# Boobs and the 12 lead



## bigbaldguy (Sep 8, 2011)

Ok so I've finally gotten to the point where I can confidently place all the stickies for a 12 lead without having to look at my little cheat sheet. I'm feeling pretty good about myself and maybe even a little cocky. Then on my next call I get a patient with really big breasts and I'm back to square one. All my landmarks are thrown off by the things. So here's my question if I get the stickies put in the wrong spot by an inch or two does it screw up the entire ECG? Is there a margin of error or do I really need to poke around on this poor woman looking for ribs so I can place the stickies in exactly the right spot?


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## Handsome Robb (Sep 8, 2011)

The biggest issue is being over a bone, it messes with the conductivity. If your way off yes it will mess with the reading, just a tid bit wont make a huge difference. I know some people who just toss them on there without palpating. We were doing 12/15 leads today. Get them as close as you can, and remember to use the back of your gloved hand haha


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## Sasha (Sep 8, 2011)

You'll be fine.

But don't be afraid to toss those things out of the way.


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## abckidsmom (Sep 8, 2011)

You must palpate, but how much you have to palpate decreases over time.


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## bigdogems (Sep 8, 2011)

Pretty much as close as you can get. Im sure some doc could tell a small difference but an inch or so off isnt bad. And It will always be a better tracing than if you tried putting it over fat where it should be. Skin prep can also be a huge help


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## 18G (Sep 8, 2011)

You dont have to be so precise. Put the electrodes where they are supposed to go and its all good. The electrodes go under the boob so it shouldnt really mess up the land marks. 

Just lift it up a little and should be the same as "normal" size boobs.


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## medicsb (Sep 8, 2011)

It can be difficult to get it exact w/ a big breasted individual so there is some guessing to be done.  

Some things to remember: don't cup your hand when moving one out of the way and wear gloves if there's even the slightest chance of under-boob-sweat (gross).


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## medic417 (Sep 8, 2011)

18G said:


> You dont have to be so precise. Put the electrodes where they are supposed to go and its all good. The electrodes go under the boob so it shouldnt really mess up the land marks.
> 
> Just lift it up a little and should be the same as "normal" size boobs.



Lift but not by pulling the nipple.  Usually the back of your hand will work but some takes the cup of the palm of your hand.  Do not be bashful.  Do not hesitate to ask the women to hold them out of the way.


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## bigbaldguy (Sep 8, 2011)

medic417 said:


> Lift but not by pulling the nipple.



Really! You think someone actually has done that, excuse me ma'am just need to grab hold of your nipple her and sling this over your shoulder? I wonder how hard she hit him.


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## abckidsmom (Sep 8, 2011)

medic417 said:


> Lift but not by pulling the nipple.  Usually the back of your hand will work but some takes the cup of the palm of your hand.  Do not be bashful.  Do not hesitate to ask the women to hold them out of the way.



<not sure if serious>

Way awkward.  Hesitate to ask the woman to hold them out of the way. 

"Excuse me ma'am, I'm not able to control your massive breast.  Can you give a hand?"

Please hesitate.  Just be matter of fact and pretend it's not a big deal.  In time, it really will be a non-event.


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## HotelCo (Sep 9, 2011)

abckidsmom said:


> <not sure if serious>
> 
> Way awkward.  Hesitate to ask the woman to hold them out of the way.
> 
> ...



If that's the case, I just say "We're going to take a better look at your heart, and we have to put some stickers on your chest. Can you lift your left breast, please?" 

Easy as pie. No mention of the gargantuan boulders.


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## Sasha (Sep 9, 2011)

Chances are they know their chesticles are larger than normal and are accustomed to having to man handle them themselves and arent shy about it.

Sent from LuLu using Tapatalk


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## Aidey (Sep 9, 2011)

HotelCo said:


> If that's the case, I just say "We're going to take a better look at your heart, and we have to put some stickers on your chest. Can you lift your left breast, please?"
> 
> Easy as pie. No mention of the gargantuan boulders.



Exactly. This also gets their arm out of the way so you can place V6.


