# vitals when stable.



## ajax (Jul 1, 2010)

you work for a transport company, and just got handed a discharge for a pt who had leg surgery three days ago due to an infection. the patient has been doing well in hospital, healing well, no specific concerns. the patient is being discharged at 1700, and lives 65 miles away down a road notorious for its rush hour traffic. 

you settle into the back, and try to talk to your patient, but he's uninterested in talking. you get a set of baseline vitals. ask him a couple open ended questions, but only get one word answers, fill out your paperwork, and you're still only a quarter of the way there. you take a second set of vitals. no change. your patient is clearly a little annoyed with you. 

protocol states you take vitals every 15 minutes. how often do you take vitals for the rest of the call?


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## Shishkabob (Jul 1, 2010)

Ask if they mind the vitals being taken, and if they do, just don't take the vitals and mark it on your sheet.


I was transporting a cancer patient the other week... she refused to let us touch her/take vitals.  I marked it on my PCR that patient refused vitals, but that I continually monitored her status during transport.


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## LondonMedic (Jul 1, 2010)

EMS is :censored::censored::censored::censored: when it becomes driven by protocol at the expence of good clinical decision making.

(Although that's not to say that all in EMS have good clinical decision making)


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## MrBrown (Jul 1, 2010)

LondonMedic said:


> EMS is :censored::censored::censored::censored: when it becomes driven by protocol at the expence of good clinical decision making.
> 
> (Although that's not to say that all in EMS have good clinical decision making)



Brown was unable to get a blood pressure on an old chap the other day, and yet he wants to be allowed to swan out the sky in an orange "DOCTOR" jumpsuit hmmm ....... I dno 

Seriously, you should be taking vital signs in a stable patient at a regiular interval; every twenty minutes or so, in ED it's generally every half hour.

If you get in trouble for not doing it exactly to the letter of some blanket CYA protocol for barely spontaneously homeostasising Patient Transfer Officers then maybe its time to find a new job.


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## LondonMedic (Jul 1, 2010)

MrBrown said:


> Seriously, you should be taking vital signs in a stable patient at a regiular interval; every twenty minutes or so, in ED it's generally every half hour.


But this isn't an ED.

The patient is is stable and (hopefully) approaching their baseline level of health. They will have had their obs taken four times a day on a surgical ward and as soon as they leave your care won't have them taken again until the next time he comes in. If the medical team who have been looking after him for the last three days think that he'll survive without his obs being checked four times a day, what makes you think he won't survive 20 minutes without them?

By all means take obs if there's a clinical indication, but equally, there's no reason to take obs if there's no indication for it.


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## MrBrown (Jul 1, 2010)

LondonMedic said:


> By all means take obs if there's a clinical indication, but equally, there's no reason to take obs if there's no indication for it.



Exactly my thinking.  I have no good answer to your question except "its how its always been done" and once again, EMS seems to do something that goes against the grain of all other parts of medicine.

We are told to take VS as "clinically appropriate intervals" however I have seen in many of the American texts 10 minutes for unstable and 20 minutes for stable.


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## LondonMedic (Jul 1, 2010)

MrBrown said:


> We are told to take VS as "clinically appropriate intervals" however I have seen in many of the American texts 10 minutes for unstable and 20 minutes for stable.


Clinically appropriate intervals is exactly the right phrase. In very unstable patients, 10 minutes is just too long an interval - you might want to even go down to beat-to-beat IABP monitoring. In stable patients, 20 minutes is unnecessary and, arguably, does more harm than good.


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## Veneficus (Jul 1, 2010)

*to expand the OP and offer perspective*

The "normal" vital signs as we have come to know them as I understand were compiled by looking at the numbers of thousands if not 10s of thousands of patients over time before they were published originally.

Pediatricians then looked at what is "normal" for kids.

Now geriatricians look at what is normal for the old timers.

All of this has something in common. They all look at people who are in the doctors office or the hospital. Not exactly the center for health and wellness. (how many people go to either when they feel great and nothing is wrong?)

To take this one step further in the effort to analyze data, medicine then came up with a whole list of "normal" numbers and more is added regularly. (so much so in medical school we stopped trying to memorize all of the lab numbers there were so many)

It was during a visit to a London hospital and attending a M&M meeting there that I had a realization. (I like to call it a "eureka moment") We were reviewing the case of a trauma patient, an elderly woman who was 67. When the intensivist gave his report, he lamented that even though they "normalized" all her numbers in the ICU, she still died. The we heard from pathology.

Sometime before this in my medical education, I learned that the human organism aapts its metabolism and functions for continued survial. In doing so, "normal" is altered and a new "baseline" is established.

It occured to me that the goal of intensive treatment shouldn't be to "normalize" the pt. it should be to return them to as near "baseline" as possible.

But that is where it becomes tricky. On an unconcious patient, how do you determine "baseline?" I have not come across a satisfactory answer. But I do have a hypothesis. By completing an exhaustive exam (physical, social, etc) and identifying as much about the patient as possible, a reasonable estimate can be made and treatment adjusted.

