Treat the patient not the monitor?

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? 
  • SVT? 
  • VT? 
  • A-Flutter?

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!

10 Comments

  • Adrienne Linn says:

    Thank you for saying what I'be been thinking. Every time we play the treat the patient and not the monitor game, whether it is the 12lead, capnography, pulse ox or even the glucometer. We are also ignoring valuable info the can help up treat the patient appropriately. Our docs use lab values, xrays, CTs, MRIs and the tools we have to help them make a diagnosis. Why are we acting like we are better that they and don't need any tools but our stethoscopes and eyes to figure out what is going on and treat it. Our ignorance as a community is killing our profession and losing us ground in our scopes of practice. As one of my attending docs told me a couple days ago, protocols are written based on the abilities of the lower third of the cohort, not the upper third. Treating the patient using the monitor and all available tools, using sound clinical judgement and constantly striving to better our education will serve our patients and our community much better than ignorant arrogance.

  • Nick Adams says:

    Very good article.  I've always said to treat the patient AND the monitor.  The monitor is just one more assessment tool that we can use prehospitally to come to a reasonable conclusion as to what is going on with our patient, so we can appropriately treat thier needs. It should never be ignored or dismissed as something that is not important because the pt is doing ok at this time.  They may not be doing ok one minute from now.  The monitor may also cause to you alter your treatment descisions based on your interpretation of the rhythm, such as seeing delta waves or bifascicular blocks based on QRS axis (RBBB w/LAFB).  Personally, I don't give anyone medication unless they're on a monitor.  I can see if the medication I am giving is working, or a sudden onset of tachycardia may be the first indication that my patient is having an allergic reaction to the medication I just gave.  The monitor has many uses other then rate and rhythm.

  • Kyle Norris says:

    Thank you sincerely. I’ve been saying for years this very thing. If I’m going to ignore what the monitor is telling me, why do I lug around 20 extra pounds of kit?

    If the monitor and what you see on exam don’t match, you have to investigate WHY. It may be a false monitor reading, it may also be your exam
    missed something.

    What the phrase means to me is “my instructor didn’t know how to correlate and sort through information, so he taught me yet another EMS proverb that overly simplifies things”.

  • Ken Grauer says:

    Excellent post by Dave with true words of wisdom! By way of illustrating when teaching ECGs – I often show tracings such as the one on my ECG Blog #2 – for which the Clinical Impression (and appropriate intervention) depends dramatically on the clinical setting – even though Descriptive Analysis of this tracing (diffuse ST elevation) doesn't change.

    I think it wonderful to expand the philosophy expressed by Dave in this post to the EMS community.

    P.S. Perhaps an even better way to say it is, "Treat the patient IN THE CONTEXT OF the monitor". By "treating the patient" – what really is implied is "the whole patient" (with presumption to the thinking clinician that this DOES include the rhythm on the monitor/ECG as well as what the patient 'looks like' ). To ensure optimal thinking by clinicians – perhaps spelling it out by adding "in the context" may help. THANKS again Dave for an excellent post!

  • K. Garner says:

    I love the articles and comments and the wonderful learning oppertunity afforded by your site. When I was in class the statement usually referred to a patient that was either completely asymptomatic despite monitor findings ie. bradycardic but no pain or confusion or low blood pressure; or very symptomatic with normal EKG findings ie. diaphoretic, extreme chest discomfort, or feeling of impending doom with no changes evident on EKG. In these situations one tends to be better served by treating the patient and not the monitor. The end take home is to pull all of the information together, EKG, SPO2, vitals, history, and physical presentation then arrive at the appropriate diagnosis and treat appropriately.

  • Danny says:

    Great post. I agree… EKG interpretation IS tough, and I think many people who fall back to saying "how about we treat the patient, not the monitor" simply do not know what is on the monitor!  In the grand scheme of things, I know very little about EKGs, but I am trying to learn as much as I can everyday. Thanks for this website!

  • Josh B. says:

    I get the point of your post.  And, I don't disagree with any of it.  But, I've used the saying forever, and I've never meant to "ignore the monitor".  It's just semantics, really.  But, I like the saying because it reminds everyone that, above all else, we have a patient in front of us that needs our care.  Sure the ECG is a critical tool in your clinical decision making process.  But, it is just that, a tool.  Effective communication and developing a rapport can be just as critical, if not more so, than whether or not the patient gets nitro.  Nothing frosts me more than watching a couple of paramedics debate the intricacies of an ECG like their starring in an episode of House.  Meanwhile, the patient's anxiety level spirals upward wondering what rare, incurable syndrome he must have to illicit such a spirited debate among healthcare professionals.  Again, I understand the point of your post.  And, I understand you aren't saying ignore the patient.  I just like to remind everyone that as we continue to advance our clinical assessment and management skills, we must maintain our ability to put the frightened patient's mind at ease with our communication skills.
    Just my $.02…thanks for the website, I enjoy readingh it and learn a lot from it.

  • Paul says:

    I prefer, and have always practiced the philosophy of “treat the patient in CONCERT with the monitor.”

  • Kidrocksbodydbl says:

    Ok, on treating the PT not the equipment.
    All I am going to give you is a stethoscope, BP cuff, and the usual assortment of meds. Now I will even give you the 1955 EKG monitor my Physician used to pick up (FINALLY) on my WPW after 20 years of blackouts which were silent heart attacks in reality.

    PT on EMS arrival was lethargic but otherwise seemed ok, this then progressed to tightness in his chest. All you have is BP and a 12 lead with no monitor. You have that strip as your only tool. The rest is old school country doctoring. Check ears and eyes for signs of a subdural Heamotoma you have visual and PT data as long as he is awake to give it.

    Time for the quiz …. How would you ddx with the above limitations… remember you have no real time monitoring. and No paddles to shock you must stabilize heart rhythm before the need for paddles. Explain your logic behind your DDX and your solutions. Treat the PT as I have to now …. no data and not even a strip. But he has the “Elephant” on his chest. DDX Time!

  • Patrick says:

    I agree with this somewhat. I do think that treat the pt not the monitor is something that is a useful tool. What i mean by that is sometimes providers to focused on what the machine says not what the pt says. When saying this you have to be able to put all of the pieces together and use everything as a tool and not as a “distraction”. Like a moth to fire. I work with people that if someone has a LBBB its we can’t dx STEMI just take them to the local hospital. Or a pt in obvious respiratory distress that has an spo2 of 96 and says well he is getting enough o2 has to be something else. I think for me the foundation of treat the pt not the monitor means being able to put everything together to make a good clinical decision on how to or the ave we want to go for treatment.

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