On initial evaluation, vital signs were BP, 77/42 mm Hg; pulse rate, 87/min; respiratory rate, 14/min; saturation, 99% on room air; and temperature, 36.5°C. Lungs were clear to auscultation bilaterally. Cardiac examination revealed a grade 2 holosystolic murmur. The abdomen was unremarkable, and there was mild pitting edema. Laboratory test results were significant for acute renal failure (BUN, 106 mg/dL; creatinine, 7.6 mg/dL) with severe hyperkalemia (potassium, 9.3 mEq/L) and metabolic acidosis (bicarbonate, 11 mEq/L). Venous blood gas values were pH, 7.191; Pco2, 34.4 mm Hg; and lactate, 1.3 mM. ECG demonstrated a wide complex QRS pattern (Fig 1). An echocardiogram showed moderately reduced left ventricular function that was unchanged from previous examinations and interval development of mild right ventricular hypokinesis. Chest radiography was interpreted by the radiologist as having no focal pulmonary consolidation and a left internal jugular catheter coursing to the left of the sternum with catheter tip presumed to be in a left-sided superior vena cava or left internal mammary vein (Fig 2). The ED team reported using ultrasound guidance for vascular access.