# Taking BP and pulse in the ambulance



## VTEMT86 (Mar 1, 2010)

Hello! I started working with a town close to me as an attendant (someone who is certified in CPR but is in an EMT-B class). All the calls we get are 911 calls. I was taught about a month ago how to take blood pressure and pulse by my crew chief. I can do both fine when I am on scene, but as soon I get in the ambulance I cannot hear/feel anything. Does anyone have any suggestions on how to get past the noise and all the bumping around so that I can take the BP and pulse en route?


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## JPINFV (Mar 1, 2010)

If possible, practice with your seatbelt on. This will get you used to operating how you should be, even if it's not how most people operate. At least for me, I care a bit less about bumps when I know that I'm strapped in.

Rest your feet on the undercarriage of the gurney if possible instead of the floor of the ambulance.

I always rest the patient's arm on the top of my thigh. This cuts out a lot of noise artifact because the leg is a much better insulator than the gurney.

The last thing I can think of off the top of my head is to clench your jaw if you're having trouble hearing. The mandable and muscles protrude slightly into the auditory canal which will make a better seal around your stethoscope. Don't believe me? Stick your fingers into your ears and clinch your jaw.


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## reidnez (Mar 4, 2010)

All the above is excellent advice.

Also, are you using the cheap stethoscope the service generally provides? If so, I'd strongly invest in purchasing a decent one for yourself. You don't have to spend $150 on Littmann to have a decent piece of gear. I read a couple of lab tests which electronically compared different models, before I bought mine. The conclusion I drew was this: there is *BIG* difference in transmission of sound between a $5 steth and a $25 steth, while there is a pretty small difference between a $25 steth and a $150 steth. Thus, the middle-of-the road models are by far the best value for us--we're not cardiologists, we just need BP and lung sounds.

I always had trouble getting BP's with the Chinese-made, generic stuff that schools and ambulance services provide, possibly because I have moderate hearing loss. I spent $25 on my own (Omron Sprague-Rapport) and it was definitely worth it. Just my 2 cents.


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## njff/emt (Mar 7, 2010)

For pulse, obviously go for radial, sometimes when your bouncing around you need to squeeze a little harder but not too much., If you have no luck there move up the arm and use the brachial as last resort, you could also use the other arm if you have no luck there either., As for BP, one trick I use is placing the scope under the cuff right on top of the brachial artery and pump the cuff up, if you hit the right spot you should be able to hear it with little to no problems.


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## EMSLaw (Mar 7, 2010)

reidnez said:


> Also, are you using the cheap stethoscope the service generally provides? If so, I'd strongly invest in purchasing a decent one for yourself. You don't have to spend $150 on Littmann to have a decent piece of gear. I read a couple of lab tests which electronically compared different models, before I bought mine. The conclusion I drew was this: there is *BIG* difference in transmission of sound between a $5 steth and a $25 steth, while there is a pretty small difference between a $25 steth and a $150 steth. Thus, the middle-of-the road models are by far the best value for us--we're not cardiologists, we just need BP and lung sounds..



You can read through the many threads that discuss "what is the best steth?"  I think we recently went from the $9 models to the $5 models to save money, but personally, I think the biggest reason to have your own scope is because who knows where those other ones in the back of the rig have been. 

That being said, unless you lose or break it, your stethoscope will last years, so I didn't see any reason not to invest a little money in a good one.  And the dual-lumen tubing on the higher-end models does make a difference, as far as I can tell.  I'd stay away from a sprague, because the tubes bump together while you're in motion, and that can give a lot of artifacts.  

Try to get at least one set of vitals before you start moving, that will give you a good baseline.


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## TraprMike (Mar 8, 2010)

well, I tryed all these methods.. feet on streatcher, feet off floor.  can't hear crap..  and something simple as resperations.. bouncing around  on streatcher. jiggling of chest parts... (nice way of saying fat and boobs) makes it hard to detect the resp's... ahhh... going crazy..


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## ExpatMedic0 (Mar 8, 2010)

Ask your supervisor or EMT partner how to take a B/P by palpation. Normally this is only done when its way to noisy or we have trouble getting a B/P. Taking a B/P can be difficult in the back of an ambulance with lights and sirens or on a noisy scene of a MVC. In addition to that keep practicing on what the above people mentioned. Its better to get a B/P with your ears, but there is no shame in grabbing a quick one by palp sometimes. 