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## KingCountyMedic (Sep 9, 2011)

Sometimes I have just gone over the top of 'em. There are some things you never want to see under...................


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## Aidey (Sep 9, 2011)

KingCountyMedic said:


> Sometimes I have just gone over the top of 'em. There are some things you never want to see under...................




*facepalm* 

To the OP, don't do this. If you think you are off on your landmarks going under the breast tissue, just imagine how far off you can be going on top of it.


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## MasterIntubator (Sep 9, 2011)

Over the years I have learned a few things to make a guy feel more comfortable about.
1 - If the pt is not in a crisis, tell them you would like to do a 12 lead, explain it to them and ask if it would be ok.  ( all male crews in my house )
2 - Using the back of your hand to roll the boob works great.
3 - You can place the patches without exposing the boob ( at least nippleage ).  Work above and below the bra/shirt.  This is great for shopping center calls, etc... anywhere that privacy is tough.
4 - You can have them hold it up to get underneath as well ( works well with the younger female crowd
5 - V4-6 go under the boob, just under the fold at the crease.  I lift the boob 1 time and place the leads all at once.  Not cool to lift it 3 times ( at least professionally )
6 - V3 does not go over the nipply.  
7 - Use your imagination and imagine that the boob in invisible to line up your leads appropriately.  You may be off a bit... but ya know... in the field, you will see the big gun waves even though you are off a little. V1,2 and 6 should be easy, V 4 will take the imagination to line up. V3  and 5 should be easy after that
8 - Limit your eyeball time on the chest with the younger crowd... they can tell.
9 - Older folks usually welcome a 12 lead and are far from shy.
10 - Have a some alcohol wipes available for those grande versions that maybe caked with talc powder.
11 - Most importantly.... be professional and give every bit of decency to the pt.  Medics have been accused of things due to inappropriate behavior.... even the ones that are not intentional.  Why risk it.

My first 30-40 times were a learning experience, and it gets easier and your tactics get better, soon its seconds nature and you no longer go home at night thinking about the experience ( whether good or bad... )


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## Farmer2DO (Sep 9, 2011)

Many good points on here.  It gets easier with time.

I still get frustrated by the little old ladies who wear the one piece dresses, where the top button goes all the way down to the start of the manubrium (about an inch below the neck!) and the dress goes below their knees.  You have to hike the damn thing up around their ears.  Ugh!


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## medicsb (Sep 9, 2011)

Aidey said:


> *facepalm*
> 
> To the OP, don't do this. If you think you are off on your landmarks going under the breast tissue, just imagine how far off you can be going on top of it.



Actually, gravity can have a profound effect on breast tissue and electrode placement may be better if placed over the breast at the points that are over the appropriate anatomic position.  You CAN be off if you go under the breast as the breast fold can descend over time.  The problem when going over the breast is a possible diminishing of the ECG signal, which is to be weighed against an anatomically INCORRECT placement when going under the breast.  Really not that facepalm-worthy.


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## Sandman-EMT (Sep 9, 2011)

medicsb said:


> It can be difficult to get it exact w/ a big breasted individual so there is some guessing to be done.
> 
> Some things to remember: don't cup your hand when moving one out of the way and wear gloves if there's even the slightest chance of under-boob-sweat (gross).



LOL...BOOB-CHEESE!! Thats funny!:rofl:


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## abckidsmom (Sep 9, 2011)

Farmer2DO said:


> Many good points on here.  It gets easier with time.
> 
> I still get frustrated by the little old ladies who wear the one piece dresses, where the top button goes all the way down to the start of the manubrium (about an inch below the neck!) and the dress goes below their knees.  You have to hike the damn thing up around their ears.  Ugh!



I get these ladies in the ambulance (unless we are starting at their home) and undress them into a gown.

Double customer service points right there:  the patient gets easier, better care, and the ER nurses think you're fantastic.


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## medicsb (Sep 9, 2011)

Sandman-EMT said:


> LOL...BOOB-CHEESE!! Thats funny!:rofl:



It was every bit as gross as one might imagine.


