What is said and what is heard

What it said is “treat the patient, not the monitor.”

What I really hear is “I don’t know how to accurately interpret the monitor, so I can just ignore what is on the monitor.”

For example: your patient is a 73 year old male. He is pale, cool, and diaphoretic. He has normal mentation and complains of weakness. His heart rate is 40, and weak at the radials.

Do we seriously not base our next treatment off the interpretation of the monitor?

He could be in symptomatic bradycardia, and might need a little atropine. He could be having a humongous inferior MI and need a large bolus of diesel. He could be in a complete heart block and need to be paced. He could be in ventricular bigeminy and need some oxygen and a fluid bolus.

But no. You treated your patient, and not the monitor.

What is said is “I know he doesn’t have neck or back pain, but I’m going to board him anyways because of the mechanism.”

What I really hear is “I totally have no idea that immobilization causes harm, and besides, I don’t know how to perform an accurate assessment anyways.”

For real. If you are going to immobilize someone to a spine board, at least have the cojones to say “I was legitimately concerned about the possibility of an unstable cervical spine fracture, so I performed the immobilization.”

We shouldn’t base any treatment based on mechanism alone. Should every victim of a gunshot wound get bilateral lines, oxygen, and transport to a trauma center?

What is said is “I have to do treatment x because it is protocol.”

What I really hear is “I’m just doing what I’m told, and may or may not know better. I might be interested in changing the protocol, but probably not.”

If your medical director wrote a protocol that instructed EMTs to apply a brown paper bag to the face of any tachypneic patient, would you do it?

If your medical director wrote a protocol that instructed you to perform spinal immobilization on every patient who might have a head injury, would you strap down the old demented lady with kyphosis who rolled out of bed on the wrong side?

Or would you stand up for your patients, and for your profession, and point out the wrongs?

I guess I’m just irritated.

Comments

  1. You just hit one of my pet peeves. The only thing worse is one someone says that “BLS always comes before ALS” as if that statement shuts down all discussion. I try to teach my students to think in terms of good clinical judgement instead of meaningless phrases like those two. Great post.

  2. Mine: “if you give 10 cardiologists this strip, you’ll get 10 different interpretations…”

    In other words: so why bother knowing anything, especially if it’s potentially lifesaving?

    • Flash Larry says:

      The problem with that one Brandon, is that it’s factually untrue.

      • There’s a bit of truth to it, but not usually in the part that matters. They’re not usually saying that about the quirky academic strips that ECG nerds pass around for fun; they’re saying it about key concepts like STEMI recognition in the setting of LBBB. Something that’s not only possible and learnable, and the fact (whether true or not) that some medics, doctors, or frankfurter-vendors might not be able to do it has absolutely no bearing on its importance.

        • Flash Larry says:

          You make a good point, Brandon. It’s the effect of Derrida and other forms of relativism and post-modern thinking to deny the existence of truth – which eventually extends to denial of reality.

          There are people who state that mathematics as we know it is a Western construct, and that the reason some cultures do not do well in math is because it’s a product of Western culture being imposed upon other cultures. (I’m not sure what they do with the Chinese and South Asian Indians). This is how far that kind of thinking proceeds but it’s always an excuse for people who either aren’t smart or don’t work.

          So your point is well-taken. It’s not just the bizarre strips that are at issue. And by the way, the problem with them is that people look at them as a strip rather than as something actually happening in the heart. If you visualize them in terms of what happens in the heart to create the little squiggles on the paper, it will often be much clearer. Or not.

          The problem is if you can do that with some obscure and strange strip with what we used to call a WAR, then it can be applied to all rhythms.

          Keeping in mind that “logic” is a Western construct.

          • I’m the first to admit that there’s a line beyond which further lint-combing is mainly for funsies — but long before that is the line delineating things you have a responsibility to understand because it directly impacts your care, and those lines are definitely not one and the same.

            In the end, they’re all just excuses to avoid doing what’s hard.

  3. Flash Larry says:

    I agree with you completely, Brandon.

  4. There is truth to everyone of those phrases you so glibly deride.

    I’ve seen people who were convinced that they had to treat some rhythm on the monitor that was totally unrelated to the complaint that the patient had. Or that decided that they just had to treat a pulse oximeter reading in a patient with no respirartory distress.

    If you DON’T see an indication of STEMI in a patient with crushing chest pain, do you not treat the chest pain because there is no ST elevation? You probably won’t call it a STEMI, but you will treat it even if the rhythm is NSR at 70.

    What about a person who does aerobic exercise on a regular basis and has a normal resting heart rate of around 50? Are you going to throw Atropine or pacing at him if his complaint is he tripped over a curb and twisted his ankle.

    If you blindly treat only what you see on the monitor you are going to over treat some patients and under treat others. What you see on the monitor might help you to narrow down your differential, but it’s not a substitute for a good H&P and actually knowing some medicine.

    Jeff Anderson, if BLS doesn’t come before ALS in your world, then you suck as a paramedic. The first five minutes of just about every call are BLS no matter how sick the patient. I’ve seen more than one medic concentrate on starting an IV and putting on the monitor without even checking to see if the patient had a patent airway. I once pushed a medic from a private service out of the way in his own ambulance because he was starting a line on a guy who needed to have his airway opened and suctioned. The medic was so intent on getting a completely unnecessary IV that he wasn’t even looking at the entire patient.

    As I’ve told students over the 25 years I’ve been teaching ACLS, “When your patient is in trouble and you can’t figure out what is going wrong, start right back at the ABCs.” If you do that, then you’ll never go wrong, If you don’t you’re going to have a lot of dead patients to your credit.

    Really people, get over yourselves.

    • There’s truth to both sides. Truisms and rules-of-thumb exist for a reason, and usually describe an important principle, but there’s danger in clinging to them forever (rather than using them as a ladder and then continuing onward to a broader perspective). And people in this job seem to have a tendency to love the simplistic heuristics.

      • Flash Larry says:

        A person who uses the term “simplistic heuristics” is certainly not trying to be simple-minded.

    • TOTWTYTR,

      Yes, such simplified phrases such as “treat the patient, not the monitor” are useful; but only when used properly. A good medic recognizes the phrases for what they are, useful reminders and rules of thumb. In the case of the “treat patient, not monitor”, it’s a reminder that we treat based on a FULL assessment and the monitor is only PART of the assessment.

      Unfortunately, poor medics (and poor instructors) turn those reminders into absolute laws. In ‘treating the patient, not the monitor” in the bradycardia example, they’d give atropine to a bradycardic patient whether it was simple sinus brady, a 3rd degree heart block, or an inferior MI. “BLS before ALS” is a very important reminder with limited manpower; but when turned into an absolute rule, can result in delays in important ALS techniques (e.g. NTG for a CHF patient) while all BLS avenues are explored or when there’s enough people for both BLS and ALS to be initiated at the same time.

      Though ultimately, I think the biggest problem is that the medics who need to learn from these discussions are the least likely to be visiting these blogs. :-(

      • “I think the biggest problem is that the medics who need to learn from these discussions are the least likely to be visiting these blogs.”

        Exactly.

Speak Your Mind

*