Here at the EMS 12-Lead Blog, we love case studies.
We love to post them, you love to read them, and many of you love to comment on them.
Not only on this blog, but on other very good blogs that are out there as well. I think it’s a great way to learn, and share ideas in this era of Web 2.0. What I want to discuss today is one comment I often see:
Treat the patient, not the monitor!
Before we start, I want to be clear about a couple of things.
First, I understand that ECG interpretation is hard. Really hard. To become proficient it takes countless hours, months, and years of study. Whatever my opinions, I am certainly not trying to suggest it is easy or routine. I make mistakes like everybody, and I will still run a difficult strip or 12-Lead by people who know more than I do for help with the interpretation.
Second, when we are talking about treating the patient not the monitor, we are not talking about defibrillating a live patient with tremors because it looked like VF on the monitor. “Oops, guess I should have looked at my patient”. No, that’s not what we mean.
Often, when someone writes, “just treat the patient, not the monitor”, what he or she really means:
I can not figure out all of these squiggly lines, so I am going to ignore them.
Hey, I get it.
Hell, I’ve been there, and so has everybody else. In fact, I am still there sometimes. Everybody has a patient whose ECG is challenging, and takes them as far as they can go with their interpretation skills. It does not mean that we should devalue the importance of the ECG just because we are having trouble interpreting it.
If we want to evolve into clinicians instead of technicians, we have to use all of the relevant tools at our disposal. When it comes to potential cardiac patients, our cardiac monitors can be some of our most important tools. These relatively small machines can give us a ton of important information, and arguably we can not really have a full picture of what is happening with our patient if we can not interpret what we see on the monitor.
Does what we see on the monitor really matter that much?
Consider your tachycardic patient, who looks sick with poor color, but an Ok mental status and a reasonable pressure. Are we looking at,
- Sinus tach?
Do you want to give fluids? Or perhaps adenosine, amiodarone, or Cardizem?
How are you going to determine what treatment he needs?
Oh that's right, by interpreting the ECG.
There is really no getting around it. I suppose you could just transport everyone to the hospital and let them deal with it, or wait until they become unstable enough that you have to shock them. But is that the optimal patient care we want to deliver?
Even if you decide all you can or should do is take the patient to the hospital, you have to ask what type hospital do they need?
- Do we just treat them all as a STEMI and take them to the PCI center?
- Is it just a baseline finding and their local hospital is Ok?
- Is it an isolated posterior STEMI that we're not seeing?
Want to hold off on NTG? Give fluids? How are you going to know?
Again, by interpreting the ECG.
How about your syncope patient. Anyone up for WPW, Brugada, or another arrhythmia?
See what I mean?
When it comes to cardiology, I really don’t think we can separate the patient from the monitor. I mean, they are hooked up to the darn thing anyway!
But even figuratively, what we see on the monitor is part of their history, part of their present illness, and very often contains the answers that we could get no other way. We are talking about cardiac patients who for the most part, look very similar, although the underlying problem can be anything we can see on the ECG from normal tracings, to arrhythmias and STEMIs and everything inbetween.
If you're good, you just might pick up something that saves their life. We see countless cases sent in by you–our readers–of patients who might not be here today if it wasn't for their prehospital ECG interpretation!
When we get that voice in our heads, the one that tells us not to focus on the squiggly lines and just look at our patient, we should listen to what that voice is really trying to tell us: that we don't know what it means, and we need to learn more.
There is no shame in that. In fact, I would take it as a sign of a good provider. To acknowledge what we need work on, and try to improve. That’s all we or our patients can really ask!
If you spend time reading Dr. Smith's ECG Blog or some of the electrophysiology blogs, one thing you will never see is "treat the patient not the monitor." That's because this is a false choice.
So let's start a trend whenever you come across a tough case study, and leave a helpful comment:
Treat the patient AND the monitor!