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## Sandman-EMT (Sep 9, 2011)

medicsb said:


> It was every bit as gross as one might imagine.



I would imagine so!


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## the_negro_puppy (Sep 9, 2011)

1) Ensure privacy. If at home, close blinds, make sure anyone that the pt isnt comfortable possibly seeing her exposed is out of the room
2) Never do a 12 lead in a public place (within reasonon). Load them first and do it in the back.
3) Ask them to lift their breast or use the back of your hand. Explain the procedure to them and why you need to do it. Get their consent


Follow these rules and you should be ok.


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## bigbaldguy (Sep 9, 2011)

Thanks for all the tips folks. Some good stuff here. I put some of them into practice today and they work well (especially the not hiking boob up by the nipple one).


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## 8jimi8 (Sep 10, 2011)

bigbaldguy said:


> Ok so I've finally gotten to the point where I can confidently place all the stickies for a 12 lead without having to look at my little cheat sheet. I'm feeling pretty good about myself and maybe even a little cocky. Then on my next call I get a patient with really big breasts and I'm back to square one. All my landmarks are thrown off by the things. So here's my question if I get the stickies put in the wrong spot by an inch or two does it screw up the entire ECG? Is there a margin of error or do I really need to poke around on this poor woman looking for ribs so I can place the stickies in exactly the right spot?



Move the boob be as exact as you can. Diagnosis quality is not possible without anatomically correct electrode placement.


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## medic417 (Sep 10, 2011)

bigbaldguy said:


> Thanks for all the tips folks. Some good stuff here. I put some of them into practice today and they work well (especially the not hiking boob up by the nipple one).



Yes that visualization will remain with you for ever.  And yes there was a medic fired for the nipple technique.


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## Sasha (Sep 10, 2011)

medic417 said:


> Yes that visualization will remain with you for ever.  And yes there was a medic fired for the nipple technique.



Ouch... 

Sent from LuLu using Tapatalk


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## JJR512 (Sep 10, 2011)

Whatever you do, don't offer to check for lumps as a complimentary additional service.


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## rhan101277 (Sep 10, 2011)

Don't cup the boob and lift it, use the bottom of your hand and always make sure to explain the procedure before lifting up the shirt.

It is difficult to place V1 and V2 without full bra exposure, unless someone is wearing a tank-top or a low cut dress or what not.

Don't start out by saying, "I've seen many of these in time" or such as that.  A simple procedure explanation is all that is needed.  If it needs to be done, do it, in an emergency it isn't the time to be modest.  You don't want to have to field a question from the doctor about why you didn't do a 12 lead on a chest pain because you were worried about boobies.  Also it isn't a good answer to say, "she is only 22 I wasn't worried about a heart attack."


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## the_negro_puppy (Sep 10, 2011)

I did a 12 lead on an elderly lady this morning. After lifting her breast with the back of my hand i had my first encounter with boob cheese:sad::glare::wacko:


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## frdude1000 (Sep 10, 2011)

http://www.youtube.com/watch?v=eA5HmQSMGHE

Good EKG vid on youtube.


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## bigbaldguy (Sep 10, 2011)

frdude1000 said:


> http://www.youtube.com/watch?v=eA5HmQSMGHE
> 
> Good EKG vid on youtube.



Cool, sounds like perfect placement is important.

On an unrelated topic, why is the basic in this video carrying a fishing tackle box


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## traumaluv2011 (Sep 10, 2011)

bigbaldguy said:


> Cool, sounds like perfect placement is important.
> 
> On an unrelated topic, why is the basic in this video carrying a fishing tackle box


That's interesting you say that, because the medics in my area have a kit that pretty much resembles a tackle box for all of their IV supplies and meds...


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## mycrofft (Sep 11, 2011)

*It's all about them bones.*

Remember, don't get diverted by the breast, it's the rib cage you need to be thinking about. You can lift the breast too far, sliding the inferior skin superiorly, so when the mammary traction is relaxed the electrode winds up lower than you were planning on. Sometimes that is unavoidable. As far as over the breast, as long as the shortest path to the target placement is through, say, an inch of tissue versus rerouting four inches or more inferiorly, go for the shorter route. Make a note on your tracing that the pt was "buxom" or some such so the kindly ER doc or cardiologist will have that likelihood of diverted placement.

