"Treat the patient not the monitor?"- Redux

 

"For heaven's sake man, treat the patient not the monitor!" 

Ahh, the angry cries appear every time we post a difficult case with a challenging ECG or treatment decision..

The attitude seems intractable, despite our best efforts.

Over a year ago, I wrote "Treat the Patient not the Monitor?", and not much has changed since!

So, I got to thinking. Where did this come from anyway? What were the intentions of the originators of "treat the patient not the monitor"?

In search of answers, I visited treatthepatientnotthemonitor.com, but surprisingly found nothing.

I am left only with my theories and opinions.

Back in the day, decades ago, I'm sure all of this wasn't an issue:

                                                                                                                  *Bonus points if you know who this is!

*image credit

 

Pulse-ox? Portable cardiac monitor? I don't think so!

However, as the advent of portable medical devices made its way to EMS, educators and skeptics alike told cautionary tales about not treating "the monitor"– just look at your patient!

There are the classic examples we are all familiar with :

You put the pulse-ox on the patient with good color and no signs of respiratory distress and it reads 88%. 

HE NEEDS O2 STAT!  Well, of course not, because we treat patients not monitors!

Because measuring blood glucose is considered a "vital sign", you check it on an A/O patient (come on, you know some of you do it) and it reads 62.

HE NEEDS DEXTROSE STAT!  Well, again, not so fast, because we are treating patients not monitors!

It is a good lesson, right? We do not treat numbers on a machine, we treat living breathing patients, and sometimes we just don't know what to do with the numbers.

By the way, cardiologists are having somewhat of a similar issue with high sensitive troponins. Because they are so sensitive, more patients without acute ischemic heart disease are showing positive readings, and now it is not clear what to do with all of them.

In Treat the Patient Not the Monitor -Part I, Rogue Medic writes that citing these words is "dangerous in the wrong setting".  I couldn't agree more.

What exactly is the wrong setting? What is the right setting for that matter?

For starters, it comes back to our patient assessments. Can we assess a patient without the help of technology? Of course we can. 

Will that assessment be as thorough and accurate as it could be? Well, maybe not!

Our technology is a key part of our assessment. If used in the correct setting, it adds information that we might not have been able to obtain otherwise.

The key word, though is "Context".

We should have a reason to use whatever technology we are using. In the setting of an AMS patient, getting a blood glucose reading makes sense to me. It is the proper context.  If a patient is short of breath, pulse pulse-oximetry, or even better, capnography makes sense to me. If a cardiac etiology is the suspected cause of a patient's presentation, the monitor makes sense.

What does not make sense to me is the blind usage of this technology on every patient. I know it is done. I know people can make good arguments for that, but it doesn't work for me.

Here's why. Without the proper context, I feel like i might not know what to do with the results.

As I mentioned earlier, many medics routinely obtain blood glucose readings on every patient as a "vital sign".

My dilemma is this: Do I have a clinical reason to obtain this information? Will it alter the way I treat my patient?

Does he have a CVA or hypoglycemia? Of course, I'll check the BGL. But check it on everyone?

If i do this, what happens when I get a reading of 62 on an alert and oriented patient?

I have two choices:

Option 1: I treat the number and give my patient glucose. Well, I'm not going to do that, because my patient is not altered and doesn't need it.

So I go for Option 2: I simply ignore the number. Write is off as an "erroneous". 

The problem is, If I am not going to use the reading I obtained, why am I getting it in the first place?

I don't use pulse-oximetry on everyone, and I don't routinely obtain a 12 lead on every patient encounter either for the same reasons. 

I realize that right now, many of you are thinking, "see, even HE treats the patient and not the monitor!"

This is where i differ.

It all comes back to context. Clinical judgment means using all available information to assess the patient and find out what is going on. Of course, that does not mean blindly following the monitor, but it certainly does not mean ignoring it.

The reason "Treat the patient not the monitor" does not apply to the cardiac monitor is that used properly, it can give us information that we could not otherwise obtain. You can not look at a patient and determine whether or not he is having a STEMI. 

Do we still examine our patients? Hands on, getting a feel for the pulse, their skin condition? Of course we do. But there is so much more to assess.