Also what state allows attendants to operate or staff an ambulance? Are you a 3rd rider or part of a 2 person crew?


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## TraprMike (Mar 8, 2010)

schulz said:


> Ask your supervisor or EMT partner how to take a B/P by palpation. Normally this is only done when its way to noisy or we have trouble getting a B/P. Taking a B/P can be difficult in the back of an ambulance with lights and sirens or on a noisy scene of a MVC. In addition to that keep practicing on what the above people mentioned. Its better to get a B/P with your ears, but there is no shame in grabbing a quick one by palp sometimes.
> 
> Also what state allows attendants to operate or staff an ambulance? Are you a 3rd rider or part of a 2 person crew?



???


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## ExpatMedic0 (Mar 8, 2010)

I want to know if he is part of a 2 guy crew (just himself and his EMT partner) or if he is a 3rd person riding with a 2 man EMS crew. 
If its just him and his EMT partner I want to know what state allows that


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## TraprMike (Mar 8, 2010)

ah,, ok,,, getting late... in MN it's a 2 EMT gig. at least.. we try to have 3, but sometimes it's not necessary. _what state allow a First Responder and EMT-B as a legal ambulance??_
nevermind, I think I'll start a new thread about this..


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## Tincanfireman (Mar 8, 2010)

VTEMT86 said:


> Hello! I started working with a town close to me as an attendant (someone who is certified in CPR but is in an EMT-B class). All the calls we get are 911 calls. I was taught about a month ago how to take blood pressure and pulse by my crew chief. I can do both fine when I am on scene, but as soon I get in the ambulance I cannot hear/feel anything. Does anyone have any suggestions on how to get past the noise and all the bumping around so that I can take the BP and pulse en route?


 
Another method is to place your hand under the patient's elbow and (gently!) hyperextend the elbow upwards.  This will sometimes help in capturing pulse sounds.  Also, keep your tubing straight and neat; nothing like sphygmomanometer noise to mask a pulse.


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## EMTinNEPA (Mar 8, 2010)

Usually what I will do is rest the patient's arm on my thigh, gently hyper extending the elbow.  Then I will apply the sphygmomanometer and palpate the brachial pulse.  Wherever I feel it, that's where I put the head of the stethoscope.  I then use my hand to seal the entire diaphragm of the stethoscope against the patient's skin and take their pressure.  99.99% of the time I have no problem auscultating a blood pressure with this method.  Sometimes you just have to take one by palp.


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## Bloom-IUEMT (Mar 13, 2010)

EMTinNEPA said:


> Usually what I will do is rest the patient's arm on my thigh, gently hyper extending the elbow.  Then I will apply the sphygmomanometer and palpate the brachial pulse.  Wherever I feel it, that's where I put the head of the stethoscope.  I then use my hand to seal the entire diaphragm of the stethoscope against the patient's skin and take their pressure.  99.99% of the time I have no problem auscultating a blood pressure with this method.  Sometimes you just have to take one by palp.



Lol so basically you just do it like you are supposed to do. B) I kept trying to do it using the carotid and it wasn't making the patients very happy.


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## JPINFV (Mar 13, 2010)

Bloom-IUEMT said:


> I kept trying to do it using the carotid and it wasn't making the patients very happy.


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## Bloom-IUEMT (Mar 13, 2010)

JPINFV said:


>



Wait...what? :wacko:  You have to use the carotid when you take BP using the neck right? Lol joking. 

I have the same problem though. I usually watch for the bounce of the sphygmomanometer needle that begins with systolic and stops at the diastolic.


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## JPINFV (Mar 13, 2010)

Is the image showing up for anyone else? When I checked the thread again, it didn't load the hotlink for me...


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## Meursault (Mar 13, 2010)

Not to promote *THE STICKY THAT I WROTE TO COVER COMMON QUESTIONS* or anything, but 


MrConspiracy said:


> *BLS vitals:*
> http://www.emtlife.com/showthread.php?t=5997 and http://www.emtlife.com/showthread.php?t=5909 Tips for taking BP and other vitals in the back of an ambulance
> http://www.emtlife.com/showthread.php?t=5474 Another thread about automatic BP monitoring; reasons why you shouldn't rely on it
> http://www.emtlife.com/showthread.php?t=12749 BP and mastectomies
> ...


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## teenageremt (Mar 15, 2010)

if having trouble finding a radial pulse sometimes you might want to make sure you have on the right glove size.  I use to always were large gloves and then i moved down to medium.  They were a little tighter on my hand and make it easier to feel the pulse.


