What ARE politicians doing that’s so important that they travel with lights and sirens?

WCBS-TV has a piece about New York mayor Bill de Blasio’s caravan ignoring stop signs and speed limits and generally driving like assholes just TWO DAYS AFTER he announced a massive plan, Vision Zero, to slow drivers down after a rash of pedestrian casualties, followed by another piece about his refusal to answer questions about his drivers driving like assholes.

The New York Times, when reporting WCBS-TV’s piece, mentioned other politicians driving speeding around with lights and sirens while presumably NOT responding to emergency calls for service.

If you’ve read anything on this blog, you’re probably familiar with the regard it has for politicians. (None.) You’re also probably aware of this blog’s disdain for responding to most kinds of calls with lights and sirens because the safety downside is high given the low rate of actual emergencies and the high rate of 911 abuse and hysterical overreaction these days.

This story is also ironic on a different level because in the very same city, the FDNY is one of those smarter agencies that, for safety reasons, does not send the entire battalion with lights and sirens to simple alarms with no other corroborating reports, which are like 99% false. So much for that joke about 200 years of tradition unimpeded by progress. At least in one regard.

You may also recall another post here about Maryland Attorney General Doug Gansler and his regular use of lights and sirens, also while presumably NOT responding to emergency calls for service.

Or the wreck involving former New Jersey governor Jon Corzine, who was not wearing a seat belt when his driver was traveling at 91 mph with lights and sirens activated, again while presumably NOT responding to emergency calls for service.

Usually, without fail, the default excuse these politicians and their staff go to is “security reasons.” I’m pretty sure we’re way past the JFK era when security was lax, and not being a historian, I struggle to recall any recent credible threats directed beforehand at local or regional politicians that would get security details in a hyperalert state. If anything, to mitigate or reduce such perceived or real threats, perhaps NOT monopolizing the roads in a city known for its extraordinary traffic and NOT acting like total asshats while doing said monopolizing of the roads may in fact be helpful.

I don’t know what the fuck these politicians are doing, but I sure as hell know they are most certainly NOT going to anything of an emergent nature that would require them to speed or even use their steering wheel horn, let alone lights and sirens.

Is MPDS really unreliable or do I just work in a shitty zone?

“M10, this is a Delta response for a 25-year-old male who is complaining of feeling shaky after drinking 4 Red Bulls.”

Or is it the people who specify whether the response is Code 2 or 3 who should re-think their policies?

Ever wonder just how accurate dispatch information is? What dying person are we driving to with lights and sirens? I happen to have 232 calls to show you. This is a relatively small sample size, but the data collection is ongoing. By the time I get bored, I may have a thousand calls logged. We’ll talk about the details in a second.

Thanks to this neat and simple graph-making tool at the National Center for Education Statistics, here are some of the numbers expressed in pie charts. Yes, it is for kids. A simple tool for a simple fool.

In June 2011, I wrote in total disbelief about how the CDC and ACEP claimed that only 8 percent of ED patients were considered “non-urgent,” the lowest level of acuity under their classification, which by extension meant 92 percent of patients should be seen within 2 hours.

That’s a weird classification, to put it nicely.

That very week, a quick tally of 19 patients resulted in me (and most normal providers, I’m sure) subjectively labeling 12 of them – 63 percent – “non-urgent,” as defined by normal English usage.

Over the past several years, as more agencies adopt the ubiquitous MPDS, I have noticed that the overtriage* based on common response models is quite significant. For those of you who aren’t familiar with MPDS, in the interest of keeping this post short, its main goals are to sensibly dispatch the appropriate type and amount of responders (or not dispatch anything at all) to medical calls based on pre-arrival information and to quickly sort out and dispatch units to the cardiac arrest calls. Think taxis for the least-serious Omegas and Alphas, and anyone with an AED for the non-breathing Echoes. One main feature of MPDS is that the determinants (Omega, Alpha, Bravo, Charlie, Delta, Echo) are set based on RPs’ responses to predetermined dispatch questions while individual jurisdictions are free to customize their response models (Code 2, Code 3, first response only, ambulance only, both, etc.) to the determinants. I like San Francisco’s old bus token idea.

