into the college, making it rank with
the classical. This plan, generally adopted by the state universities,
places them nearly in line with the natural development of the public-
school system. The state universities also show their regard for
popular demand by admitting special students.
By offering free tuition, the state university reaches many who
would otherwise fail to enjoy higher training. It tends to equalize the
conditions for rich and poor in the struggle for the survival of the
fittest.
The state university, as it develops and realizes its true function,
must be thoroughly catholic in spirit, because it stands for humanity,
truth, and progress. Nowhere is the professor or the scholar
permitted to use such intellectual freedom as in the state university
in Germany, and in the natural course of events the same freedom
will be allowed in the United States. Not only will the free and
inventive spirit become characteristic, but our Western universities,
standing in the midst of the most advanced ideas of civilization, must
furnish some of the most important contributions to the study of all
social, economic, and ethical problems.
In the state universities the mental and moral atmosphere is
healthful. A strong, honest manhood is cultivated. There all ideals
are strongly maintained, not according to a particular creed, but with
regard to all the implications of man’s higher nature. All influences
tend to make citizens who are in harmony with the national spirit. An
extended acquaintance with graduates of various state universities
shows that, as a whole, they are broad-minded citizens, loyal to the
public interest.
The relation of the religious denominations to the state university
is one that commands serious attention. The university says to each
class of people: “Here is an institution which is equally for the
advantage of all—it is yours. Its platform, founded on ideals of truth,
beauty, and goodness, is as broad as humanity. Since there must be
diversity of religious views, establish your theological schools, halls,
guilds, or professorships in the vicinity of the university, and, making
use of what the state offers, supplement in your own way the work of
the state.” The plan is in the highest degree economical; it combines
unity of effort with variety of independent view; it makes the general
good and the special interest mutually helpful. It is the plan of
business common sense and of wise insight into the problems of the
age. That the denominations—granting their point of view—should
join their interest with that of the state university is shown also by the
fact that often a given denomination finds more of its students there
than at its church school.
Many state universities are beginning to receive private
endowment. Every consideration of public interest in each state
should turn the contributions for education toward the one great
centre of learning. Very few states can support more than one such
centre. Libraries, art collections, museums, laboratories, buildings,
well-endowed chairs, beautiful grounds, should testify to the
munificence of private wealth as well as to the benefactions of the
state.
Speaking generally, the state universities have large incomes and
good facilities. They require high standards for admission and
graduation. Wherever feasible, they maintain professional schools
and schools of applied science. They do this upon the theory that the
state should both regulate and provide professional education in the
interest of proper standards, and that, in the interest of the state and
of the individual, such education should be made available to the
sons of the poor. Every leading state university is developing a
graduate school.
In the matter of electives, the state university occupies a middle
ground. Yale and Princeton represent the conservative side, and
Harvard and Stanford the liberal extreme. An examination of the
curricula of ten leading state universities shows that the
requirements for admission are definitely prescribed, although two or
more courses are recognized; that about half the college studies are
required, while the remaining half are offered as group or free
electives. The state universities naturally show a tendency toward
the German university system.
In America the college has been frankly maintained in accord with

