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



## kashton (Nov 28, 2007)

I went through EMT Basic in January and have finished all but the NREMT exam for Paramedic certification and I still have a little trouble getting an accurate BP while enroute to the hospital on occasions. Sometimes it is easy to hear but other times I simply have no way of getting an accurate reading... which can be a critical part of my assessment of my patient... are there any tricks you know of to help me out a little bit since I am rather new at this? Thanks!


----------



## katgrl2003 (Nov 28, 2007)

You will probably get tired of hearing this.  Practice, practice, practice.

I work with a medic, and I was having the same issue about a week ago on a long distance run.  I told him to pull over.  If you have the time, and the patient condition allows it, take the pressure before you start transporting.  That way, you will have a good baseline for the next one you take.

-Kat


----------



## kashton (Nov 28, 2007)

In my clinical times we almost always took at least one BP before leaving the scene it was just the enroute times were sometimes difficult, but yes, practicing will probably solve the problem.


----------



## seanm028 (Nov 28, 2007)

Have you tried getting it by palpation?


----------



## kashton (Nov 28, 2007)

Yes, that usually works but the diasolic is important too, especially in a hypertensive crisis


----------



## enjoynz (Nov 28, 2007)

THe EMT-I's I crew with, always use the lazy person's BP, NIBP off the Defib.:blink:
But pulling over and taking it on route is the other best option I've found. 
It's a 1/2 hour drive for us to transport to hospital, so we have set places on route to pull over and take vitals. Of course this depends on how sick your pt is as well:excl:

Cheers Enjoynz


----------



## katgrl2003 (Nov 28, 2007)

Ok, I gotta admit, I use the lazy person's BP too.  But if I start getting some really wonky numbers, I'll take it the regular way.

-Kat


----------



## BossyCow (Nov 28, 2007)

This is a basic skill and there is no excuse for not developing it well.  Practice, practice and practice.  I think a lot of new EMT's use palp as a way of avoiding doing an accurate BP under difficult conditions.  

Keep your feet stable, make sure the pt's arm isn't thumping against the stretcher frame, make sure your scope is firmly in your ears and adjusted so you can hear properly.  Place the bell firmly against the artery and listen carefully.  

There are a lot of more detailed threads here about doing good B/P's and "Just find a lazy shortcut" is never, ever good advice.  If you want to be a good EMT than learn how to do the skills well.  Nobody ever starts out knowing everything, and you will get there if you want to improve.


----------



## kashton (Nov 28, 2007)

BossyCow said:


> Keep your feet stable, make sure the pt's arm isn't thumping against the stretcher frame, make sure your scope is firmly in your ears and adjusted so you can hear properly.  Place the bell firmly against the artery and listen carefully.



I do this and it is still difficult


----------



## katgrl2003 (Nov 28, 2007)

Make sure you are over the artery.  Try palpating the artery and placing the bell directly over it.  On the practice side, grab your partner and take his/her bp.  A few months ago, we had a new EMT with the same issues and he ended up taking the bp's of everybody on shift.

-Kat


----------



## ErinCooley (Nov 28, 2007)

Do you have a good stethescope?  I was having lots of trouble until I bought a good one.. I havent have any problems since!!


----------



## kashton (Nov 28, 2007)

Yea I have the master cardiology by Littman, I will just practice a ton


----------



## medic001918 (Nov 28, 2007)

Definitely practice.  A pressure by palp is not acceptable to me in most cases.  If I ask for a blood pressure, it means I want a blood pressure.  Not a short cut.  As far as using the NIBP, my partners are not allowed to use it to obtain a blood pressure.  I don't use it myself most of the time, and when I do it's only after obtaining a manual blood pressure.  As far as pulling over to obtain a blood pressure, that's not something I'm really into either.  It's great if you have a stable patient, but those stable patients are great practice to learn to take one in the back of a moving ambulance.  That way when the patient is not stable, you're capable of doing the job that's expected of you.

Like other's said, make sure your scope is over the artery and that you're pressing hard enough to maintain a good seal from outside noise.  Try to eliminate excess movement.  And practice over and over again.

Shane
NREMT-P


----------



## Meursault (Nov 28, 2007)

With a bit of practice (I'm fairly new, but I've learned to do it), you can get accurate BPs without possibly inaccurate shortcuts. 
The tips in here are good, and there are more tips, more detailed discussion, and some fun flamefests about the need for accurate, rapid blood pressures by auscultation buried in the forums. 