For instance, for the data that I’ve collected, responses to Omegas and Alphas are Code 2, the rest are Code 3. This is a fairly common setup in other jurisdictions.

In the United States, because the typical staffing configuration in most emergency response jurisdictions only consists of engines, trucks and ambulances, and because the typical disposition options with which most oversight agencies (and their lawyers) are comfortable are “transport” and “no transport,” in practical terms, the only real noticeable result is the increase in Code 2 responses in place of the riskier yet not more fruitful Code 3 responses, which isn’t a bad thing. It just doesn’t go far enough.

Judging by the details involved in the implementation of EMS systems as well as MPDS, there are plenty of signs out there that even many EMS jurisdictions and the people who think they know enough to make decisions do not understand the purpose of MPDS, which is exacerbated by the fact that most administrators have absolutely no or pathetically little time working in actual field-level EMS capacities, but this seems to be the norm and not something that will go away anytime soon.  It’s the Dilbert principle as applied to EMS.

A common way jurisdictions misuse MPDS is how they use determinants to establish response time standards. For example, 20 minutes to Alphas, 15 to Bravos, 12 to Charlies, 10 to Deltas, 8:15 to Echoes.

Really? With the exception of Echoes, I’m wondering if this is set up for the sole purpose of generating fines for late responses. Based on what I’ve seen and done, there is no way anyone can convince me a Delta is 2 minutes more serious than a Charlie, and a Bravo is 5 minutes more serious than an Alpha.

Worse, units get re-directed from Bravos to Charlies, Charlies to Deltas, etc. This is colossally stupid. The only diversions should be to Echoes.

We once were dispatched to a Bravo for someone who fell off a horse on the outskirts of town, and nearly 10 minutes into the call, less than a half mile from it, we were re-routed to a Delta for chest pain on the other side of town because we were the closest unit. I tried to insist on continuing to the Bravo but was overruled by dispatch. We turned around, and after about 6 minutes, we were canceled by fire, implying total bullshit. We then were put back on the Bravo since we were still the closest unit, and drove back to the original call. There were several factors at play here, but none of them was common sense.

Anecdotally, my co-workers are quite often upset when they are dispatched Code 2 to a call and they find a patient legitimately sick. Frankly, I’m not much bothered by this. There has not been any substantial evidence demonstrating the benefits of shorter response times (or transport times) in the form of clinical outcome in any cases other than salvageable out-of-hospital cardiac arrest. On the other hand, I am more unhappy about being dispatched Code 3 to a call and finding some complete bullshit. There certainly have been plenty of actual negative outcomes of unwarranted Code 3 responses, usually in the form of wrecks. This is not an easy problem to solve for the simple fact that (a) callers are notoriously unreliable and sometimes downright dishonest, and (b) it is difficult to definitively determine (a) over the phone.


  • Quantify patient acuity as determined by MPDS and response modes
  • Evaluate patient acuity as observed on scene
  • Compare the related distributions

Initially there were suggestions to include information on first responders’ (or lack of) actions and interventions. I did not include this because ultimately this project was about MPDS and response modes. We hardly ever went to any good calls, and I spent most of my time writing paperwork and not providing any treatment anyway, so I can hardly expect first responders to provide any treatment either, let alone single them out for the lack of treatment.

I also did not include details on interventions. The main reason is that there simply aren’t many interventions to record. Seriously, look at the shit calls we went to. Besides, I think that subjective acuity is sufficient to express the disparity between MPDS, response modes and actual disposition.

Inclusion criteria:

All 911 calls for medical assistance during which a patient presenting with a complaint of illness or injury is found.

Exclusion criteria:

  • Canceled en route
  • Canceled on scene by first unit on scene
  • Unable to locate
  • No complaint of illness or injury
  • Psych holds and self-committals

As you well know, these incidents make up a sizable portion or our responses. I did not record the numbers, and sometimes I wish I did. Every canceled or excluded call means that any response was for the most part unnecessary in the first place. As for the psych calls, well, what a waste of time and resources**, from the perspective of 911 ambulances. If it’s not some guy who wants a place to crash and a sandwich to eat, it’s another guy who’s going for the fourth time this week because he’s “going to kill himself” again. If it’s not those guys, then it’s the guy who’s trying to get out of an arrest, and he knows how to play the system. If you didn’t actually hang yourself or legitimately slice your wrists down the bone or ingested 230 pills, psych calls are absolutely not 911 ambulance calls. When are we going to grow a spine and make the cops take the psych calls?