The fact is, there is no other surrogate for the monitor. We can not "look at our patients" and have an idea of what the monitor will reveal. That is quite different from blood glucose, NIBP, pulse pulse-oximetry, etc where there will be signs and symptoms of what those "monitors" will show.

The cardiac monitor? You just won't know until you apply it.

You might feel a slow regular pulse, but you don't know if it is Sinus Brady, Mobitz 1, or complete heart block.

That rapid pulse you palpated? Is it VT, AVNRT or A-Flutter? 

Is there a STEMI, sending them straight to the cath lab?

Is that Brugada in your syncope patient?

Maybe it's WPW or ARVD!

To be blunt, in many cases you simply can't diagnose (yes we do that) your cardiac patient correctly without the monitor:

 

There are limitations to the cardiac monitor. They need to be troubleshooted like every other piece of technology. Part of our job is to be able to diagnose problems with the monitor, and not be led astray.

In "Reversals", Peter Canning writes about a case where the arm leads were put on reversed, and the rhythm looked like VT.

     "The only thing going for me is that he doesn't look like he is about to die. I did not expect to see a rhythm like this. I look at it closer…I have the left and right arms                 mixed up. That'll do it."

If what you see on the monitor is totally out of left field, you have be a critical thinker and ask whether something could be wrong with the data. It happens some times. Leads are switched, cables break. That's part of clinical judgment, and our responsibility when using technology. You've got to have your "Spidey Sense" working at all times.

The limitations, however, do not overshadow the fact that we are supposed to figure out what is going on with our patients, and the cardiac monitor can play a crucial role in doing that. 

I looked at many of the posts by Dr. Smith of Dr. Smith's ECG Blog looking for cases of "treat the patient not the monitor". Guess what I found? He actually uses the information on the monitor! 

Dr. Mattu recently had his 100th video case presentation at his video blog. 100 videos? Why in heavens name would he do that when he could have just 1!

         "This week, we have a very difficult case… squiggles here, some blipity-blips there… Oh hell with it, just look at your patient!"

That would be one short video series! In all seriousness, they present tough cases. Difficult ECGs. Why aren't they saying "Treat the patient not the monitor?

We (all of us) don't always like to hear it, but every time we throw our hands up and say "treat the patient not the monitor", it has more to do with our limitations than those of the monitor. It means, "help, I can't figure this thing out, so I'll just treat the patient until we get to the hospital". 

That's what we do when we can't figure out what is going on. All of us.

Just know what it means when you do that. There was something on the monitor that you couldn't interpret. It is an opportunity to learn. That's what ems12lead.com is here for, and what other ECG blogs are here for as well.

"Treat the patient and the monitor".

Remember, it's all about the context!

As always, your comments are welcome!

 

 

 

 

 

 

12 Comments

  • FLMedic311 says:

    Well Said!

  • Michael Ruff says:

    I always when I see Acute MI suspected, I give the cardiac monitor a thrombolytic and a beta blocker, and then I look at the patient.  
     

  • CCC says:

    "We (all of us) don't always like to hear it, but every time we throw our hands up and say "treat the patient not the monitor", it has more to do with our limitations than those of the monitor. It means, "help, I can't figure this thing out, so I'll just treat the patient until we get to the hospital".

    That pretty much sums it up right there. If we don't really know what we are looking at on the monitor, we have that old stalwart excuse to fall back on. Some of us prefer to learn more, and to rely on excuses less, though.

    Someone, somewhere, once told me that "you should know what the monitor is going to say before you put it on."  Essentially what is said here: the monitor is a piece of the assessment, a vital piece, but just a piece nonetheless. 

    That is Dr. Marcus Welby, by the way.

  • Brooks Walsh says:

    David -
    A great article, and a cogent reminder of why we lug around so many monitors.
    Another example: An intubated patient was brought in to the ED by EMS, and I asked the medic about the end-tidal CO2 numbers. He replied that "It's not working, because it kept giving me real low readings, under 10. Clinically, though, the tube is in the right place."
    Except it wasn't.

