# Old school



## Pittsburgh Proud (Mar 5, 2008)

OK so the question is with these new monitors etc. do you ever do a manual Bp or actually take a pulse?
I had mentioned in another post that I have been in and out of running ems call for 24 years and past couple of years got back into things. 
With these new monitors I find everyone goes right to it to take a B/P and I must say I like it but still like to take a manual B/P first then after that I'll depend on the monitor . I do much of the same with the pulse ox. I take a manual pulse then move on to the machines. So the question is am I an odd ball? ( I mean I know I am but about this at least)
I just don't like to depend 100 % on those things.


----------



## VentMedic (Mar 5, 2008)

I always take a manual pulse usually apically and at the radial or brachial.  I also continue to monitor the pulse manually periodically during transport.

The BP depends on the patient.  If the radial is weak or thready, I do a baseline manually first and then the monitor.   If some do the monitor first, they try to "match" what they hear with the numbers from the monitor.


----------



## skyemt (Mar 5, 2008)

Pittsburgh Proud said:


> OK so the question is with these new monitors etc. do you ever do a manual Bp or actually take a pulse?
> I had mentioned in another post that I have been in and out of running ems call for 24 years and past couple of years got back into things.
> With these new monitors I find everyone goes right to it to take a B/P and I must say I like it but still like to take a manual B/P first then after that I'll depend on the monitor . I do much of the same with the pulse ox. I take a manual pulse then move on to the machines. So the question is am I an odd ball? ( I mean I know I am but about this at least)
> I just don't like to depend 100 % on those things.



you shouldn't rely on them at all...
electronic BP's can be notoriously inaccurate, and you really don't need the pulse-ox for anything... it will hardly ever alter your treatment...

the only way to have a solid baseline set of vitals is to take them yourself!!


----------



## Pittsburgh Proud (Mar 5, 2008)

I thought so also, just wanted a few other opinions on that. Thanks... B)


----------



## Ridryder911 (Mar 5, 2008)

I take a baseline B/P manually and then an electronic one for comparison. For long transports I will use an electronic one if it appears to within reason, and every so often still do a manual for comparison. 

Pulse I will check (one needs to check strength & other descriptions). 

R/r 911


----------



## JonathanGennick (Mar 5, 2008)

I was about to chime in with my belief that taking a manual set of vital signs is a best-practice, when the thought occurred to me: "I can't back that belief with a factual argument." So if you don't mind too much, let me play a bit of devil's-advocate here:

1) My local hospital e/r always goes to the machines. 

2) Ditto the trauma center in the next city over.

3) If the machines are good enough for the trauma center and the local e/r, who am I to go around believing that they aren't good enough for me?

All that said, my preference is to grab a manual set of vitals, if only to keep in good practice for when the machines aren't around, or for when the batteries die (like they did on me yesterday).


----------



## VentMedic (Mar 5, 2008)

Most hospitals also have policies that a manual BP must be taken if the BP varies X amount or if there is any clinical question.  An Arterial line will usually be inserted in trauma if time before the OR (or it is done in the OR) and in the ICUs to assess BP and a cuff will also remain in place to verify line measurements.  Oxygenation/ventilation can be verified with an ABG/CO-OX to trend the SpO2.  Central lines will be inserted to monitor CVP for fluid levels.  Rectal or esophageal temperature probes will be placed if the lactate levels are high for a sepsis protocol.  

Many people with many different levels of expertise will be assessing the patient.   There are many different checks ongoing by many different people in the hospital to thoroughly assess every patient.  We even have doctors and RNs at a remote site monitoring by videocam all of our ICU patients and asking questions periodically if something doesn't look right.


----------



## SC Bird (Mar 5, 2008)

Initial BP is always a manual for me.  Then I get an electronic....then I recheck with a manual if there's a change in the BP or if I have time during a longer transport.

Can't beat a good set of ears...plus it helps keep you trained at your skills.