Why not invent a dorsal EKG?

Such a cultural exercise! Reminds me of the recently changed ARC CPR guidance to administer compressions "between the nipples". ..silly people.


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## firecoins (Sep 11, 2011)

Another example of boobs getting in the way.


---
I am here: http://maps.google.com/maps?ll=40.882050,-73.874684


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## EMSrush (Sep 11, 2011)

abckidsmom said:


> <not sure if serious>
> 
> Way awkward.  Hesitate to ask the woman to hold them out of the way.
> 
> ...




+1. The more awkward you act, the more embarrassing it will be, for both of you. Use the back of your hand, be quick and smooth and don't make a big stink out of it.... 

.... if you don't make a big deal of it, they won't either.


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## Fish (Sep 11, 2011)

18G said:


> You dont have to be so precise. Put the electrodes where they are supposed to go and its all good. The electrodes go under the boob so it shouldnt really mess up the land marks.
> 
> Just lift it up a little and should be the same as "normal" size boobs.



Agreed, there is not a one person in the ER who I have ever seen "Palpating" for landmakrs, after a few times you know where they go by visualizing. Every once in awhile I will get a patient that I am not so sure about, and I will palpate for ribs.


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## MotorCity (Sep 17, 2011)

I haven't done it but in Europe the standard is to go over top the breasts. What's the difference: big boob or big fat man boob. 

Give it a try. If it don't work, flip em out the way and redo it. Have fun and play with them suckers.

P.S. V1 and 2 work great on top of the nipples. It's something to do with the electrical pathways of the mammary gland in women.  Try it and tell my what you think.  


---
I am here: http://maps.google.com/maps?ll=42.412568,-83.170260


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## abckidsmom (Sep 17, 2011)

MotorCity said:


> I haven't done it but in Europe the standard is to go over top the breasts. What's the difference: big boob or big fat man boob.
> 
> Give it a try. If it don't work, flip em out the way and redo it. Have fun and play with them suckers.
> 
> ...



Yeah, only V1 and V2 don't belong anywhere close to most nipples.  I think I will stick with standard placement.  Besides, I refuse to be responsible for the patient having to peel an EKG electrode off her nipple.


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## 8jimi8 (Sep 17, 2011)

Fish said:


> Agreed, there is not a one person in the ER who I have ever seen "Palpating" for landmakrs, after a few times you know where they go by visualizing. Every once in awhile I will get a patient that I am not so sure about, and I will palpate for ribs.





BOTH OF YOU ARE WRONG.

Palpate every time, unless your patient is so cachetic that you can SEE the intercostal spaces.


This is a DIAGNOSTIC procedure, lead placement is of the utmost importance.

Please don't teach new providers that you can visualize proper placement.  Absolutely   w r o n g.


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## bigbaldguy (Sep 17, 2011)

8jimi8 said:


> BOTH OF YOU ARE WRONG.
> 
> Palpate every time, unless your patient is so cachetic that you can SEE the intercostal spaces.
> 
> ...



Who the hell thought it was a good idea to give 8jimi8 a megaphone.


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## mycrofft (Sep 18, 2011)

*motorcity, I assume you refer to antique-style electrodes*

.





..when you refer to "them suckers"?

Not cool. How old are you?


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## MSDeltaFlt (Sep 18, 2011)

I cannot believe the language of this particular thread.  It reads as if written by 8th graders.  "Cupping", "boobs", "unable to control massive breasts", "pulling of the nipples", "putting them on nipples"?!?!?!?  Are you kidding me????

It shouldn't take you more than 5 minutes to perform a 12 lead even On the largest cup size and STILL keep her covered up throughout the entire procedure, proper placement with bra still in place.

