Why paramedics need to read EKGs... Part III (Return of the EKG)

In this occasional series (see Part I and Part II) I have presented pairs of EKGs, typically with one that reads

*** *** ACUTE MI *** *** 

from one patient, and one that doesn't, from a second patient. The fun part is figuring out who went to the cath lab, who didn't, and why.

This time, however, while we still have 2 EKGs, there is only one patient.

"What a twist!"

The patient
A young fit man in his early twenties, was brought in by members of the local constabulary, complaining of chest pain. I was told that the symptoms were not typical of ACS, being pleuritic and mostly reproduced with palpation. He did not look particularly intoxicated, and denied any inciting trauma.

An EKG was obtained:

Hmm. I went to see the patient myself, and after a brief re-interview and exam, I requested "an intervention."

Thirty minutes later, a repeat EKG was obtained:

Some labs were obtained, they were fine, and he was released back into custody.

So what did I do?

Lytics, nitro, a bolus of magnesium? A door-to-ballon of 30 minutes? A precordial thump, indicated because... well, just because?

The intervention
I moved around the anterior chest leads, putting them in their proper location. His initial lead placement was disturbingly similar to that pictured here:

Courtesy CBS

My patient had had the V1 and V2 leads placed, not only a few interspaces too high, but also in different interspaces - the 2nd ICS for V1, and a subclavicular placement for V2.

Meanwhile, placement of V3 was optimized, as Brandon Otto has described, to monitor pancreatic function (the MPL3, perhaps?)

The Bottom Line
I don't want to drone on about lead placement, as I've already written at length about it. And sometimes it doesn't matter too much.

Other times, however, it certainly changes the picture!