-Matt


----------



## skyemt (Mar 5, 2008)

JonathanGennick said:


> I was about to chime in with my belief that taking a manual set of vital signs is a best-practice, when the thought occurred to me: "I can't back that belief with a factual argument." So if you don't mind too much, let me play a bit of devil's-advocate here:
> 
> 1) My local hospital e/r always goes to the machines.
> 
> ...



i always love how the medics take manual set of vitals, and the basics insist on using the gadgets, and playing devil's advocate and the like...

that must mean something... hmmm....

the hospital uses superior equipment than what's on our ambulance anyway, and the patient is in his gown, proper placement of the cuff is assured, and the hospital/bed/patient/machine are not bouncing around...

hardly apples to apples...

also, using the "its good enough for me" argument, the hospital relies on advanced techniques... so, i should assume you are in Medic class?
since that is what's good enough for the hospital, it must be good enough for you?


----------



## skyemt (Mar 5, 2008)

also, just out of curiosity...

if you don't have a very long transport, and you have enough crew resources, what is the advantage of even using the electronic BP?

it's not like manually taking one is a taxing technique, or one that takes more than a minute?

is it lack of confidence in being able to take a BP?

just wondering.


----------



## JonathanGennick (Mar 5, 2008)

skyemt said:


> i always love how the medics take manual set of vitals,
> and the basics insist on using the gadgets, and playing devil's advocate and the like...
> 
> that must mean something... hmmm....



No need to insult me. And there is no medic versus Basic issue here at all. The truth is that I am often in the field with more senior people, some of them medics, and some Basics, who prefer using the machines. I have just about the least seniority in my service. I can hardly hold up a call and say to the person in charge: "whoa there, I need to take manual blood-pressure because some dudes on a forum said so." 

There is nothing in my protocols about taking manual vitals.

There is nothing in my textbook, that I can recall, arguing that manual vitals are better.

I cannot point to any run in my personal experience in which care was compromised due to machine-taken vitals, so I cannot (yet) argue from personal experience.

The local hospital emergency rooms use the machines.

Most (all?) of the more experienced medics and Basics whom I run with use the machines.

I am not trying to be argumentative here. It would just be nice to have some authoritative sources (preferably print sources) to point to when discussing the issue of manually-taken versus machine-taken vital signs. 

My preference, for my own reasons, is to try and get a manually-taken BP and pulse. But I don't yet feel that I can discuss the issue with others and make a strong case for doing so. I'm honestly not entirely convinced on the point myself.


----------



## skyemt (Mar 5, 2008)

JonathanGennick said:


> No need to insult me. And there is no medic versus Basic issue here at all. The truth is that I am often in the field with more senior people, some of them medics, and some Basics, who prefer using the machines. I have just about the least seniority in my service. I can hardly hold up a call and say to the person in charge: "whoa there, I need to take manual blood-pressure because some dudes on a forum said so."
> 
> There is nothing in my protocols about taking manual vitals.
> 
> ...



there is no insult intended here whatsoever... perhaps you are new to the forum... but if you research past threads out here, you will find that in general, medics prefer tried and true methods, while basics will want to use all gadgets possible.  just an accurate observation of the threads i have read on this site.

i myself am a Basic, and i am not putting down basics in any way shape or form.  this is strictly about manual vitals, as a baseline, versus just using the machines.


----------



## JonathanGennick (Mar 5, 2008)

skyemt said:


> there is no insult intended here whatsoever...



I may have read too much into your earlier post then. I'm sorry for that. 

Again, I'm not trying to be argumentative. I'm interested in best-practices. I'd like to develop a sound foundation for discussing the issue of manual versus machine-taken vital signs with coworkers. 

It might be interesting, actually, to begin a "Best Practice" thread on the topic of taking blood-pressures. It's been in the back of my mind to perhaps begin such a thread, but I've got some reading (and rereading) on the topic that I want to do first.


----------



## BossyCow (Mar 5, 2008)

I take manual vitals. I cannot stress enough the importance of having hands on contact with your patients. The human touch is reassuring and begins the trust relationship that can allow your patient to stop the fear based response to the situation they are in. 