Of the information recorded, some of the relevant data are used:

  • MPDS card, determinant, subcode
  • Response mode
  • Chief complaint as reported to the call-taker
  • Chief complaint on scene, provider impression and relevant information
  • Poor historian(s)
  • Drugs
  • ETOH
  • Psychiatric component
  • Frequent 911 caller
  • Subjective acuity
  • Disposition

Subjective acuity is categorized into “Very Minor,” “Minor,” “Urgent” and “Emergent.” It’s just what I decided to label these patients, based on their presentation, their history, my experience and common sense. Their meanings are very plain. It is nothing like what the CDC and ACEP did. In all of these cases, my subjective acuity was broadly in agreement with how the ED decided to manage them, in terms of resources assigned. The EDs use triage categories more in line with what the CDC and ACEP use than my subjective ones, but in many instances this has more to do with theory than practice. For example, “chest pain” may automatically be triaged as something more serious even if it’s been ongoing “for 2 years.” As nosy as I am, I made quite some effort to follow up unofficially just to see what patients ended up with. I don’t remember any ED finding something that made a patient more acute than I rated, but if that happens in the future, I fully intend to adjust the subjective acuity I assign a patient.

To give you a better idea of this so-called subjective acuity, while dependent on specific cases and presentations, and not absolute, here are some examples:

Very Minor – no complaint, toothache, not feeling well for days, obvious death, etc.

Minor – abdominal pain, vomiting, anxiety, s/p seizure, etc.

“Urgent” and “Emergent” are self-explanatory and do not interest me much since they are not the source of our collective aggravation, anger, eye-rolling and dash-pounding.

I also want to point out that the main description of these subjective categories is best defined by the most reasonable and least self-centered way to go to the ED. For example, a few years ago when I ended up needing emergency surgery, I found a ride. Just because someone ends up being diagnosed with a legitimate entity doesn’t mean at the time this person called 911 it was absolutely necessary for us to respond Code 3. In fact, far from it. Studies typically use discharge diagnosis as the typical measure of patient acuity, because it is objective. However, I think there is some value in using such subjective measures as providers’ impressions. Seriously, how often do we get patients who elicit, from EMS to RN to PA to MD, a continuous chain of eye-rolling, accompanied by, “This is bullshit.”?

Findings (no shit, Sherlock):

  • MPDS and common response models produce significant overtriage
  • Large majority of 911 calls for medical assistance are mind-numbingly routine
  • Please keep all of this in mind when you drive to a call

Less obvious findings (based on this relatively small sample size):

  • Alphas tend to be quite accurately triaged
  • The ratios of Very Minor/Minor to Urgent/Emergent are quite similar in Bravos, Charlies and Deltas, implying there is no practical difference in these determinants. Given that most jurisdictions dispatch different equipment traveling in different modes to scenes depending on whether it’s Bravo, Charlie or Delta, and given that units are often re-directed from Bravos to Charlies and Charlies to Deltas, this seems pointless. I think we’re dicing these calls too fine by differentiating between Bravos, Charlies and Deltas.
  • Charlies and Deltas have similar respective breakdowns to the overall breakdown in acuity.
  • Deltas include all the “unknown medicals,” “non-triaged medicals,” PD requests, etc. The lack of information automatically makes these calls Deltas, but there were very few legitimate patients found as a result of these dispatches. This makes no sense when contrasted with medical alarms, which usually have no information as well, and are basically “indoor unknown medicals.” These calls are automatically categorized as Bravos, but they are in essence no different from the Deltas.
*Other overtriages: Patients who meet trauma center criteria and the use of spinal immobilization, but those are entirely separate posts.
**Some years back when we were self-reporting call data on Scantron forms on every single call, I took it very seriously because they’d give us our numbers at the end of the year. One year I think I went to more than 1400 calls, and the most common chief complaint I had marked was “Behavioral/Psychiatric” at 12% of all complaints. “Shortness of Breath” was second at 11%. That should have been a huge red flag as far as 911 ambulance utilization is concerned. But obviously nothing has changed.