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## Bloom-IUEMT (Mar 15, 2010)

MrConspiracy said:


> Not to promote *THE STICKY THAT I WROTE TO COVER COMMON QUESTIONS* or anything, but



I actually found that sticky you posted after the fact.....that is REALLY helpful by the way.  The powers that be should organize a sort of categorized table of helpful and informative posts that newcomers (and old comers, ha ha ziiing ) can reference before posting on the forums.  everything is very disjointed and disorganized now and the search function works as well as 1996 yahoo.com did.  Maybe we could put all those threads in a table format a top of the main page or something? Idk just a thought...Ive learned more perusing your organized sticky in one night than I did aimlessly sifting through the forums for several weeks.


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## EMTinNEPA (Mar 16, 2010)

Bloom-IUEMT said:


> Lol so basically you just do it like you are supposed to do. B) I kept trying to do it using the carotid and it wasn't making the patients very happy.



There are times when "by the book" works best ^_^


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## Sizz (May 6, 2010)

MrConspiracy said:


> Not to promote *THE STICKY THAT I WROTE TO COVER COMMON QUESTIONS* or anything, but



Thank you for this article!


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## Sizz (May 6, 2010)

Originally Posted by MrConspiracy  View Post
BLS vitals:

http://www.emtlife.com/showthread.php?t=5997 and http://www.emtlife.com/showthread.php?t=5909 Tips for taking BP and other vitals in the back of an ambulance
http://www.emtlife.com/showthread.php?t=5474 Another thread about automatic BP monitoring; reasons why you shouldn't rely on it
http://www.emtlife.com/showthread.php?t=12749 BP and mastectomies
http://www.emtlife.com/showthread.php?t=12656 A short thread on dialysis graft/fistula sites. Useful if you work for a private.

    Pulse points: I've seen a few short threads, but I'll summarize. Practice when not at work, and if you're really unsure and they don't look dead, auscultate (over the heart, that is). For practice, it helps to start with someone skinny and, once you know where everything is, to try a variety of patients. 


Edit sorry this one above to be clear


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## esmcdowell (May 11, 2010)

get on as many runs as you can for practice. what really helped me was watching for the needle bounce and stablizing the pt's arm on my thigh.

If you keep having troube there is a "simple" solution, the ZOLL M-series....automatic NIBP and pulse/SaO2


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## Frozin (May 13, 2010)

TraprMike said:


> well, I tryed all these methods.. feet on streatcher, feet off floor.  can't hear crap..  and something simple as resperations.. bouncing around  on streatcher. jiggling of chest parts... (nice way of saying fat and boobs) makes it hard to detect the resp's... ahhh... going crazy..



I thought I was the only one, I've done 2 days in a rig and have all the same trouble as you, so your not alone.  I think it is just a thing that requires more experience.

Of course the company I work for gave me a cheap steth, I think i better go get a real one


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## EMT-Tony (May 17, 2010)

I can definitely relate to the problems regarding the BP in the back of a rig, what I was advised was just what ever method you use, i.e. needle jumps, monitor, or the good ol' way with a steth, just be consistent, if you get baseline with needle jumps get your next sets the same way.


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## Sandog (May 18, 2010)

Frozin said:


> I thought I was the only one, I've done 2 days in a rig and have all the same trouble as you, so your not alone.  I think it is just a thing that requires more experience.
> 
> Of course the company I work for gave me a cheap steth, I think i better go get a real one



Tools of the trade are always a good investment. May I share a link on scope reviews?

http://www.forusdocs.com/reviews/Acoustic_Stethoscope_Review.htm


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## clibb (May 18, 2010)

Bloom-IUEMT said:


> Wait...what? :wacko:  You have to use the carotid when you take BP using the neck right? Lol joking.
> 
> I have the same problem though. I usually watch for the bounce of the sphygmomanometer needle that begins with systolic and stops at the diastolic.



I usually put the BP cuff around the neck and palp the carotid pulse 

I'm still trying to master the skill of taking a BP in a moving ambulance. I was told to either close my eyes and to have the patients arm on my thigh when I'm taking BP.


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## JPINFV (May 18, 2010)

clibb said:


> I usually put the BP cuff around the neck and palp the carotid pulse




Ah, the Kevorkian scarf...


