# Breath sounds/BP



## swinf1 (Jul 27, 2017)

Any tips for trying to listen for breath sounds and getting a manual BP in the back of an ambo that's bouncing all over the streets?


----------



## luke_31 (Jul 27, 2017)

bandaidslinga said:


> Any tips for trying to listen for breath sounds and getting a manual BP in the back of an ambo that's bouncing all over the streets?


Wait for a stop sign or stop light. If you're getting bounced around that crazy, tell your partner to slow down, smooth is fast, quick is not.  Experience will get you able to hear the BP better, try putting your feet flat on the ground.  You need to minimize the movements that you do while listening to the BP


----------



## Underoath87 (Jul 27, 2017)

luke_31 said:


> Wait for a stop sign or stop light. If you're getting bounced around that crazy, tell your partner to slow down, smooth is fast, quick is not.  Experience will get you able to hear the BP better, try putting your feet flat on the ground.  You need to minimize the movements that you do while listening to the BP



Putting your feet on the ground channels more vibration sounds up through your own body.  Try to lift your feet up to isolate yourself from the truck (so that you're only touching the paded bench) seat to hear better.


----------



## luke_31 (Jul 27, 2017)

Underoath87 said:


> Putting your feet on the ground channels more vibration sounds up through your own body.  Try to lift your feet up to isolate yourself from the truck (so that you're only touching the paded bench) seat to hear better.


I knew it was one of those, it's been so long since I've done a manual BP in the back of the truck I forgot which way it was and went with trying to keep steady and not be moving


----------



## StCEMT (Jul 27, 2017)

I've never found it to really make a difference. If it's that bad, palp it.

Lung sounds do on scene and in the back of the truck won't be an issue unless you are checking up effects of your treatment. Then you just work with what you got.


----------



## captaindepth (Jul 27, 2017)

Practice Practice Practice. For BPs I've found the most important things are to keep the pts arm from touching the stretcher, keeping anything from bouncing on the tube of your stethoscope (for example, the tube from the gauge to the cuff, the tube from the cuff to the hand pump, EKG cables, IV lines, Oxygen tubing), I like to put just the balls of the feet of my feet on the floor of the ambulance and rest the pts arm over my knees (this acts like shocks for shock absorption), and like getting a manual BP any other time you should have good control of the air release valve so you don't miss the true systolic or diastolic beats.

Lung sounds are tough anywhere and take a lot of practice, being in the back of the ambulance doesn't help. Getting them on scene is great, especially when can listen to posterior lung sounds - easiest place to start identifying abnormal lung sounds IMO. If you cant get to their back its all about good stethoscope placement and that can be challenging on obese patients (there's usually a lot of lifting and wiggling through body folds). I use the upper anterior chest wall and the anterior/mid/posterior axillary area on larger patients that are seated on the he stretcher. It's a good idea to get a baseline idea for a patients lung sounds while on scene (not driving) and then you can start to anticipate how they should change in relation to your treatment. 

Waiting for stop signs, smooth rides, and hoping for a better time to get V/S is putting too much faith in an unreliable scenario. What if you are transporting the patient emergently? No stop signs, red lights, or smooth rides in that case and you better still walk in with accurate V/S. Practice Practice Practice.


----------



## GMCmedic (Jul 27, 2017)

Good stethoscopes go a long way. I also took the ear buds off my scope and reversed them. Makes for a better fit in my opinion. 

Sent from my SAMSUNG-SM-G920A using Tapatalk


----------



## agregularguy (Jul 27, 2017)

GMCmedic said:


> Good stethoscopes go a long way. I also took the ear buds off my scope and reversed them. Makes for a better fit in my opinion.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk



+1 on a good scope. I lost my scope on a call a few weeks back, and have been using whatever scopes are on the trucks, and it makes a world of difference.


----------



## Medic27 (Aug 11, 2017)

From my experience I had an entry-level stethosocope, I decided to upgrade.. I went big and bought an expensive one, but I am weird like that... It pairs to my iphone .. Like I said, I spent a little much I can also turn up the sensitivity. This is awesome, but I think a more mid-tier higher end stethoscope could help if you are still having problems.


