# Near disaster averted



## Gymchick (Nov 14, 2010)

...barely.  I am very new as an EMT. I went to a hospital to pick up a patient and I went to take his blood pressure, and as I put the cuff on his arm, a nurse said,  "No, not on that arm! He has a dialysis shunt on that arm! You could have killed him!"

Needless to say I was horrified. There was nothing posted in the area, no tags on his arm, saying not to take a BP on that arm; what he had on that arm was a bandaid over a cotton ball. (As a matter of fact there WAS a tag on his arm saying no known drug allergies, even though his chart said penicillin allergy, but we'll just let that one go. I took the NKDA tag off his arm.)

Now, I'm going to be honest - I did not know that you can't take a BP on the arm where a patient has a dialysis shunt. It's not in my textbook, and no teacher ever told me that, and no-one at my job ever told me that.

As soon as I got home I did a bunch of research on the internet to find out what else I should avoid, but I want to make sure I didn't miss anything. I already know that if a patient had a mastectomy you don't take the BP reading on that side.

So - three questions:

1.) From now on I am going to ask the patient's nurse which arm I can take a BP on before I take a BP, and I will always ask if the patient has a dialysis shunt, AND check their chart, before I take a BP; is there anything else I can do to ensure this doesn't happen again?

2.) What other conditions would prevent me from taking a BP? (Other than the obvious - fractured arm, gushing blood from that arm, etc.) I have heard conflicting opinions on what to do if they have a pacemaker implanted. 

3.) Any other advice for a new EMT on not making potentially lifethreatening mistakes?


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## 18G (Nov 14, 2010)

You should try to avoid taking a B/P in the arm that is on the same side as a mastectomy.

With the newer techniques of breast surgery it's said the issues of lymphedema are decreased but still advisable to just avoid the mastectomy side if possible. If the patient has bilateral mastectomy ask your patient if they had lymp nodes taken out on both sides or just one. If just one side use the side that did not have the lymp nodes taken out. 

The issue is this... when the lymph nodes are taken out there is less capacity for lymp drainage and the increased pressure from  the B/P cuff can cause lymphedema which results in pain and can lead to infection. Mastectomy patients are explained how to reduce lympedema and are assertive in telling you not to take a B/P in a certain arm.


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## reaper (Nov 14, 2010)

If the pt is a dialysis pt and is awake, ask them which are they do b/p's on. If they are not able to answer, look! A shunt or fistula is not hard to miss. 

A pacemaker is not a worry for b/p's. Always ask the pt or check the chart. Pts will know better then anyone else.


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## Gymchick (Nov 14, 2010)

I normally would ask a patient, but in this case he was A&0 times one and he could barely speak. He had no idea where he was or why he was there. All he knew was his name. 

Thanks for the advice!  Actually, I had been told that about a mastectomy before - but again, this was not in my textbook or told to me by an instructor or boss. A coworker told me this and I looked it up online to confirm.

Information like this REALLY should be in the curriculum - I mean, EMTs do BLS. We take vitals all day long. It is CRITICAL to know that taking a BP on the arm where they have a shunt or fistula or mastectomy could cause them harm!


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## Veneficus (Nov 14, 2010)

Gymchick said:


> I normally would ask a patient, but in this case he was A&0 times one and he could barely speak. He had no idea where he was or why he was there. All he knew was his name.
> 
> Thanks for the advice!  Actually, I had been told that about a mastectomy before - but again, this was not in my textbook or told to me by an instructor or boss. A coworker told me this and I looked it up online to confirm.
> 
> Information like this REALLY should be in the curriculum - I mean, EMTs do BLS. We take vitals all day long. It is CRITICAL to know that taking a BP on the arm where they have a shunt or fistula or mastectomy could cause them harm!



Unfortunately it is not always possible to avoid taking a BP on a patient because they have bilateral lymph issues or bilateral fistuals. 

Best you can do is look for them and try to avoid it, if not you have to do what you have to do.

In the case of fistula, the newer it is the more danger there is, once arterialization is complete, it is not as bad.


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## LucidResq (Nov 14, 2010)

Gymchick said:


> Needless to say I was horrified.


Although it's an uncomfortable experience, you will likely be very diligent about this in the future and not make the same mistake twice. 



Gymchick said:


> 3.) Any other advice for a new EMT on not making potentially lifethreatening mistakes?


Be proactive in your learning, learn from your mistakes, and ask lots of questions of those more educated and/or experienced than you. You can learn a lot by asking your patients questions too... especially those with chronic conditions. Although many don't manage their health as well as they should, some are very educated in their conditions and all of them can at least give you a first-hand perspective of what having that disease is like.


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## Aidey (Nov 14, 2010)

Veneficus said:


> Unfortunately it is not always possible to avoid taking a BP on a patient because they have bilateral lymph issues or bilateral fistuals.
> 
> Best you can do is look for them and try to avoid it, if not you have to do what you have to do.
> 
> *In the case of fistula, the newer it is the more danger there is, once arterialization is complete, it is not as bad.*



That basically. Some patients have "dead"* fistulas/grafts that you can take a BP over without an issue, often the patient will know. 

Honestly, the nurse was being a little melodramatic. Yes, taking a BP on that arm isn't good for a dialysis access, but it isn't an instant death issue. 


* a dead fistula/graft is one that doesn't work anymore for whatever reason.