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## Sandog (May 19, 2010)

Forgive me for asking if the reason is obvious, but why are digital cuffs not used in the ambulance?


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## Frozin (May 19, 2010)

Well after about a 5 days in the rig I've gotten a lot better.  I'm more confident in my BP taking.  I still have some problems finding weak pulses while the rig is going.  

I was told to start bumping the cuff up while coming to a stop light and when then take it while the rig is stopped, which is quite helpful.


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## Shishkabob (May 20, 2010)

Sandog said:


> Forgive me for asking if the reason is obvious, but why are digital cuffs not used in the ambulance?



Some places have NIBP, some places don't, it really depends on if your company is willing to pony up the dough.

However, every first BP should be manual.


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## alphatrauma (May 21, 2010)

For stable patients, get a BP before you leave the scene and one right before you unload at your destination...  grabbing NIBP vitals from the ER monitors can get you by in a pinch.


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## JPINFV (May 21, 2010)

This just hit me... what's the utility of grabbing a NIBP at the hospital? After all, you're at the hosptial. It's not affecting any of your decision making since, well, you're already handing the patient over.


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## Hal9000 (May 21, 2010)

JPINFV said:


> This just hit me... what's the utility of grabbing a NIBP at the hospital? After all, you're at the hosptial. It's not affecting any of your decision making since, well, you're already handing the patient over.



I've seen some lazier and less scrupulous emergency medical professionals take all the vitals from the hospital because they'd not gotten their own.  However, I doubt that was the point.


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## emtstudent04 (May 21, 2010)

I tend to have a problem getting vitals in the ambulance especially when your going Code 3 or you hit a ton of bumps in the road. It's to noisy so i will usually just palp a pressure if i can't hear it after two or three trys. I will usually try to get a BP when im at a stop light because if your quick at it and you have enough time you can just knock it out while your stopped. I keep hearing that getting vitals such as BP and checking there pulse in the rig while your moving just takes time and a little experiance. I'm sure after awhile of doing it you'll learn to drown out the sounds around you as much as possible.


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## vienessewaltzer (May 24, 2010)

I just learned how to do BP the other day in my EMT-B course.  It seems rather simple, but doing it on a rig with chaos/traffic noise pollution seems pretty tough.  Excited to do it, thought!


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## clibb (May 24, 2010)

vienessewaltzer said:


> I just learned how to do BP the other day in my EMT-B course.  It seems rather simple, but doing it on a rig with chaos/traffic noise pollution seems pretty tough.  Excited to do it, thought!



It's nothing like the class-room setting. I remember when I learned to do BP for the first time. My dad was so pissed that I kept taking his blood pressure all the time, he hid my stethoscope.


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## Fbarba123 (May 30, 2010)

I don't know if it's been mentioned about BP and Pulse. But when i'm taking BP, I freeze the needle and count the lub dub's i hear for six seconds, then multiply by ten, and then continue my BP.

I now has a pretty accurate pulse, and of course bp


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## Focallength (May 30, 2010)

Fbarba123 said:


> I don't know if it's been mentioned about BP and Pulse. But when i'm taking BP, I freeze the needle and count the lub dub's i hear for six seconds, then multiply by ten, and then continue my BP.
> 
> I now has a pretty accurate pulse, and of course bp



Thats a pretty fast and loose way of taking BP, NR minimum is 15 seconds and you never watch for needle bounce, your reading can be off as much as 20 points this way, a patient could have a BP of 80/70 but watching for needle bounce you may read it as 100/70 which is a huge difference, imagine assuming your patients BP was 100/70 only to find out that your patient has been i decompensated shock for the full 20 minute ride to the hospital.. As far as the 6 second times 10 rate again you get alot of room for error. We examined it once and found that using 6 seconds times 10 had an average discrepancy of 10 BPM as oppsed to 15 times four had an average of 3-4 and 30 times 2 had an average discrepancy of only 1-3 compared to a full 60 seconds.

if you cant hear the pulse just go with the palpation method of obtaining a BP, 90% of the time you uses this technique anyway.

no offense to your technique but it seems fairly risky to me.


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## Fbarba123 (May 30, 2010)

Focallength:

I don't count needle bounce for my BP, as you stated, it's way to risky. i just freeze the needle and count lub dubs for a few seconds for a pulse, then unfreeze the needle to continue my bp by means of ascultation. I do this only when i'm strapped for time. most of the time, i take pulse radially.


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