Does anyone have trouble getting accurate BPs in the back of the ambulance?

[lfsvr0114]

Something I've found useful is to brace my foot against the bottom rails on the cot and rest the patient's arm on my knee.

I also will place a towel or something similiar between the pt arm and my knee if I still hear a lot of road noise. It helps to absorb the noise making it easier (for me anyway) to hear.

Not everyone can hear through every stethoscope. Try several different ones and see which one is best for you. Expensive does not always mean better. (I do have a master cardiology, tho and can hear very well). It also never hurts to have your hearing checked to make sure that you do not have any hearing loss.

Also to train yourself to hear better, practice taking your crew members b/p's with a radio or tv on. You will actually train yourself to block out outside noise and focus on the pulse to get an accurate reading.

 

[yay4stress]

I don't agree with your assertion that palpated BP is just a guess.
I do agree that other methods should be tried first.

I don't think either of us is going to be able to convince the other here.

Going back to the original post, I think a lot of us have trouble getting BP in the back of the truck, but methods to make it easier vary from person to person.

 

[yay4stress]

Also to train yourself to hear better, practice taking your crew members b/p's with a radio or tv on. You will actually train yourself to block out outside noise and focus on the pulse to get an accurate reading.

I like that idea

 

[medic001918]

hold on now, what's with this bashing of BP by palp?

I agree that a BP should be taken by auscultation before leaving the scene, but if you have that, then a BP by palp en route is not going to be a huge problem. Plus, if your pt is still talking to you and they're not bleeding profusely, there's a good chance that the diastolic BP isn't quite as important as the systolic, and if they're not talking to you, or they are bleeding profusely, if your not on a BLS truck then I'm guessing you have them on the monitor already.

not to be argumentative or anything, and I definitely agree that auscultation is better (more accurate, more useful), and that practice is by far the best solution to any problem like this, but BP by palp is definitely useful if your having trouble hearing.

okay, all done.

Noone is bashing him about the blood pressure by palp. But as an ALS provider if is all you have for me is a pressure by palp and don't have a good reason for it...you've totally discredited yourself as a provider and everything you say will most likely have less credibility with me. Blood pressure by palp is not really an accurate means. I also care about trending of blood pressures, which is best done with a complete pressure. Your comment about if you're an ALS unit, the patient is probably on the monitor doesn't make sense either. Just because a patient is on the heart monitor, doesn't mean that I'm using the NIBP. Those are historically inaccurate.

Please don't discount yourself as a provider or EMS as a profession by not being able to perform the basic skill of obtaining a blood pressure. Short transport time or not, you can obtain two COMPLETE sets of vital signs. Especially on a BLS call since there isn't much else to be done.

Shane
NREMT-P

 

[yay4stress]

ok, first off, my apologies to the person who started this thread for sidetracking it.

Secondly, to those who think I'm advocating using just palpation, I think I've misrepresented my point, so I'm going to try and clear this up.

I am NOT advocating using just BP by palp.
I AM saying that auscultation is more accurate, and should always be the first way to get someone's BP.
I am NOT saying the palp is a good way to do reassessments.
I AM saying that with short transports, when complete vitals have already been procured WHILE IN TRANSPORT, and when the pt's well-being in no-way depends upon a diastolic BP being checked, that taking a quick BP by palp while en-route is a good way of verifying QUICKLY that nothing bad is about to happen. It should go without saying that the BP gotten this way should be taken with a grain of salt, but as far as quick, and admittedly dirty, ball park assessments go, palp does function.

let me reiterate, I am NOT advocating palp as a first resort, I am NOT advocating using palp as even a definitive reassessment. I am just saying that it isn't as bad as previous posts have made it out to be (from my interpretations).

as for my comment about the monitor, every single ALS call I've been on, regardless of the medic, vitals (pupils and lungs [sounds and resps] aside) have all been done by the monitor. This wasn't my decision, it's what the medic did, and I can only say what I see happening, so I apologize if that isn't how you run your calls, I don't know how other services do their ALS, and I may have worded my previous posts more than a little poorly.

My intent on speaking up was a little non-sequiter, so, sorry.

 

[daedalus]

Thread poster- like everyone here said, it takes practise. As for BP by palp, just dont do it. as Ridryder has said, we don't guess vital signs. Our job is to look after our patient and not guess on their condition. I do however recall that while in a primary care setting while I was a student of a dermatologist who was doing GP work because we were at a busy and underfunded free clinic, I was unable to get a pressure on a obese diabetic patient, and the dermatologist took it by palp. he explained to me that sometimes the sounds are not present in some people.

 

[Ridryder911]

, I was unable to get a pressure on a obese diabetic patient, and the dermatologist took it by palp. he explained to me that sometimes the sounds are not present in some people.

It is not that the sounds are absent rather unable to hear the sounds due to fat tissue absorbing the sound. I would be sure to document such, " unable to auscultate B/P due to morbid obesity"; that is after I attempted radial blood pressure. Remember, blood pressures can be taken at any pulse point. I personally use the forearm and the wrist on obese, I have better luck of obtaining an auscultated B/P, and again document such (radial B/P) which the values will be different.

R/r 911

 

[wlamoreemtb]

It is not that the sounds are absent rather unable to hear the sounds due to fat tissue absorbing the sound. I would be sure to document such, " unable to auscultate B/P due to morbid obesity"; that is after I attempted radial blood pressure. Remember, blood pressures can be taken at any pulse point. I personally use the forearm and the wrist on obese, I have better luck of obtaining an auscultated B/P, and again document such (radial B/P) which the values will be different.