  • Robert McCusker says:

     
    Whenever I see a low sat in a talking, A and O x 3 person is check the waveform. Just like in asystole, confirm in a second lead. Know your equipment and more importantly its limitations. Remember accuracy vs precision in chem 101? It is important to know that each device has these same limitations. 
    There is a reason that AHA guidelines state "seek expert consultation."  OLMC is treated as a hindrance when it should be considered another valuable asset. Medical awareness is not learning more but becoming cognizant of how little you actually know.  Sometimes, the hardest thing is to say "I don't know."  There is nothing wrong with uttering that phrase so long as you attempt to do no further harm and seek immediate assistance. 

  • mark raines says:

    I recall telling the nurse to throw that useless pulse oximeter away when it recorded sats of 88% on a drunk patient who had been thrown from his car but sitting up talking to me about football, not in pain with normal heart rate, blood pressure and respiratory rate. His drunken mate suggested he had done cpr on him after dragging him out of a puddle on the side of the road then fell aslpee again.
    20 minutes latter his respiraory rate climed to 30 and his GCS fell to 8 and the sats monitor – well it was in the bin. When he was tubed out came the inhaled puddle. Maybe the nurse should have chucked out the doctor!

  • Petar S says:

    Ah the classic BG as a vital sign.  Yup, everyone gets a BG reading because:
    -It won't hurt to have
    -The nurse wants it
    -You never know
    -Because I can
    Not the main message of this post but a great illustration of doing something because we can and then ignoring the context around the data.

  • Andy says:

    I don't work in the states so as an EMT I have a broader scope of practice.  At our weekly trainings and during continuing education I seem to always be telling staff take everything in context.  Like said before are you taking a 12 lead because you clinically suspect cardiac issues or is it just because you'll look cool to the receiving nurse. Though some of the staff will hook up everything then sit in the captains chair and never look at the patient.  These also happen to be the people who hate coming to continuing education because they "already know it all" 

  • James says:

    - I check blood sugar on every patient, but I only treat symptomatic hypoglycemia

    - I check O2 sat on everyone, but I treat hypoxia.

    In the field, you need to check all the information you can to develop a better understanding of your Pt's condition. You are the medic and it is your brain that is the best diagnostic equipment in your toolbox.

  • David Baumrind says:

    James, with all due respect, I do not follow. So, your patient is asymptomatic but you check the BGL anyway, and it is low. You aren't going to treat the patient, so I don't see how you now "better understand" your patient. The reading is quite possibly erroneous, and there is seemingly no clinical correlation, so what is the payoff?

  • Jason says:

    David-
    I agree with your post to a point.
    I wholeheartedly agree with your frustration at those who post the catch phrase in question when we are discussing ekg’s on line in a learning environment. This website has no room for the phrase. Give it your best attempt and read what others have to say. Then go follow the links to mattu and smith. Learn something here; don duck the oppertunity saying the tired old words.
    Now as we get towards assessment tools and clinical context I have a few thoughts. Don’t us the monitor, pulse ox, or any other tool when applying them can help you prove your suspected diagnosis. Rather don’t us them when you know they will not aide you in your diagnosis and treatment plan. As an example I had a patient the other day who was weak an dizzy. I believed him to be dehydrated. I did not think it was a cardiac etiology. Did I use a monitor? Damn right! I know enough to know it could be a cardiac etiology. I’m glad I did. It was a wild ride. That story another time.
    The next idea is this; what is our minimum data set for every patient? It’s an open question. I invite everyone to consider it. As a paramedic in my system I often make the decision if a pt goes to the hospital with an ALS provider or a bls one. I always get hr, bp, rr, and Spo2% before making that decision. Just my process but that is my minimum data set in my practice.
    My final point is this and I trust most will find it obvious but I feel it’s important. If you decide not to use an assement tool you have and you miss something you own that choice and it’s consequences!

  • David Baumrind says:

    Jason,

    thank you for your comments!

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Jewel
53 Year Old Male: Severe Leg Pain
Hmm it appears like your site ate my first comment (it was extremely long) so I guess I'll just sum it up what I wrote and say, I'm thoroughly enjoying your blog. I as well am an aspiring blog writer but I'm still new to the whole thing. Do you have any helpful hints for…
2014-08-31 17:51:28
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14

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