"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!

This great case was sent in by faithful reader Bryan Brzycki, a Medic from Beaufort County. As usual, some minor information may be changed to protect patient confidentiality.

It's a cloudy fall morning when the tones go off and your unit is dispatched to the residence of a 53 year old male. 

When you and your partner arrive, you are greeted by the patient's wife, who leads you to your patient who is sitting on his couch in the living room.

He tells you that he was taking a shower this morning, and developed sudden onset of severe pain in his left leg. He feels discomfort throughout his leg. You inspect it, but do not notice anything abnormal. He tells you that no position seems to help the pain. You ask if he had any injuries that would account for the pain, and he can not remember anything, and that he has never felt anything like this before.

You ask about any other symptoms, and he tells you he also experienced some "mild" chest discomfort. He describes the leg pain as an 8/10, and the chest discomfort of a 3/10. You ask about any other symptoms and he denies anything else. 

He has no significant history, takes no medications, and has no allergies. In fact, he tells you he just had his annual physical last month and he was given a "clean bill of health". 

Your partner applies the leads as you get a set of vitals. The patient is agitated and uncomfortable, telling you his leg is "killing him".

• HR:  100 and regular
• BP:  182/92 (right arm)
• RR:  20
• skin: warm and moist
• lungs: clear bilat

Here is the 12 lead:

You try to sort out what is going on as you move your patient to the back of the truck. 

Although hard to connect it to the leg pain, he did mention some chest discomfort, so you give him 4 chewable ASA and begin transport.

You decide to acquire another ECG:

What do you think is going on with your patient?