R/r 911

You know R/r i never thought of auscultating on a forearm or wrist on the obese thanks for the insight thats going to be very useful
-Wayne

 

[skyemt]

i think in 240 calls i did this year, i only took BP by palp once... and it was a very heavy pt, and i just could not hear it...

i also documented quite carefully why i couldn't get the BP and took it by palp... for me, it is an admission that i could not even do a basic skill, and it doesn't sit well with me... with practice you can be good enough to get a reading...

the other point, is that i don't really think it saves much time... you still have to get the cuff positioned, and then find and establish the radial pulse before inflating the cuff... is it that much faster than placing the stethoscope on the pt?

i understand the reasoning of not being able to auscultate the BP and taking it by palp, but to say it is a "quick easy way" seems a bit off the mark, and more than a bit amateurish.

 

[daedalus]

It is not that the sounds are absent rather unable to hear the sounds due to fat tissue absorbing the sound. I would be sure to document such, " unable to auscultate B/P due to morbid obesity"; that is after I attempted radial blood pressure. Remember, blood pressures can be taken at any pulse point. I personally use the forearm and the wrist on obese, I have better luck of obtaining an auscultated B/P, and again document such (radial B/P) which the values will be different.

R/r 911

We attempted to use the large cuff on his forearm, he was very large.
Good point on the documentation.

 

[BossyCow]

There are times when palp is acceptable, I don't think anyone is saying that a palped B/P is never, ever acceptable. But, the original post was asking about how to improve a basic skill and it was suggested that palp was an acceptable stand-in.

I have seen new EMT's abandon attempts to take a real BP after they learn to palp one. They will make a stab at it and immediately go to palp. I think part of this is nervousness over not having 'a number' to give the ER or the ALS crew contacting us by radio.

There are times to use palp. But it should not be our automatic fall back position for the more difficult to hear BP's. Training is key, practice is the path. Taking a BP in the back of a rig is a basic skill and needs to be developed. Telling a new EMT to use a shortcut to that when they are sincerely asking for assistance on developing their skill set is irresponsible.

 

[kashton]

Personally, I use palp only when I cannot get an accurate bp, I think that is the only time it is necessary

 

[TheDoll]

i was just given a great tip by a wonderful paramedic.
first, i always rest as much of the pt's arm as possible on my knees, and tell the pt to relax their arm.

second, (and this was the helpful tip) if you can't seem to get a good pressure. rest the pt's arm on one of your knees, and when you are listening, raise your foot, so your leg isn't touching anything. now, you don't have to be doing major calisthenics's for this. just raise your foot a few inches off of the floor or cot. i found this really helpful!

 

[kashton]

Great tip! Thanks

 

[katgrl2003]

It is not that the sounds are absent rather unable to hear the sounds due to fat tissue absorbing the sound. I would be sure to document such, " unable to auscultate B/P due to morbid obesity"; that is after I attempted radial blood pressure. Remember, blood pressures can be taken at any pulse point. I personally use the forearm and the wrist on obese, I have better luck of obtaining an auscultated B/P, and again document such (radial B/P) which the values will be different.

R/r 911

I transport quite a few obese people, and the wrist is the way to go. Like R/r said, document. Values will even be different from arm to arm. Think about this situation (one I actually dealt with). Taking a bp in a pt's foot because he had no arms due to a birth defect.

The best hints I can come up with are get a good stethoscope, adjust it so it fits you, find the artery, put the bell directly over it, and take the pressure. If you do it the same way every time, it will become habit, and you will get better at hearing the pressures.

-Kat

 

[Aileana]

I used to have a lot of trouble getting a BP in the back of a moving truck, but on the last shift I worked, got a BP done on every patient on the first try ^^. I find that if you're doing a non-emergent call, getting a BP when at a red light makes life a lot easier. Otherwise, I just try to ignore the background noise (get quite a lot, using a $15 steth til I can afford something good) and make sure the steth has a good seal against the arm. I find I have the most trouble getting BPs on elderly patients, because of the lack of elasticity in their skin. Any advice specifically for these cases?

Regarding palp., I've only ever used it on a patient once, when we were going lights and sirens, and her skin was too wobbly to keep my steth in one place. I'm trying to pick up good habits from the start, and get full BPs whenever possible.

 

[Ridryder911]

I used to have a lot of trouble getting a BP in the back of a moving truck, but on the last shift I worked, got a BP done on every patient on the first try ^^. I find that if you're doing a non-emergent call, getting a BP when at a red light makes life a lot easier. Otherwise, I just try to ignore the background noise (get quite a lot, using a $15 steth til I can afford something good) and make sure the steth has a good seal against the arm. I find I have the most trouble getting BPs on elderly patients, because of the lack of elasticity in their skin. Any advice specifically for these cases?

Regarding palp., I've only ever used it on a patient once, when we were going lights and sirens, and her skin was too wobbly to keep my steth in one place. I'm trying to pick up good habits from the start, and get full BPs whenever possible.

Poor skin turgor (tenting of skin) can be reduced by holding the arm with the fingers in a Y formation, allowing the arm to rest in your hand and stretching the skin outward. Of course palpate the brachial artery first and locate the pulsation.

R/r 911

 

[katgrl2003]

Oh, I like that idea Rid. I never thought about doing that.

-Kat

 

[mikie]

Too much?

I'm new around here and this is a great topic for me to stumble across:

The other day I too had difficulty taking a pt's blood pressure and I didn't want to take it by palp-as it wasn't eminent to obtain the BP but I just couldn't hear it! Someone brought up the point of using their own stethoscope...

As a Basic on an volly. ILS squad (often just BLS providers), would it be "wacker-eqsue" to bring my own scope along (just a basic Littmann Lightweight II SE)?

 

[bstone]

I often bring my own BP and steth. I don't trust the $5 ones that the company provides us.