----------



## bakertaylor28 (Aug 12, 2017)

If the bus is bouncing all over the street it either means A) the shocks need to be replaced or B) Someone had too many energy drinks while driving.


----------



## bakertaylor28 (Aug 12, 2017)

But seriously, one of the things that can help with this is to make sure you place your stethoscope either more or less laterally, as to make sure that the artery is properly covered. That said, the question becomes WHY on God's green earth your using a manual cuff to begin with. I mean it's a nice backup skill but still- not something that I think we should be doing in practice, unless this is the 1980s and a certain president is still in Arkansas.


----------



## DesertMedic66 (Aug 13, 2017)

bakertaylor28 said:


> But seriously, one of the things that can help with this is to make sure you place your stethoscope either more or less laterally, as to make sure that the artery is properly covered. That said, the question becomes WHY on God's green earth your using a manual cuff to begin with. I mean it's a nice backup skill but still- not something that I think we should be doing in practice, unless this is the 1980s and a certain president is still in Arkansas.


A lot of areas do not have NiBP. We got them about 2 years ago. I will say that even if you are using a NiBP you should still be taking manual pressures often. In the event you have a failure or the NiBP will not give you a reading, if you haven’t taken a manual BP inside a moving ambulance in 10 years you are going to suck at it.


----------



## elshion (Aug 13, 2017)

DesertMedic66 said:


> I will say that even if you are using a NiBP you should still be taking manual pressures often. In the event you have a failure or the NiBP will not give you a reading, if you haven’t taken a manual BP inside a moving ambulance in 10 years you are going to suck at it.



This. Always have a backup, and practice with the backup to make sure you can use it when needed. You WILL need it


----------



## bakertaylor28 (Aug 13, 2017)

DesertMedic66 said:


> A lot of areas do not have NiBP. We got them about 2 years ago. I will say that even if you are using a NiBP you should still be taking manual pressures often. In the event you have a failure or the NiBP will not give you a reading, if you haven’t taken a manual BP inside a moving ambulance in 10 years you are going to suck at it.



Interesting, and what, next your going to tell me that not all areas have pulseox or EtCO2 either? I mean one would think that NiBP would be pretty much standard everywhere considering the fact that you can get them for a little more than the cost of the manual. That said, I agree that one should always keep their back up skills honed. One never knows what situation one might find themselves in.


----------



## DesertMedic66 (Aug 13, 2017)

bakertaylor28 said:


> Interesting, and what, next your going to tell me that not all areas have pulseox or EtCO2 either? I mean one would think that NiBP would be pretty much standard everywhere considering the fact that you can get them for a little more than the cost of the manual. That said, I agree that one should always keep their back up skills honed. One never knows what situation one might find themselves in.


Our BLS units do not have SpO2....

There are actually still areas that do not have waveform EtCO2. 

The only reason we finally have NiBP is because they are on the LP15 that we upgraded to.


----------



## luke_31 (Aug 13, 2017)

bakertaylor28 said:


> Interesting, and what, next your going to tell me that not all areas have pulseox or EtCO2 either? I mean one would think that NiBP would be pretty much standard everywhere considering the fact that you can get them for a little more than the cost of the manual. That said, I agree that one should always keep their back up skills honed. One never knows what situation one might find themselves in.


Don't need to have pulse ox, at least at the BLS level at all. You should be relying on a proper assessment to tell if the patient needs oxygen or not. I get that hospitals sometimes like to know what their oxygen saturation is before oxygen was administered, but in the context of prehospital care it's not important. If a patient needs oxygen you give it to them, would you hold off on giving oxygen if the patient had a 99% oxygen saturation, yet was complaining of SOB. That's one of the big reasons that some counties don't let EMTs use pulse ox.