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## Gymchick (Nov 14, 2010)

She was one of those generally crabby miserable nurses who make our life so much more pleasant,:glare:, but she was right to be angry in this case - the last thing a healthcare provider wants to do is hand over their patient to someone who might make a really bad mistake.

I asked the paramedic I was with (who had been out in the hall getting the paperwork, face sheet etc.) and he actually said yes - putting a BP cuff on a patient on the arm where the patient has a dialysis shunt could cause the patient to have an arterial bleed in his arm. That's why I was so freaked out.

Oh well, as I read on someone's blog, "A good EMT won't make the same mistake twice." The thing that worries me is making the mistake in the first place - and causing someone harm. That's what I'm trying to avoid.


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## Aidey (Nov 14, 2010)

Ok, I used to work in a dialysis clinic. The biggest risk is causing structural damage to the fistula. Bleeding is possible, but is more of a secondary concern, especially if the access wasn't used that day. The risk of bleeding comes from re-opening the hole that was made by the needle during treatment. It is possible to rupture a fistula, but if it is a mature fistula I think you would probably have to pump the BP cuff up all the way. As Vene said, the newer the fistula the higher the risk of causing damage.


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## Veneficus (Nov 14, 2010)

Gymchick said:


> The thing that worries me is making the mistake in the first place - and causing someone harm. That's what I'm trying to avoid.



Let me set your mind at ease.

You will make mistakes. 

We all made/make mistakes, nobody here is perfect, but you learn from them and move on.


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## DrParasite (Nov 14, 2010)

Gymchick said:


> ...barely.  I am very new as an EMT. I went to a hospital to pick up a patient and I went to take his blood pressure, and as I put the cuff on his arm, a nurse said,  "No, not on that arm! He has a dialysis shunt on that arm! You could have killed him!"


oh please.  you aren't going to kill him.  You won't get an accurate number, but it isn't an immediate death sentence like she is making it out to be.

When I was doing my orientation for my job, we encountered a patient who needed dialysis on a 911 call.  I was taking his BP, and kept hearing weird noises when I tried to hear the beats.  After my FTO pointed out why I couldn't hear the right sounds (taking a BP on a side that got dialysis), I got it on the other arm.  The patient didn't die, and didn't suffer any negative outcomes.  The only issue was I was embarrassed for not realized the problem sooner.

We all make mistakes.  The important part is to not repeat the same mistakes.


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## nemedic (Nov 14, 2010)

There's always taking the thigh/biggun BP cuff and getting BP from someone's thigh.


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## EMSLaw (Nov 15, 2010)

nemedic said:


> There's always taking the thigh/biggun BP cuff and getting BP from someone's thigh.



Not as easy as it sounds, though.  Especially if the patient is obese or just has large thighs.


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## LucidResq (Nov 15, 2010)

Or really tight pants XD


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## EMSLaw (Nov 15, 2010)

LucidResq said:


> Or really tight pants XD


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## Veneficus (Nov 15, 2010)

EMSLaw said:


>



Are you sure those are men?


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## Gymchick (Nov 15, 2010)

EMSLaw said:


>



My eyes! My eyes! Must bleach my brain with clorox, stat! 

As for the original topic - Jeez, I wish there were a universal answer to...everything. My paramedic AND the nurse both made it sound as if the patient would definitely have died if I took a BP on the arm with the renal dialysis shunt. But some of you are saying that is not correct. 

Either way - I certainly will never do it again!


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## Aidey (Nov 15, 2010)

That is what we are saying. Basically, it isn't good for the patient, but it isn't a death sentence either. Think about this, a tourniquet is used on that arm to insert the needles in most patients (just like an IV).

An example in the mastectomy patient - I once did a BP on the patient's "wrong" side. Her other arm was broken. At the hospital they got her undressed and did them on the leg. She was in down snow pants and on a back board, so we couldn't get them off easily in the amb.


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## MediMike (Nov 16, 2010)

Just to gang up on your angry RN and your possibly confused paramedic...Never in all my years have I ever heard of killing someone with a BP cuff. If you circumferentially compress the fistula you can cause damage to it...but I agree with the melodramatic observation made earlier


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## Minnick27 (Nov 24, 2010)

I worked in dialysis for 7 years. There are some people that have very delicate fistulas simply due to the age of the fistula or other underlying factors, but they are rare. The biggest issue you have is if you compress the access too much you can clot it off and then they have to get it unclotted, which is a minor procedure, but not pleasant. You shouldn't be scared off the access, just be aware. I had a partner who was in the back of the truck and the access started to bleed and she didn't apply pressure because she was so afraid of hurting the access.


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## fast65 (Nov 24, 2010)

Just a trick that I like to use is to ask the patient "so, is there any side you'd prefer that I take your blood pressure on?". It just kind of helps me cover my basis if I forget to ask about any dialysis shunts or mastectomies. It actually saved me when doing an IV about a month ago when I asked this elderly woman "is there any side that you would prefer me to get your IV on?" and she told me "the right arm please, I had a mastectomy on the left".


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## Aidey (Nov 24, 2010)

Minnick27 said:


> I had a partner who was in the back of the truck and the access started to bleed and she didn't apply pressure because she was so afraid of hurting the access.



*facepalm*

How did she think they got the bleeding to stop after the treatment?


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