With the overall tone of this thread no wonder your female patients might feel uncomfortable.  The ones performing the 12 lead are at least as uncomfortable if not moreso. Self-consciousness breads self-consciousness.

Get over it, do the procedure with her still covered, and get on with the rest of your assessment.


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## Sasha (Sep 18, 2011)

MSDeltaFlt said:


> I cannot believe the language of this particular thread.  It reads as if written by 8th graders.  "Cupping", "boobs", "unable to control massive breasts", "pulling of the nipples", "putting them on nipples"?!?!?!?  Are you kidding me????



Dont forget my use of the word chesticles.

Sent from LuLu using Tapatalk


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## Anjel (Sep 18, 2011)

Sasha said:


> Dont forget my use of the word chesticles.
> 
> Sent from LuLu using Tapatalk



I like it.


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## bigbaldguy (Sep 18, 2011)

So do the pads go over the chesticles under the chesticles or on the nipples of the chesticels?


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## Sasha (Sep 18, 2011)

No no no. You cup the massive chesticle or pull it up by the nipples. Then wipe off the boob cheese and place your electrode. Do not massage the nips.

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## medic417 (Sep 18, 2011)

MSDeltaFlt said:


> I cannot believe the language of this particular thread.  It reads as if written by 8th graders.  "Cupping", "boobs", "unable to control massive breasts", "pulling of the nipples", "putting them on nipples"?!?!?!?  Are you kidding me????
> 
> It shouldn't take you more than 5 minutes to perform a 12 lead even On the largest cup size and STILL keep her covered up throughout the entire procedure, proper placement with bra still in place.
> 
> ...



Disagree with the bra statement.  Better to have all bras removed and hospital gown put on.  You can easily shuffle the gown to protect patients privacy.  Ensures proper landmarks found and eliminates any possible interference.  I have not seen cardiologists or ekg techs leave the bras on so why should we be different, perhaps it is you that are uncomfortable with your job which might as you say make your patient uncomfortable.

As to statements of those listed there was only one that was a true problem and it was obvious the poster was trying to be rude.  The other comments including the one of mine you quoted were used to help illustrate accurately how or how not to do the job.  When these items are not discussed people are bound to make mistakes.  

Using clear simple even if disgusting plain English helps avoid misunderstandings or surprises.


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## MSDeltaFlt (Sep 18, 2011)

medic417 said:


> Disagree with the bra statement.  Better to have all bras removed and hospital gown put on.  You can easily shuffle the gown to protect patients privacy.  Ensures proper landmarks found and eliminates any possible interference.  I have not seen cardiologists or ekg techs leave the bras on so why should we be different, perhaps it is you that are uncomfortable with your job which might as you say make your patient uncomfortable.
> 
> As to statements of those listed there was only one that was a true problem and it was obvious the poster was trying to be rude.  The other comments including the one of mine you quoted were used to help illustrate accurately how or how not to do the job.  When these items are not discussed people are bound to make mistakes.
> 
> Using clear simple even if disgusting plain English helps avoid misunderstandings or surprises.



Irregardless.  It isn't rocket science. If you disagree I can introduce to one of the most awesome helicopter mechanics in the business. He used to build missiles for Lockheed-Martin. Those are rockets. He knows what rocket science is and he can assure you that this isn't it.

Bra, no bra.  Point being is you should be able to perform this procedure with her still covered up and her dignity intact.  Period.  

Some of us are still needing to get over our insecurities involving mammary glands.  And we wonder why we don't get paid more.  I mean really.


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## Anjel (Sep 18, 2011)

No one is saying they are exposing them. 

They were wondering about where to put the leads. 

GET OVER IT!


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## Aidey (Sep 18, 2011)

MSDeltaFlt said:


> Irregardless.  It isn't rocket science. If you disagree I can introduce to one of the most awesome helicopter mechanics in the business. He used to build missiles for Lockheed-Martin. Those are rockets. He knows what rocket science is and he can assure you that this isn't it.
> 
> Bra, no bra.  Point being is you should be able to perform this procedure with her still covered up and her dignity intact.  Period.
> 
> Some of us are still needing to get over our insecurities involving mammary glands.  And we wonder why we don't get paid more.  I mean really.




