Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Treat the Patient, Not the Monitor – Part I

 

Treat the patient, not the monitor, is a nice phrase that is sometimes appropriate and sometimes not.

In other words, it is dangerous in the wrong setting.

If we are using this as a way of encouraging paramedics to be minimalists as far as treatment of tachycardias, that is great.

If we are using this as a way of encouraging paramedics to be minimalists as far as treatment of bradycardias, that is great.

If we are using this as a way of encouraging paramedics to be minimalists as far as treatment of hypotension, that is great.

If we are using this as a way of encouraging paramedics to be minimalists as far as treatment of hypoxia, that is great.

If we are using this as a way of encouraging paramedics to be minimalists as far as treatment of hypoglycemia, that is great.

However, this does not mean that we should convince patients to refuse, or that we should not treat them, only that we should be aware that the life=threatening presentations may only be life=threatening because of the unnecessary treatment that we provide because we have been taught to over-react to the monitor.
 

 

Is isolated hypoxia something that should be treated?

Is isolated hypoxia life=threatening?

Probably not, but the monitor is only a part of the assessment.

Maybe the phrase should be changed to do not treat the patient based on only a part of the assessment that is inconsistent with a full assessment.

A full assessment is going to depend on the patient’s condition. A pulseless, unresponsive patient does not receive the same pre-treatment assessment as the patient with spurting blood, or the patient with hypoxia on the monitor.

Another consideration is the way we assess the accuracy of the information provided by whatever monitor is being used. I had a recent patient with a sinus bradycardia in the 30s, an oxygen saturation in the mid-90s, and a touch of hypertension. The staff at the receiving ED were only looking at the ECG measurement of the heart rate and ignoring the lengthy distance between QRS complexes. The indicated heart rate was in the mid 70s, while the actual heart rate was half of that. Was the monitor also counting T waves, or P waves? Probably.

A more complete assessment can provide more information.

Is that enough?

The 12 lead showed no ST segment elevation or depression and no changes to the T waves.

Is that enough?

The patient is pink, warm, and dry and denies: chest pain, difficulty breathing, weakness, dizziness, nausea, vomiting, . . .

Is that enough?

The patient is awake and alert, speaking in full clear sentences, joking around, but complaining of a cold and congestion that has been going on for a couple of weeks.

Is that enough?

On further questioning the Medicare-aged patient does mention neck and jaw pain.

Is that enough?

No beta blockers. No calcium channel blockers. No other drugs that might slow the heart rate. Some unknown cough medicine.

Is that enough?

Treat the patient? Treat the monitor?

No. We should assess the patient by whatever means necessary.

The doorway assessment of this patient was clear – BLS transport or refusal.

The full assessment is not the same.

A STEMI alert depends on a monitor showing a STEMI, not a patient with GERD-like symptoms – pale, cool, sweaty, epigastric pressure, response to nitrates, et cetera.

What is appropriate for this patient?

What about the neck and jaw pain combined with the bradycardia?

Also read – Computer STEMI Interpretation at Street Watch: Notes of a Paramedic.

Feel free to suggest different treatment and an explanation for the different treatment.

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Comments

  1. I agree wholeheartedly with your comments and discussion, and we as healthcare providers need to recognize and appreciate how serious of a problem this has become. It is very deleterious to ignore findings from the H&P and the exam, but it is just as much so to ignore the other 50% of the information the cardiorespiratory monitoring is providing us. One of my favorite quotes that I have always taken to heart and applied in clinical practice, is a statement made by Mike Taigman in the text “Taigman’s Advanced Cardiology(in plain English).” His quote is “Don’t treat the patient and not the monitor. Treat the patient IN CONCERT with the monitor.” A clinical pearl we should all apply to everyday practice.

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