This is a very funny music video from Diary of a Mad Firefighter/Plugs and Hoses Records, reposted after a bit of drama. There is nothing offensive or inappropriate in this video, but as usual, it was initially taken down because of concerns from the powers that be.

I absolutely love it when the firefighter walks into the wall in the dark at 2:05.


Update #1:

Never mind – it was removed again. The powers that be apparently didn’t like the video. They usually don’t like anything, I’ve noticed.

Update #2:

I’ve just received permission to re-post it. Once it made its appearance that very first time, it quickly went viral, and it was hard to keep it from spreading like wildfire.

Update #3:

Since I’m not very hip, I didn’t even know what the original song was until it was pointed out to me. Of course, listening to that song only makes the EMS version so much more brilliant!

A&Ox4 doesn’t mean shit

When dealing with patients with a slightly altered level of consciousness who are either not cooperative or straight-up refusing care, I’m so tired of hearing medics say, “Well, if she’s A&Ox4, we can’t do anything…” or, “We can’t kidnap her…” or, “We can’t force her to go to the hospital…”

“Yeah, but she’s DRUNK OFF HER ASS with her face firmly planted on the toilet seat and glued to it with dried puke, you idiot.”

No one is saying this is always going to be easy, but since we’re getting paid to make responsible decisions… or did you miss that day they explained this?

I also see medics trying to coach patients into answering the 4 questions just so they can abdicate their responsibilities. C’mon – I can get a toddler to answer the 4 questions properly.

If you really want to weasel out of transporting patients that badly, perhaps there is another question you should ask yourself.

Now, A&Ox4* (alert and oriented times 4 – name, time, place, event) doesn’t mean shit if patients are not OBVIOUSLY MENTALLY COMPETENT ENOUGH TO MAKE RELIABLE DECISIONS. Many patients can answer these 4 stupid questions while having an altered level of consciousness. As far as I’m concerned, A&Ox4 is more like being able to appropriately answer something like 25 questions** while demonstrating the ability to carry on a coherent conversation with me during the assessment. And with no reason for me to believe that there are a lot of drugs and/or alcohol involved.

I once equated, in a legal setting, A&Ox4 with being able to sign loan documents. Of course, that was in the middle of the subprime fiasco, which sort of undercut my statement. I guess my timing sucks. I’m not good at a lot of things.

Anyway, this is yet another example of our non-thinking protocol/checklist mentality. I have no problems with standard protocols or checklists, but they are tools, not the be-all and end-all.

*In EMS, it’s A&Ox4. In nursing, it’s usually A&Ox3; they don’t include event. So when a paramedic tells a nurse that a patient is altered because he’s only A&Ox3, hilarity ensues.
**Random number I pulled out of my butt. Could ask fewer questions if patient is a butthole and you don’t really want to talk to him/her. Just don’t stop after the 4th question and make the 5th one something about wanting to go to the hospital. And definitely don’t ask about hospitals before the 4th question.

What do you think of this 12-lead? ***UPDATED

Without any details to accompany this tracing, what do you think?

(Hint: You probably won’t see too many similar strips at Prehospital 12-Lead ECG Blog or Dr. Smith’s ECG Blog, the two blogs on this subject that I visit the most.)



Thanks for all the responses. Reading through them, there are different opinions regarding this tracing.

I wasn’t sure if I wanted to post this relatively boring tracing in the first place, since the other blogs (ahem, Tom) always have way more exciting cases, but based on the feedback, it seems that we can have a worthwhile discussion about it. I’ll try to make it so you don’t feel like you’re wasting your time.

Let’s take a look at some of the boring technical stuff:

Rhythm: Normal sinus.

Rate: 67, regular.

P waves: Present, all the same shape.

PR: 0.154 s, constant, 1 P wave per QRS complex.