That is cute. One of the worst medics I know is a retired rocket scientist out of Boeing.


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## Sasha (Sep 18, 2011)

MSDeltaFlt said:


> Irregardless.  It isn't rocket science. If you disagree I can introduce to one of the most awesome helicopter mechanics in the business. He used to build missiles for Lockheed-Martin. Those are rockets. He knows what rocket science is and he can assure you that this isn't it.
> 
> Bra, no bra.  Point being is you should be able to perform this procedure with her still covered up and her dignity intact.  Period.
> 
> Some of us are still needing to get over our insecurities involving mammary glands.  And we wonder why we don't get paid more.  I mean really.



Who said anything about letting her flop out in the wind? This thread is about lead placement and how to preserve the patients dignity when dealing with those on the larger size. Sorry but the use of the word boob or otherwise doesnt make one insensitive to breasts. Hell i own a pair of fantastic breasts, i am not insecure about them at all.

The only one who talks about leaving the patient exposed is you, really.

Sent from LuLu using Tapatalk


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## abckidsmom (Sep 18, 2011)

Sasha said:


> Who said anything about letting her flop out in the wind? This thread is about lead placement and how to preserve the patients dignity when dealing with those on the larger size. Sorry but the use of the word boob or otherwise doesnt make one insensitive to breasts. Hell i own a pair of fantastic breasts, i am not insecure about them at all.
> 
> The only one who talks about leaving the patient exposed is you, really.
> 
> Sent from LuLu using Tapatalk



LOL!

Absolutely agree.  And the words of mine you quoted in your first post were sarcastic, anyway.  

It is fairly standard, and something that you can deal with easily if you just ask the patient to take off his or her shirt, put a gown on, and then pull the gown up to attach the leads.  I usually leave them on for the duration of the transport to get any changes that may happen, and then remove them when you arrive at the hospital.


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## MSDeltaFlt (Sep 18, 2011)

Apparently you misread my original post.  I wasn't addressing technique.  I was addressing the demeanor of the practitioner while performing the procedure. And I quote, "selfconsciousness breads selfconsciousness".


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## Sasha (Sep 18, 2011)

MSDeltaFlt said:


> Apparently you misread my original post.  I wasn't addressing technique.  I was addressing the demeanor of the practitioner while performing the procedure. And I quote, "selfconsciousness breads selfconsciousness".



You were berating people as insecure for using the word boob.

Judgemental much?

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## MSDeltaFlt (Sep 18, 2011)

And I also believe I mentioned language.  The title of this thread is the indicator.  We as professionals should be beyond reproach.  We are taught technique, not demeanor.  Apparently we have a long way to go.  Sad.


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## Sasha (Sep 18, 2011)

We arent on shift when we are here. Figuratively.

Relax a little i highly doubt most here would approach the patient going hey lady can.you hold your titty?

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## Aidey (Sep 18, 2011)

So we should be expected to use the anatomical term no matter what the setting? Sorry but "Adipose tissue plus mammary glands and the 12 lead" is a little excessive.


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## medic417 (Sep 18, 2011)

MSDeltaFlt said:


> Apparently you misread my original post.  I wasn't addressing technique.  I was addressing the demeanor of the practitioner while performing the procedure. And I quote, "selfconsciousness *breads* selfconsciousness".



BBG brought his concern here is a simplistic manner and we provided him the mental pictures to do the job right.  Also the simplistic answers will help the BDG ( Big Dumb Guy )learn proper technique as well.  

Oh and why is *bread* mentioned here?  Usually the *bread* sandwiches items rather than being sandwiched itself.  Perhaps *breeds* would be the word you seek?


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## bigbaldguy (Sep 18, 2011)

Boob


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## STXmedic (Sep 18, 2011)

Nipple


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## Sasha (Sep 18, 2011)

Clevage

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## JPINFV (Sep 18, 2011)

[youtube]http://www.youtube.com/watch?v=Ci-LX9fd064[/youtube]


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