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. If the road's especially bumpy, that's not going to work, but it usually helps steady their arm and get good scope contact. 

Having a Littmann Master Cardio also helps, you lucky :censored:.


----------



## Ridryder911 (Nov 28, 2007)

Palpation = guessamation... basically means nothing. 

Like others stated.. practice, practice, practice. If you still cannot get it, have someone demonstrate over and over. It is a BASIC skill. 

Using an automatic blood pressure is not accurate in the field, if one does not obtain a base line value first, before using an automatic B/P cuff. Movement, road vibration, can give inaccuracy or false reading. *Each number is improtant!* Hence the reason is part of a *VITAL* sign! 

If all else fails, get hearing checked.. (no joke) many can hear low tones...

R/r 911


----------



## yay4stress (Nov 28, 2007)

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.


----------



## Ridryder911 (Nov 28, 2007)

Okay, how accurate is that palpated blood pressure? Can you explain pulse pressure and alternans that can commonly effect palpated pressures. As well, how much pressure is needed to get a radial/brachial pulse? 

Please do not refer to the old myth radial pulse = 70-90 systolic, etc.. It has never been proven scientifically to ever guess-a-mate by pulse points pressure, and has been removed from the ATLS instruction. 

If you want a "ball-park" pressure, sure palpated, or better yet use a doppler. (Yes, we carry one on every truck) 

The only time a palpated pressure should be obtained is because it is impossible to hear or auscultate a blood pressure due pt.'s poor perfusion level or temporary extreme ambient noise. Most of the time they are performed because of laziness. 

R/r 911


----------



## Alexakat (Nov 28, 2007)

MrConspiracy said:


> 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've had good luck with this method as well!


----------



## yay4stress (Nov 28, 2007)

I agree whole heartedly, I refer only to those situations when an estimation is all you need.  At my service, we use palpation frequently with BLS patients when calling the vitals in to the receiving facility and a full set of vitals is just not viable with the timing.

Our service requires us to get at least two sets of vitals for every call, so if we have a 4 minute transport (which does happen sometimes), BP/palp becomes a great option due to the fact that most of our transports are on the highway and it's a lot quicker.  Palpation fulfills our charting requirements and, like it or not, does give the hospital a decent idea (key word, idea) of the progressions of the patient's condition.

That being said, I want to be clear that when I say "bp by palp", I don't mean "pt has a radial pulse, therefore his bp is 90/palp".  I mean, putting on a bp cuff, increasing pressure until a radial pulse is no longer present, and then releasing presssure until the radial pulse shows up.  I think it goes without saying that this method isn't always the best idea, but palp is often viable, at least for our service.


----------



## Ridryder911 (Nov 28, 2007)

So basically you are guessing at the vitals? Sorry, there is no point of reporting estimated vital signs. Why? They are worthless, and as well presents that you are unable to perform your job. It appears you are only placing numbers for charting purposes. Remember, you will held be accountable if there is problems later on. If the patient suddenly deteriorates and your vital signs reflects differently or questioned why an accurate set was not taken, (as set out by the national curriculum) are you going to say .."_It was easier"_....

Taking a B/P takes <30 seconds, even those that are hard to hear. If one is proficient in their skills, then one does not have to take short cuts. Remember taking short cuts only leads to long term problems. 

Again, the only reason palpation is even taught is for the patients with such poor perfusion and ambient noises it be impossible to auscultate. I am not against palpated blood pressures, but when one gives me a palpated B/P it should mean other methods has been attempted prior, like doppler B/P. 

R/r 911


----------



## lfsvr0114 (Nov 28, 2007)

MrConspiracy said:


> 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 (Nov 28, 2007)

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 (Nov 28, 2007)

lfsvr0114 said:


> 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 (Nov 28, 2007)

yay4stress said:


> 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.
> 
> ...



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 (Nov 28, 2007)

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 (Nov 29, 2007)

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 (Nov 29, 2007)

daedalus said:


> , 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 (Nov 29, 2007)

Ridryder911 said:


> 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 (Nov 29, 2007)

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 (Nov 29, 2007)

Ridryder911 said:


> 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 (Nov 29, 2007)

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 (Nov 29, 2007)

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


----------



## TheDoll (Nov 29, 2007)

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 (Nov 29, 2007)

Great tip! Thanks


----------



## katgrl2003 (Nov 30, 2007)

Ridryder911 said:


> 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 (Dec 4, 2007)

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 (Dec 4, 2007)

Aileana said:


> 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 (Dec 5, 2007)

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

-Kat


----------



## mikie (Dec 6, 2007)

*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 (Dec 6, 2007)

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


----------



## katgrl2003 (Dec 6, 2007)

I usually steal my partner's stethoscope - a Littman.  Boy is he grateful I'm getting one for Christmas.