EMS plays a vital link in this. Because without EMS, if the patient cannot respond appropriately, there would be no record of what conditions the pt lived in which would fill in the social history.

Did the patient smoke? Did EMS notice signs of it?

Was there food all around?

Home in disrepair?

Did the patient set up their dwelling or appear to have habits that would provide clues?

It is commonly said that in EMS providers develop hyperacute awareness of their surroundings. Life is not "House MD" there is not a team of doctors who are professional housebreakers on their spare time. Why is this information never documented or relayed by EMS? What would happen if it was?

Even the location a pt is found can be of benefit. We all know what goes on in various sections of town. 

As for how often to check vitals?

Well medicare/medicade in the US generally requires 2 sets of vitals to pay. So unless your organization is a charity, 2 sets at least would be a good idea.

On a critical patient, very often, I like the automated stuff to cycle about every 3 minutes or be constant.

On a stable patient, it depends on what is wrong with them, and what therapy were provided. I like a set a about 20-40 minutes after giving some PO meds for pain. Especially if I might need to give some more. 

When I was doing ann inhouse rheumatology rotation they were done every 4 hours, but I really only wanted to know about 2 times a day. (once when I came in, and once before I left)

I think a good rule of thumb in EMS is when you first encounter the pt and then after every significant treatment of the pts chief complaint or condition.


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## Aidey (Jul 1, 2010)

Our service requires two sets unless the transport is under a specific distance. Two sets means two pulses and two blood pressures. Beyond that it is what is indicated by the patients presentation (or something like that). I believe it is also recommended that we have a set of vitals within 5 minutes after giving a medication. 

I know there are also exceptions for critical patients, or if you are unable to obtain something for whatever reason. You just have to document it like "Unable to obtain BP by auscultation or palpation after 2 tries in each arm" or whatever.


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## MMiz (Jul 1, 2010)

I took vitals every 15 minutes on stable patients.  After the third set, on long transports, I'd ask the patient if they'd rather I didn't take a blood pressure and check for a pulse every fifteen minutes.  If that was the case I'd just count respirations and if the patient was alert and oriented if we were talking.  Then I'd grab one last set before we arrived at the hospital or at home.

I had some partners that would just write "patient refused" after their second set, and some that would just do one set.  When it came down to it I always felt that the minute of work (30 seconds on pulse/respirations, and 30 on BP) was worth it.


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## LondonMedic (Jul 1, 2010)

MMiz said:


> I took vitals every 15 minutes on stable patients.  After the third set, on long transports, I'd ask the patient if they'd rather I didn't take a blood pressure and check for a pulse every fifteen minutes.  If that was the case I'd just count respirations and if the patient was alert and oriented if we were talking.  Then I'd grab one last set before we arrived at the hospital or at home.


That's as protocol based as just taking them every 15 minutes anyway.


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## MrBrown (Jul 2, 2010)

Veneficus said:


> Sometime before this in my medical education, I learned that the human organism aapts its metabolism and functions for continued survial. In doing so, "normal" is altered and a new "baseline" is established.
> 
> It occured to me that the goal of intensive treatment shouldn't be to "normalize" the pt. it should be to return them to as near "baseline" as possible.



If only more people realised that very important fact.

I do wonder how many out there still infuse a gallon of fluid into trauma patients in an effort to get a systolic BP of 100 or 120 ... to name but one example.


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## Akulahawk (Jul 6, 2010)

Veneficus said:


> Sometime before this in my medical education, I learned that the human organism adapts its metabolism and functions for continued survival. In doing so, "normal" is altered and a new "baseline" is established.
> 
> It occured to me that the goal of intensive treatment shouldn't be to "normalize" the pt. it should be to return them to as near "baseline" as possible.
> 
> I think a good rule of thumb in EMS is when you first encounter the pt and then after every significant treatment of the pts chief complaint or condition.





MrBrown said:


> If only more people realised that very important fact.
> 
> I do wonder how many out there still infuse a gallon of fluid into trauma patients in an effort to get a systolic BP of 100 or 120 ... to name but one example.


Years ago, I have had some severe disagreements with my "boss" (who was a relatively new medic) over this very topic. One patient I had was, for all intents and purposes, unresponsive. She had been doing the Nausea/Vomiting/Diarrhea for 3 days with very poor PO intake of food or water. I took her VS and found that she was basically "textbook" normal... (I forget her meds, but beta blockers and whatnot wouldn't be too far out of the picture). Fortunately for me, she was in an assisted living environment and they had a record of her VS (taken 2x daily) going back months or more. She normally kicked along at about 180/120... on her meds. Yes, that's actually about correct for HER. I started a line and gave her small boluses as I deduced that she was in shock, from relative hypotension. During transport, about 750cc infused, she went from unresponsive to fully alert. The line went to KVO at that point. Her VS "improved" towards the upper end of the "normal" range...

