In medicine we want objective, but we are soaked in subjective.

My posts on the Hapmed trainer sent me into new realm of neurotic questioning. In medicine we want objective, but we are soaked in subjective. www.MDCalc.commakes my point. It’s an amazing website to check out and can be very comforting if you want to make the shades of life a bit more pixellated. But it shouldn’t replace a good history.

Even our beloved vital signs, which are billed as “objective”, all have Achilles heals. Let’s run the list:

Temp
Where? Axillary? Rectal? Sublingual?… Should I trust an electronic device slid across a forehead that never gives the same number twice? Does one slightly elevated number send a sneezing 29 day old infant down a septic workup?

Resp rate
When’s the last time you saw someone measure this for 30 or 60 seconds? Actually, more useful to me in a triage note would be something more subjective like an “FSN” scale for “Fast, Slow, Normal”.

Heart rate
Arewe talking pulse rate? Ventricular rate? Atrial rate? My father had atrial flutter in December. A pulse ox gave one number. An iWatch gave another. Kardia revealed another. Radial artery palpation gave another. We think of 100 in adults as a magic number for when to get worried or send folks home. But far from it.

Pain scale
Don’t get me started.

BP
This is the one I’m most hung up on and my reason for typing. When I started testing tourniquets I wrapped a BP cuff around a bag of water and watched the column rise. The water column was always a bit lower than predicted by my BP cuff and my mind questioned the water column rather than the other way around. Now that I have a digital manometer that agrees with the water column pressure, why would I not consider that the right number rather than the pneumatic cuff on the outside? The pressure in the water, or the limb itself, is what I actually care about, not the indirect air pressure in the inflated bladder adjacent to the limb.

When my mother’s BP at home is consistently normal, then she has an elevated reading when she goes to see her doctor and they say maybe it’s time for some meds, is it just white coat syndrome? Or are BP cuffs suboptimal?

“Treat the patient, not the numbers” is probably my favorite saying in medicine. … that and “Don’t just do something, stand there.”

For the full post and to add comments, continue the conversation on Linkedin on the link below.