QRS: 0.104 s, constant, not quite at the 0.12 s cutoff that is generally used for BBB/IVCD. (Be sure to apply the full interval across ALL 12 of the leads, or you’ll mistake the terminal part of the QRS for ST-deviation, such as aVR in this case. It can also help measure J-points.)

QT: 0.368 s

QTc: 0.388 s

Lead placement: It doesn’t stick out to me as incorrect.

Frontal axis: Normal quadrant, probably closer to 90° than 0°.

Z axis: 50° posterior, which is a bit more posterior than normal, and possibly why I and aVF are both nearly isoelectric at the same time. (Picture this in 3-D space.)

Hypertrophy: R in V2 (22mm) + S in V5 (12mm) = 34mm, not quite at the 35mm cutoff that is generally used for LVH, but close. Anyway, it’s not a yes-or-no, hard cutoff.

U waves: Present in V1-V4. Seen in many cases, including LVH.

R-wave progression: Other than the late transition from negative to positive, it looks fairly normal to me without notable loss of amplitude. LBBB typically has poor R-wave progression in V1-V4, and so does anterior MI.

T-wave discordance: No lead really sticks out as abnormal. In any case, experts (not me) don’t really agree on which part of the QRS – terminal or dominant deflection – to use to determine T-wave concordance/discordance. I think it’s more of a pattern recognition thing; I just kind of know when I look at it.

Ischemia/infarction: The precordial T waves are fairly large, so are they hyperacute in the setting of an anterior MI? The J-point is mostly fuzzy, so there is arguably ST-depression in I, II, III, aVF and V6. There is ST-elevation in aVL and V1-V4. Along with the T waves, is this significant? How do we even measure the J-point? What to do?

This is why EKG interpretation remains, for the most part when it comes to crucial decisions, more of an art than a science. A lot of this goes back to pattern recognition, which only comes with looking at a lot of 12-leads. Some may say the concavity in V2-V4 is likely benign, possibly due to early repolarization. As different commenters pointed out, there are a number of things that may or may not be wrong with this tracing. I’d like to tell you that it goes without saying that the patient’s presentation and a thorough history are very important, but I keep running into crews who activate cath labs for 25-year-olds with toe pain. It also helps immensely if we have old EKGs for comparison. Of course, in the pre-hospital setting, we don’t usually have a lot of those lying around.

Well, fortunately, I happen to have a 12-lead of the same person from 2007.

With the exception of a few tenths of a millivolt in a couple of precordial leads, this tracing is pretty much the same as the one from 4 years ago.

Both tracings were obtained at routine medical exams administered by the person’s employer. Both were done properly – correct lead placement and connections – by the same provider.

One of the things I’ve slowly learned over the years is that while it’s sometimes difficult to identify badness on a 12-lead, it’s even more difficult to tell yourself to stand down and relax.

So, does this mean that these 12-leads show significant pathologies?

I don’t think so. I know it’s not a picture-perfect tracing, the ones you see when you Google “normal EKG,” but everything about human beings has a wide range of (usually) normal variants. In addition to normal variants, there are countless unhealthy people with normal baseline tracings. This is what makes things so difficult sometimes.

I think these tracings are fairly close to normal, for the most part. I know this because I feel pretty healthy.

CDC and ACEP say only 8% of ED patients are “non-urgent”

I happened across an article stating that the CDC’s statistics show that only 8 percent of ED visits are non-urgent. Now, ask anyone who works anywhere near an ED and s/he will tell you that number is absolutely bogus. Fuck, even the janitor will tell you that 8 percent is horseshit.

Of course, during the ensuing research, if you can call it that, I then came across this letter by Dr. David Stern blasting the methodology used by the American College of Emergency Physicians (ACEP) to obtain the numbers in the “non-urgent” category.

Being the nosy type, I went to the CDC’s website to see what this “non-urgent” business is, and according to them, it’s defined as ED patients who should be seen within “2-24 hours.” Problem is, there is no other category that is defined as “more than 24 hours”* or, similarly, “go home and you’ll get better with time and rest.” In other words, according to the CDC, even the most bullshit of patients should be seen within 2-24 hours, and by extension, 92% of patients should be seen in less than 2 hours.

One must seriously question the meaning of these so-called categories of acuity.

