12-lead placement is simple, so why do so many people fuck it up?

I see incorrect lead placements all the time, especially precordial leads. I see this in prehopsital settings. I see this at the EDs. Some days, it seems like no one on Earth knows how to do it correctly.

The other day, some idiot medic had the gall to tell me that my placement of V1 was too high. I ran my fingers down the normal-sized patient’s ribs, counting out 4 intercostal spaces along his sternum, just to make a point. This idiot removed all the leads and put them on incorrectly anyway, without any evidence he physically touched and counted any intercostal spaces.

I don’t understand it. There are not many different ways to do it. Entire diagrams of lead placement are printed in protocols and textbooks, in color, in black and white, superimposed on ribcages, described in detail – you just have to follow it. Endless pages of images of proper lead placement are searchable on Google if one simply bothered. In fact, for this post, it took me HOURS on Google just to find 3 or 4 images of incorrect precordial lead placement.

So what the fuck? Why can’t people put these leads on right?

Limb leads go on limbs. Not the torso.

Precordial leads go like this:

OBHG Education Subcommittee
OBHG Education Subcommittee

Another view:

Wikipedia/Mikael Häggström
Wikipedia/Mikael Häggström

This image shows why we do precordial leads a certain way:


Another image:


Another one:


One more:


Therefore, with axis in mind, this is absolute bullshit:


So is this:

AP Photo File/Thomas Kienzle
AP Photo File/Thomas Kienzle

As is this:


Or this:


Further reading:

You said it

Code 3 for seizure. I recognize this address.

A tough-looking, tattooed man in his 30s is on the kitchen floor, not responsive, and not for the first time. His girlfriend tells us, also not for the first time, that he has pseudoseizures and PTSD after being beaten up some time ago.

We go through the usual dog and pony show of an assessment.

I’m totally on autopilot and I don’t even think about word choice before I casually ask, “So, ma’am, what other medical problems does he have besides fake seizures?”

“He doesn’t fake seizures!”

“You just said he has pseudoseizures.”


“That is LITERALLY what ‘pseudoseizures’ means.”

I know you can open your legs

Code 3 for pregnant female whose water broke.

We walk all the way around to the back house. Two toddlers are asleep in the only bed in the house, on either side of a pregnant woman, whose pinkish water is gushing through her underwear onto the bed. Totally gross.

I cut the sides of her panties and try to spread her legs to check for crowning. Third pregnancy, broken water – I can’t believe there are people who still don’t LOOK. She resists, trying to keeping her legs together. I have no idea why. You call me – I’m going to see what your problem is and manage it, and that includes those parts between your legs.

“Oh NOW you can’t open your legs?”

You call, we haul. Now get in the friggin' ambulance.

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