Platonic ideals. A full rounded manhood, drawing its power from
each chief source of knowledge, and prepared in a general way for
every practical activity, has been the aim. The American college is
dear to the people, and it has done much to make strong men who
have powerfully influenced the nation. There are, however, various
tendencies which are likely to modify the whole organization of the
American university, including that of the college.
The recent tendency toward free election, reaching even into the
high school, is a subject of animated controversy. This tendency I
have frequently discussed elsewhere, and must still maintain that, in
its extreme form, it is irrational. One university of high standing
makes it possible to enter its academic department and graduate
without mathematics, science, or classics. This is an extreme that is
not likely to be sanctioned by the educational world. If there is a
human type with characteristics by which it is defined—
characteristics which can be developed only by looking toward each
field of knowledge—then a secondary and higher education which
makes possible the entire omission of any important group of
subjects is likely to prove a great wrong to the average student.
According to some high educational authorities, no one can be called
liberally educated who does not at least possess knowledge of (1)
mathematics and science, (2) language and literature, (3)
philosophy. Philosophy, as it was in Greece and as it is in Germany,
may become a larger factor in our American education.
There is another tendency which is working toward an inevitable
result. The average American student who desires higher or
professional education will not spend four years in high school, four
years in college, and three or four years in a graduate or
professional school. There is a movement to shorten in some
manner the whole course of education. Already many colleges and
collegiate departments of universities offer electives that will count
for one or two years of law, medicine, or theology. Already the
university system in the form of group electives is introduced into the
last two years of college.
The outcome will probably be a gradual reorganization of the high-
school studies and those of the first two or three years of college.
The new curriculum should lay for the student a broad and firm
foundation in knowledge and power for all subsequent aptitudes.
Upon this should be built the graduate school, the professional
school, and perhaps the school of technology. In this plan the
American college need not be lost, for the bachelor’s degree could
be granted for a given amount of work beyond the college in the
graduate school. The claim that the student should begin university
work almost anywhere along the line of education, before laying a
complete foundation for a specialty, appears absurd. It may be
added that only by partial reorganization of our educational system
can the admission standard to the American professional school
ever be made respectable.
The scientific spirit—the term is used in the broadest sense—in all
investigation and instruction is a most encouraging feature of present
tendencies. If the American professor cannot always be an original
investigator, he may keep abreast of investigation and impart its
inspiration to the student. To this end the Lehrfreiheit, freedom in
teaching, is necessary. It is a sad comment that the spirit of the
inquisition has recently appeared in a New England university. The
professor’s thought must not be prescribed for him by any creed,
religious, political, or scientific. Of course, he must stand on the safe
foundation of the past—he is not expected to soar in a balloon or
leap over a precipice. A recent work on “The Ideal of Universities”
says: “We can distinguish four chief currents in the theology of the
present era: (1) The Roman Catholic; (2) the Protestant; (3) that
objective-historic theology which simply states the origin and
development of the Christian doctrine; and (4) the inception of a
theology based upon recognized facts of science, of human nature,
and of history.” All philosophy of nature and of human nature must
become truth-seeking—this is a mere truism. No philosophy or belief
can afford to maintain any other attitude. Leaders in the orthodox
churches are teaching us this fact by their bearing toward new
conceptions. And we need have no fear of the outcome. The highest
ideals and hopes of humanity will be confirmed by the most thorough
investigation in which metaphysics shall use the contribution of every
department of objective and subjective science. A course in theology,
scientific theology, should be found in every university, including the
state university—and some dare to think the latter is the place for it.
The facts of man’s higher intellectual and emotional life are the most
important data for investigation.
The doctrine of Lernfreiheit, the freedom of the student, unhappily
has been ignorantly applied in this country. It may properly be
employed for the German university student at the age of twenty to
twenty-five, after his training in the gymnasium, but not to the
American college student at the age of eighteen to twenty-two. In

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Electrocardiography for healthcare

professionals 4th edition Edition Booth

Electrocardiography For Healthcare Professionals Ise

Communication: Core Interpersonal Skills for Healthcare

(eBook PDF) Medical Terminology for Healthcare

(Original PDF) Infection Control Manual for Healthcare

(eBook PDF) Handbook of Informatics for Nurses &

Handbook of Informatics for Nurses & Healthcare

(eBook PDF) Strategic Planning in Healthcare: An

(eBook PDF) Strategic Planning in Healthcare: An

Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS

Thomas O’Brien, AS, CCT, CRAT, RMA

This book is printed on acid-free paper.

Senior Vice President, Products & Markets: Kurt L. Strand

Library of Congress Cataloging-in-Publication Data

Booth, Kathryn A., 1957- author.

1.1 The ECG and Its History 2

CHAPTER 2 The Cardiovascular System 28

2.1 Circulation and the ECG 29

CHAPTER 3 The Electrocardiograph 54

3.1 Producing the ECG Waveform 54

4.1 Preparation for the ECG Procedure 83

CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121

5.1 Rhythm Interpretation 121

CHAPTER 6 Atrial Dysrhythmias 147

6.1 Introduction to Atrial Dysrhythmias 147

CHAPTER 7 Junctional Dysrhythmias 166

7.1 Introduction to Junctional Dysrhythmias 166

CHAPTER 8 Heart Block Dysrhythmias 186

8.1 Introduction to Heart Block Dysrhythmias 186

CHAPTER 9 Ventricular Dysrhythmias 204

9.1 Introduction to Ventricular Dysrhythmias 205

CHAPTER 10 Pacemaker Rhythms and Bundle Branch Block 234

10.1 Introduction to Pacemaker Rhythms 234

CHAPTER 11 Exercise Electrocardiography 253

11.1 What Is Exercise Electrocardiography? 253

12.1 What Is Ambulatory Monitoring? 282

CHAPTER 13 Clinical Presentation and Management

13.1 Coronary Arteries 308

CHAPTER 14 Basic 12-Lead ECG Interpretation 334

Appendix A Cardiovascular Medications A-1

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3.1 Producing the ECG Waveform

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Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 139

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