If I, right now, walked up to the ED triage nurse and said I simply wanted to be seen for no particular reason, I’d be told to wait for my name to be called, and according to the CDC, and thus ACEP, I’d be categorized as a patient who should be seen within 2-24 hours. For no particular reason.

Besides, the EDs that I’ve been to do not even use any uniform method of classifying acuity, so how does the CDC even reconcile this basic difference? Details, people. Details.

Basically, if you don’t want to read the links, the story as I understand it is that the ACEP apparently is attempting to derail plans for payors to provide public education on what is and what isn’t an appropriate ED visit by obfuscating facts and statistics. Because, as we all know, ignorance is bliss, and those lazy EDs just aren’t busy enough.

Before finding Dr. Stern’s letter, knowing that 8 percent is unbelievably low for non-urgent ED visits, I thought to myself: What patients did I see during my last rotation at work?

  • Chest pain
  • S/p witnessed seizure
  • ‘Flu-like symptoms
  • Pseudoseizure
  • Weakness
  • Hypoglycemia
  • “Infection” s/p hip surgery
  • Back pain x 4 days – walked to gurney
  • Blueberry up nose, supposedly – can’t find it
  • Chronic leg pain
  • Small leg laceration
  • Multi-patient freeway wreck
  • Auto-ped
  • Drunk homeless guy
  • Homeless guy with chest pain at payphone
  • “I’m sick” at 7-Eleven payphone
  • Weakness – 4th response in 2 weeks
  • Drunk college kid
  • Chest pain x 4 years

Don’t get me wrong; I love this work, as do the majority of providers. However, out of these 19 events, without remembering a whole lot of details – why waste brain space remembering most of this junk – I would argue that 12 of them are pretty much silliness, meaning that 63% of these patients are “non-urgent” by my definition and the way most normal providers would define it, NOT the way the CDC defines it.

Granted, this sample size isn’t large, but based on experience, I think it’s fairly representative of the types of patients we come across.

Eight percent, my butt.

*I’m using the 2007 form since the 8 percent ACEP quoted is from 2007.

Who is Kevin Bronson, who (allegedly) said employees should “kill themselves”?

Every agency has its issues, but this Richland County, South Carolina story is remarkable, apparently prompted by a meeting with employees over long-standing operational problems.

Several Richland County EMS employees are making claims that a county administrator told them they should kill themselves or just quit if they are unhappy with their jobs.

Kevin Bronson, the assistant county administrator for public safety, reportedly said those remarks during a Thursday morning meeting with about 100 Richland County EMS workers.

wistv.com – Columbia, South Carolina

Both Kevin Bronson and Michael Byrd, the Director of Richland County EMS, refused to answer questions, hiding behind closed doors, subordinates and even sheriff’s deputies. Bronson did not dispute the reports and issued an apology.

A hat tip to Streamlight

I apologize for the lack of activity.

I do want to mention how pleased I have been with Streamlight. I have been using several lights from Streamlight for years, and they have been nothing but reliable. Let’s just also say I have not been gentle with my lights, one poor Strion LED in particular even suffering the unfortunate fate of being dropped in the street and run over by vehicles (and it still worked).

From time to time, the lights need servicing, especially mine, and Streamlight products have a lifetime warranty. I have been sending them back to Streamlight, and they have basically been extremely generous and completely taking care of the lights.

Location, location, location

Another year, another type of medium for PCR writing, another piece of software.

One thing I’ve noticed at different agencies, no matter how data are gathered, is that the options provided to us for location data never include the truly applicable. For instance, there would be such no-brainer selections as “residence” or “grocery store” or “office” but there are other way more specific locations that generate far more emergency responses that are never listed.

Just to name a few:

  • payphone (by far the most under-appreciated location as far as data collection is concerned)
  • bus stop
  • subway/train station
  • liquor/convenience store
  • shelter
  • rehab
  • homeless encampment
  • gas station
  • airport
  • doctors’ office/clinic/dialysis center
  • sidewalk
  • someone’s front lawn
  • someone’s back yard
  • someone’s doorway
  • in a car
  • on a bus
  • parking lot

Can you think of any others?

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.”