Well, of course, with the circles there it's obvious there is something wrong. I circle lots of things on ECGs I'm handed to make sure that if I don't see the patient (usually the case), then whoever does will know my thinking.
Last September, Michael and I went to Amal Mattu's Emergency Cardiology Conference down in Melbourne and one of many good pearls he dispensed was that straightening of the upslope of the T-wave may be the first sign of ischemia - he dubbed this the ST sign. So when I examined this ECG, I could see that phenomenon occurring in V2,3,4. (Also noted is the flipped TW in AVL which may be an early reciprocal change in inferior ischemia.) It caught my attention so naturally we got another in 30 minutes:
Now you can see the same change in the T-wave occurring inferiorly in II and III. Dynamic changes!
Due to a few critical patients, he didn't get another for about 90 minutes but this is what we saw:
Now we see Wellen's type of T-wave changes!! Later we found out he had spent the day prior doing "ice".
This was a patient who could have easily been sent home with atypical symptoms and a "normal" ECG especially given his age. Spending extra time working on your ECG skills and learning some of these subtle signs can save a life. Like an instrument, it's not easy and I find that the more I learn, the more I realise how little I know. Everyday, I see 20-30 ECGs and on many I see things I'm not sure about and I'm tending to overcall. A good place to start is Amal Mattu's two volume ECG series (volume 1 and 2 - [ed I like using Booko to find the best online shop]).