Electrocardiogram (ECG or EKG)


281 - Examples of Precordial 12-Lead Electrocardiogram Lead Placement Found on Google Images Are Often Incorrect and Lack Gender and Racial Diversity

Thursday, May 18
2:00 PM - 2:08 PM
Location: Celebration 11: Convention Level

Objectives:Malposition of precordial ECG leads can falsely generate patterns of Brugada or myocardial infarction, and inaccurate placement is common. By providing “real-life” illustrations of proper lead placement, Google images could aid in training of ED and EMS staff. It is unknown if a Google Images search would provide quality examples, or if EM and EMS providers would recognize incorrect ones.

Methods: A Google Images search was conducted using “ECG chest leads,” “ECG leads,” and “precordial leads ECG” on 12/15/2014 and 12/16/2014. Included were all realistic illustrations of a human torso with precordial electrodes placed. We excluded images that also displayed bone or cardiac anatomy. Image inclusion and exclusion was decided by consensus. Images were then used to construct a survey asking if each example of lead placement was “good enough” for clinical use. No explicit criteria for “good enough” was provided; participants used their own impression for determining the appropriateness of lead placement.The survey was presented to a group of 7 experienced ECG educators and researchers (the “Expert group”), and responses were analyzed for agreement within the group. Finally, we recruited an “Internet group” via the ECG teaching website EMS 12-Lead.com and its associated Facebook page Prehospital 12-Lead ECG blog.The 330 participants took the same survey as had the Expert group, and their responses were compared with those of the “Expert group.”

Results:A total of 22 unique images met the inclusion and exclusion criteria. All images displayed male figures, and all had Caucasian or light skin. All but 1 were adults. Only 9/22 examples of precordial lead placement were seen as “good enough” by > 50% of the Expert group. Agreement within the Expert group was good (Fleiss kappa = 0.41). The Expert and Internet groups showed substantial agreement, with Krippendorff’s alpha = 0.643.

Conclusion: The majority of examples we found via Google Images were not clinically acceptable. There was significant agreement both among the expert group, and between the expert and internet groups, about which examples were acceptable. Of note, no images were found that demonstrated ECG lead placement on either a dark-skinned person, or on a female.

Brooks M. Walsh, MD

Bridgeport Hospital

Brooks Walsh, MD, is an attending emergency physician at Bridgeport Hospital in Bridgeport, CT.


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Derek P. Sifford, FP-C, CCP-C, NRP

Attending physician
Superior Air–Ground Ambulance Service


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Brandon Oto, PA-C, NREMT

Critical Care Paramedic
Johns Hopkins Hospital


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Ken Grauer, MD

Physician Assistant Resident, Critical Care
University of Florida College of Medicine


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Vincent M. DiGiulio, BS, EMT-CC

Professor Emeritus in Family Medicine
Our Lady of Lourdes Hospital


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Christopher A. Watford, BS, NRP

EMT-Critical Care
Leland Volunteer Fire/Rescue Department


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Stephen W. Smith, MD

University of Minnesota/Hennepin County Medical Center

Stephen W. Smith, M.D.

Dr. Smith is a Faculty Physician at Hennepin County Medical Center and Professor of Emergency Medicine at the University of Minnesota School of Medicine. He is the author of a textbook “The ECG in Acute MI” and many chapters and book sections on the ECG in ACS. He has also authored many peer-reviewed publications, especially on the ECG in acute MI and on the use of Troponin in the ED.

He is the creator of “Dr. Smith’s ECG Blog,” a free open access (non-commercial) site which has over 7 million pageviews from readers around the world, 35,000 Facebook followers, 9300 Twitter followers (@smithECGBlog), and over 40 million views on Google Plus. It is ranked 5th Worldwide on the Emergency Medicine Social Media Index.


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Sean Kivlehan, MD, MPH

Faculty Emergency Physician, Professor of Emergency Medicine
Brigham and Women's Hospital

Sean Kivlehan, MD, MPH is the Associate Director of the International Emergency Medicine Fellowship at Brigham and Women’s Hospital. He works as an attending physician in the Emergency Department at Brigham and Women’s and is an Instructor in Emergency Medicine at Harvard Medical School. He has worked as a consultant to the Emergency, Trauma, and Acute Care Program at the World Health Organization and helped develop their Basic Emergency Care course. He also has an extensive background in EMS, working as a New York City paramedic for ten years. His current work involves developing and researching emergency care systems and global disaster response.


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281 - Examples of Precordial 12-Lead Electrocardiogram Lead Placement Found on Google Images Are Often Incorrect and Lack Gender and Racial Diversity


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