Well, I got reamed (by my boss) for treating her as if she was a shock patient... because her vital signs were clearly normal. I just asked my boss what would happen if her blood pressure suddenly dropped about 60 points... She got more mad and I got an attaboy from the ED and the patient. I have absolutely no doubt that the ED was going to run tests to determine just how dehydrated she was and how to best rehydrate her. 

Anyway, the point is that if you recognize what is _normal for that patient_, you have a good baseline to work with. As to frequency of vitals for discharge patients? Well, I usually do 3... once when I pick up, once en-route, once on arrival (or just prior to) the destination. Otherwise, I do them as necessary.


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## Melclin (Jul 6, 2010)

LondonMedic said:


> Clinically appropriate intervals is exactly the right phrase. In very unstable patients, 10 minutes is just too long an interval - you might want to even go down to beat-to-beat IABP monitoring. In stable patients, 20 minutes is unnecessary and, arguably, does more harm than good.



But how many American EMS providers can you really trust to know what clinically appropriate means. You've gotta have some form of protocol for people who have 5 months of technical school behind them.


Also, I don't see what the patients "minding" or "wanting" vitals has anything to to do with it. Of course, if they straight up refuse, that's a different matter, but asking a person if they mind having it done and then taking or not taking vitals based on that seems silly. Either you need the vitals and they have to put up with it, or you don't. 

I seem to remember numbers like 5 and 10 mins being thrown around once, but I'm fairly certain nobody here actually gives a stuff. You collect the information you need to make a clinical decisions as far as I'm concerned. Generally it seems people take a full set of vitals when you get to the patient, and at least one set of selected vitals at the ED/clinic if you transport. On top of that its what ever is "clinically relevant", and I believe people here have enough education to competently make that decision in most cases.

I think its reasonable to take vitals with greater frequency in 000 ambulance, considering you need be able to observe some kind of trend to properly figure out whats going on with a person. Low acuity IFT may be a different matter. Half the time, I don't really understand why "BLS IFT" even exists, let alone why they _need_ to be taking vitals. Still, I don't know anything about that world.


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## DrParasite (Jul 6, 2010)

Melclin said:


> Low acuity IFT may be a different matter. Half the time, I don't really understand why "BLS IFT" even exists, let alone why they _need_ to be taking vitals.


because on 99% of the patient you need a stretcher to go home/to rehab, because they can't sit in a taxi/wheelchair.  These patient are super stable, and there is no real need for an EMT to be monitoring the patient.  for that 1% (maybe even closer to 0.1%), when the patient crashes, codes, seizes, passes out, develops a problem during the transport etc, at least the EMT will be able to manage the patient and transport the patient to a hospital better than the wheelchair coach driver or taxi cab driver.


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## Melclin (Jul 6, 2010)

DrParasite said:


> because on 99% of the patient you need a stretcher to go home/to rehab, because they can't sit in a taxi/wheelchair.  These patient are super stable, and there is no real need for an EMT to be monitoring the patient.  for that 1% (maybe even closer to 0.1%), when the patient crashes, codes, seizes, passes out, develops a problem during the transport etc, at least the EMT will be able to manage the patient and transport the patient to a hospital better than the wheelchair coach driver or taxi cab driver.



I kinda feel like I'd rather invest in CPR training for taxi drivers and give them a big sticker with 911 written on it in case anything goes wrong  I know there are a few olds that _need_ to be shuttled back to the nursing homes in stretchers, but even in my short time, I've seen plenty who would do just as well plonked in a wheel chair and taxi. 

I'm fairly certain our service actually has cars (actual sedans) and certainly we have mini buses for BLS IFT. They are often literally the same model car/minibus as taxis, but they're driven by paramedics. I'm not even sure they carry any gear. Confuses me to no end.


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## Sassafras (Jul 6, 2010)

My IFT unit does mostly stretcher patients that really cant use a wheelchair.  Now whether they need monitored is up for debate and I'll leave that to my boss to decide LOL.  But I've done recumbants that are in full cranial halos with gear down to their waste inhibiting their ability to sit, plus doped up on so much morphine they fell asleep mid sentance the entire transport, to paralytic dyalisis patients.  The idea of sticking them in a wheel chair and slapping them in a taxi just wouldn't work.


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## Melclin (Jul 7, 2010)

Sassafras said:


> My IFT unit does mostly stretcher patients that really cant use a wheelchair.  Now whether they need monitored is up for debate and I'll leave that to my boss to decide LOL.  But I've done recumbants that are in full cranial halos with gear down to their waste inhibiting their ability to sit, plus doped up on so much morphine they fell asleep mid sentance the entire transport, to paralytic dyalisis patients.  The idea of sticking them in a wheel chair and slapping them in a taxi just wouldn't work.



Fair enough  I stand corrected.


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## Aidey (Jul 7, 2010)

An issue we run into are patients that can sit and travel in a wheel chair, but it has to be a specialized one. So they get brought to the ED by ambulance after someone calls 911, and then they end up going back by amb because they don't have their own wheel chair and can't use the ones the vans have. Think the CP patients who sit way tipped back.


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