----------



## DesertMedic66 (Aug 13, 2017)

luke_31 said:


> Don't need to have pulse ox, at least at the BLS level at all. You should be relying on a proper assessment to tell if the patient needs oxygen or not. I get that hospitals sometimes like to know what their oxygen saturation is before oxygen was administered, but in the context of prehospital care it's not important. If a patient needs oxygen you give it to them, *would you hold off on giving oxygen if the patient had a 99% oxygen saturation, yet was complaining of SOB*. That's one of the big reasons that some counties don't let EMTs use pulse ox.


I have withheld oxygen to patients like that before. You have to take the whole patient assessment into account and not just look at a complaint and a number. Is this patient having chest pain while breathing and that is the reason for the SOB. Is oxygen going to benefit the costochondritis patient? Probably not. Or a COPD patient has a normal SpO2 of 92% who is now at 80% but has no complaints of SOB. 

SpO2 does have a place in EMS but it one must remember the issues with it and also use it in the whole clinical picture.


----------



## luke_31 (Aug 13, 2017)

DesertMedic66 said:


> I have withheld oxygen to patients like that before. You have to take the whole patient assessment into account and not just look at a complaint and a number. Is this patient having chest pain while breathing and that is the reason for the SOB. Is oxygen going to benefit the costochondritis patient? Probably not. Or a COPD patient has a normal SpO2 of 92% who is now at 80% but has no complaints of SOB.
> 
> SpO2 does have a place in EMS but it one must remember the issues with it and also use it in the whole clinical picture.


Exactlly


----------



## bakertaylor28 (Aug 13, 2017)

luke_31 said:


> Don't need to have pulse ox, at least at the BLS level at all. You should be relying on a proper assessment to tell if the patient needs oxygen or not. I get that hospitals sometimes like to know what their oxygen saturation is before oxygen was administered, but in the context of prehospital care it's not important. If a patient needs oxygen you give it to them, would you hold off on giving oxygen if the patient had a 99% oxygen saturation, yet was complaining of SOB. That's one of the big reasons that some counties don't let EMTs use pulse ox.



However, in that Scenario, is O2 really going to help anything in the long run??? Most probably not, absent one of the few exceptions to things, and even then its only going to be marginally effective. (such as CO poisoning causing a false O2 sat reading.)  Notably, the trend has been recently to start becoming a bit more discriminate with O2 admin. It's also information we want to have in the event of an arrest, because when placed in context of the other pre-arrest vitals it can POINT to some of the H's and T's (i.e. the reversible causes of cardiac arrest)  a little more strongly than others. For example, if we KNOW that a patient had a 99% O2 sat and we end up with an arrest, we have a pretty good idea that most probably hypoxia DIDN'T cause the arrest, absent more specific information that might prove as more an exception to the rule as to why the sat might be a false-high value.


----------



## Akulahawk (Aug 13, 2017)

bakertaylor28 said:


> Interesting, and what, next your going to tell me that not all areas have pulseox or EtCO2 either? I mean one would think that NiBP would be pretty much standard everywhere considering the fact that you can get them for a little more than the cost of the manual. That said, I agree that one should always keep their back up skills honed. One never knows what situation one might find themselves in.


Not all areas allow all service levels to have SpO2 or EtCO2 and typically if a service level can't have one of those, then they're also not going to get NIBP. In my career, I (conservatively speaking) have done just over 21,000 _manual_ vital signs measurements, with the majority of those being done in the back of an ambulance and a good number of those while travelling RLS on some fairly bumpy roads (many of California's roads are horrible). So, I got very good at hearing Korotkoff sounds even through all that.

NIBP doesn't do all that well when the pulse is irregular or even irregularly irregular. I've seen it fail and retry several times in a _hospital_ because of an irregular pulse.


----------



## Jubal (Jul 7, 2018)

Manual bps should be taken BEFORE the ambulance rolls or at a stop.  We use nibps, but they fail a lot. If it's not a code 3, there's no reason to not get a manual at the scene.  If all else fails, palate.


----------



## Kevinf (Jul 7, 2018)

Jubal said:


> ... If all else fails, *palate*.



No thanks.


----------