Some like the machines, and frankly I haven't seen a bias with either Paramedics or EMTs on the preference. Personally, if a machine confirms what I see, I will allow it to monitor for changes. But my first preference will always be hands on, manual vitals.


----------



## skyemt (Mar 5, 2008)

BossyCow said:


> I take manual vitals. I cannot stress enough the importance of having hands on contact with your patients. The human touch is reassuring and begins the trust relationship that can allow your patient to stop the fear based response to the situation they are in.
> 
> Some like the machines, and frankly I haven't seen a bias with either Paramedics or EMTs on the preference. Personally, if a machine confirms what I see, I will allow it to monitor for changes. But my first preference will always be hands on, manual vitals.



i couldn't agree more, and that's really all i was saying...
anyone who has used the machine will attest to the fact that you can get some CRAZY readings... if you don't have a manual BP as a baseline, how would you know??

and i still don't see the advantage... you should be able to take a manual BP in short order.


----------



## JonathanGennick (Mar 5, 2008)

skyemt said:


> anyone who has used the machine will attest to the fact that you can get some CRAZY readings...



Yeah, it only took a couple of times reporting crazy BP readings such as 60/80 in my radio patch before I began to think more critically about what the machine was telling me.


----------



## skyemt (Mar 5, 2008)

JonathanGennick said:


> Yeah, it only took a couple of times reporting crazy BP readings such as 60/80 in my radio patch before I began to think more critically about what the machine was telling me.



i don't really know how to put this, but if you are actually reporting a BP of 60/80 over the radio, you have more pressing issues than machines vs. manual BP.

perhaps, you don't feel confident in your understanding of BP's?
if that is not the case, please explain your thoughts while you were reporting such a number of the radio.

also, perhaps you don't feel confident in your skill to take a BP?

unfortunately too often, i have found the machines are used not to ease the workload, but to cover the inadequacies felt by an emt.


----------



## MSDeltaFlt (Mar 5, 2008)

I may be a little late chiming in, but here's the deal regarding NIBP's.  There are no NIBP manufacturers that will say that their NIBP's are dead on accurate.  They are only meant for  trends.

There is only one method of obtaining a blood pressure that is as accurate as a manual.  That is a properly zeroed and properly functioning Arterial Line.


----------



## Ops Paramedic (Mar 5, 2008)

Treat the patient, not the monitor.


----------



## JonathanGennick (Mar 5, 2008)

skyemt said:


> i don't really know how to put this, but if you are actually reporting a BP of 60/80 over the radio, you have more pressing issues than machines vs. manual BP.



Well, I'm sorry I ever got into this discussion. If you never did anything similarly silly early on in your career, then you're a better man than I am. 

I don't recall whether the numbers were upside down like 60/80. I just remember once or twice reading the numbers off the machine only to immediately realize that they couldn't possibly be true. And that is how I learned not to trust the machine.


----------



## VentMedic (Mar 5, 2008)

JonathanGennick said:


> Well, I'm sorry I ever got into this discussion. If you never did anything similarly silly early on in your career, then you're a better man than I am.
> 
> I don't recall whether the numbers were upside down like 60/80. I just remember once or twice reading the numbers off the machine only to immediately realize that they couldn't possibly be true. And that is how I learned not to trust the machine.



The lessons learned from our mistakes.   It only took me one time to forget to switch the nasal cannula from the ambulance tank to the portable when unloading a sweet 85 y/o grandmotherly patient.  That was probably the worst cussin' out I have still to this day taken from a patient and it was well deserved.


----------



## MSDeltaFlt (Mar 5, 2008)

VentMedic said:


> The lessons learned from our mistakes.   It only took me one time to forget to switch the nasal cannula from the ambulance tank to the portable when unloading a sweet 85 y/o grandmotherly patient.  That was probably the worst cussin' out I have still to this day taken from a patient and it was well deserved.



I always forget to do that.


----------



## Ridryder911 (Mar 5, 2008)

What I have found when I seen people read numbers incorrectly is that they are reading the MEAN pressure as a systolic instead of the systolic number. Many do not see that it is a MEAN number, and as well do not understand what that means. 