-Kat


----------



## mikie (Dec 6, 2007)

bstone said:


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



so even as a 'newbie,' i won't look bad (not that it's the 'looks' when its the pt's vitals that matter) / like a whacker?


----------



## mikie (Dec 10, 2007)

mikie333 said:


> so even as a 'newbie,' i won't look bad (not that it's the 'looks' when its the pt's vitals that matter) / like a whacker?



let me rephrase:

If I brought my own steth., I'm not going to look foolish or be 'looked down upon' because I'm new and only a basic?


----------



## katgrl2003 (Dec 10, 2007)

About half the people in my company use the ones that are provided.  Personally, I wouldn't touch them with a 10 foot pole.  They're out there for everyone to use, so they most people don't take care of or clean them.  Please, don't ask what I found when I cleaned them.

Like I said earlier, I use my partner's stethoscope (mainly because he knows I will take care of it) and am getting my own for Christmas.  It's a good tool to own, because you be able to practice with it and become better at listening to lung sounds, BPs, that kind of thing.

-Kat


----------



## BossyCow (Dec 10, 2007)

Just be careful.  If it's a really cool one it better have your name on it.


----------



## emtwacker710 (Dec 20, 2007)

try watching the needle on the BP cuff, I work in an area that covers quite a bit of highway so at times at an MVA it's hard to hear but watching the needle helps a lot.


----------



## skyemt (Dec 20, 2007)

emtwacker710 said:


> try watching the needle on the BP cuff, I work in an area that covers quite a bit of highway so at times at an MVA it's hard to hear but watching the needle helps a lot.



actually, you can get false readings by just watching the needle... 
bp auscultations are not accurate unless you hear the kortikoff sounds.


----------



## emtwacker710 (Dec 20, 2007)

well, I'm saying it helps, if you can hear a bit and combine that with the needle you can get pretty accurate


----------



## Ridryder911 (Dec 20, 2007)

emtwacker710 said:


> well, I'm saying it helps, if you can hear a bit and combine that with the needle you can get pretty accurate



Sorry, that is just incorrect. What you are seeing is pulsations of the artery or even contractions of the muscle and any movement. Again, let's just stick to performing it correctly. 

R/r 911


----------



## Nocturnatrix (Dec 21, 2007)

it could be your stethoscope.... some of them are really hard to hear anything from!


----------



## BossyCow (Dec 21, 2007)

"Tis a poor workman who blames his tools"


----------



## thowle (Dec 21, 2007)

Ridryder911 said:


> 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.



That's something good to remind yourself -- I never really though that far ahead into that, I can sure see how that would come in handy.


----------



## MSDeltaFlt (Dec 21, 2007)

Like everyone said, practice.  Bare in mind that even seasoned providers know that the "P" on the gear shift works just as good as the "D".  I have no problem pullin that bad boy over.  I've even been known to turn ALL the environmental noise off a time or two.  As in: AC, Sx, turn the flush NRM down to 15 L/M.  Rado - off.  Turn the whole damn truck off if need be.

The thing is, yes, you need to get your skills down pat.  EVERY skill.  Basic skills.  Even the skill of thinking outside the box.

I don't mean to be rude.  On the contrary, I'm concerned FOR you.  Going from Basic school to finishing medic school in a year tells me you have NO experience.  That's the one thing that cannot be taught.  Practice, practice, practice until you're blue in the face and then practice some more.

The best medics have strong basic skills.

Good luck.


----------



## disassociative (Dec 21, 2007)

I could not live without my Littman.

Anyways, unlike airways, and IV's--this is a skill you can practice at home. Practice taking pressures on your friends and family members. Some people have good pulses; others you have to really listen for; practice, practice practice.

Tip: Ask your medical/ER director at a local facility if you can spend a day in the 
      emergency room taking vitals. There is no shame in needing a little practice; 
      I still seek every learning opportunity I can get. Ask your partner if they
      have any tips to offer; I'm sure they would be more than happy to help you.


----------



## cakilcrease (Jan 6, 2008)

they make stethescopes for the hard of hearing where the pressure is more amplified... they are more expensive but worth it


----------