R/r 911


----------



## Rattletrap (Mar 5, 2008)

I prefer manual vitals for the reason that Rid pointed out. There is information that can be gathered about the patient by looking and listening that a machine can't tell you. You hear the pulse with manual bp cuff and you feel the pulse with your fingers.


----------



## Pittsburgh Proud (Mar 6, 2008)

Rattletrap said:


> I prefer manual vitals for the reason that Rid pointed out. There is information that can be gathered about the patient by looking and listening that a machine can't tell you. You hear the pulse with manual bp cuff and you feel the pulse with your fingers.




I felt the same way myself just watching some folks that in my opinion are just to lazy to do mauls checks. I'm sure in time they will learn as well.


----------



## EMTIA2-7747 (Mar 6, 2008)

JonathanGennick said:


> I was about to chime in with my belief that taking a manual set of vital signs is a best-practice, when the thought occurred to me: "I can't back that belief with a factual argument." So if you don't mind too much, let me play a bit of devil's-advocate here:
> 
> 1) My local hospital e/r always goes to the machines.
> 
> ...



OK, so hospitals use them just about religiously....but they do so in a controlled environment, not in a moving vehicle. If the roads in your area are anything lile ours, you are lucky to have your electronic monitor work at all. many things affect the workings of an electronic BP monitor. bumps and vibrations can register as heartbeats. arm movement can change readings. 
You should always begin with a manual set of vitals. then, if you opt to use the electronic monitor (it is handy), you have a fairly accurate baseline to compare to. if the numbers are way of, then you'll need to continue with manual BPs.


----------



## firetender (Mar 12, 2008)

Since I couldn't figure out how to link to the post, here's my post regarding my first ambulance call. It set the scene for anything I did after that when I had to make a choice between using a machine or me.

New York. Flushing Community Volunteer Ambulance Corps. 1973. Converted hearses. Load and Go! EMT not required yet. Things were on the verge of humongous change!

Rookie as rookie could be. Just got through Basic First Aid. Showed up at quarters to hang out. One medic present. Emergency transfer call comes in. Hospital in Flushing to Columbia Pres, in Manhattan. The other guy scheduled didn’t show. Not yet trained in driving. Guess I was the patient guy!

Loaded an 80 y.o. man into the rig. Was told the transfer was to Intensive Care, Code Three. My seasoned partner helped me take BP and pulse, both WNL, though the man seemed barely conscious. Before he left, my partner took the man’s hand and clamped a clothes-pin-like device over his pointer finger. A green light on the end of it blinked on and off. 

My partner, beaming with pride said, “We’re getting to test out these new devices. They’re pulse-monitors. It’s lots easier than feeling for it while we’re moving.”

Now this was rush hour. Bumper to bumper on the Long Island Expressway. New Yorkers, at that time, could give f***-all about an ambulance with lights and sirens blaring behind them. As my partner stopped and started, twisted and turned the ambulance wherever he could to make headway into the City, me and my patient were jostled around mightily. It was so bad that I had all I could do to watch the damn blinking green light! 

We’re talking 68 minutes to go 15 miles. On a Highway! By the time we landed at the hospital, I had the feeling the patient wasn’t doing very well, but that light kept blinking. The Doctor was actually there to meet us. My partner opened the door and took one look at the patient and said, “Doc, you better take a look!”

The doctor got in and as he put his hand under the patient’s nose to check for breathing I noticed the patient was a lot grayer than before. Wasn't moving much, either. There was no breath. I missed something, I thought.

The Doctor paused a couple seconds and then muttered under his breath, “Expected. He’s done. It’s too bad we didn’t get him here in time to get the pacemaker electrode re-embedded properly!”

I looked at the blinking green light responding heartily to the electrical impulses that were not getting to the man’s tissue at about the same time as I noticed a squarish bulge close to the man's left armpit over his chest and under his skin. It was there I got my first critical lesson in the difference between man and machine.


----------

