# more BP questions



## monkeyfeet (Jul 19, 2007)

while i'm starting to feel pretty skookum on the actual process of taking bps, i do have some bp-related questions i was hoping some of you folks could help me out with...

if a pt has a distal iv, can you still take a bp on that arm so long as the line is closed/capped?

how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?

is it ever ok to take a bp on the same side on which a pt has had a mastectomy? (i've heard both no and yes so long as the mastectomy was more than 2 yrs ago.)

i know if a pt has hemiparesis not to take the bp on the flaccid side, but i'm curious as to why not. there's still blood flow to the limb... is there an issue c the neurological process that controls vasodilation/constriction being affected? or something?

are there any other medical conditions that would make taking bp on a particular arm ill-advised?

and finally, if neither arm is an option, how the heck to you take bp on a leg?

thanks much!


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## MICU (Jul 19, 2007)

About the IV case, I'm allways taking BP from the second hand, the only one time I didnt, blood was getting to the Saline bag, not recomended at all...

The leg case, as much as I remember you take it just above the ankle, but I'm not entirely sure:wacko:


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## Asclepius (Jul 19, 2007)

monkeyfeet said:


> if a pt has a distal iv, can you still take a bp on that arm so long as the line is closed/capped?


No, just take it on the other arm. If not the arm, then the bottom half of the leg. 



> how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?
> 
> is it ever ok to take a bp on the same side on which a pt has had a mastectomy? (i've heard both no and yes so long as the mastectomy was more than 2 yrs ago.)


Again, there is no good reason to attempt either of these. You can seriously mess up a pt. in your attempt. Stay clear of both of these.



> and finally, if neither arm is an option, how the heck to you take bp on a leg?


Place your cuff on the bottom half of the leg. Now feel for a pulse on the top of the foot. Once you find the pulse, inflate the cuff until you no longer feel it. Then bring down your pressure until you feel it again. That is your systolic by palpation.


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## VentMedic (Jul 19, 2007)

Women (and becoming more common in *men*) who have had mastectomies should have their BP taken on the opposite or leg due to lymph node removal.  In a few cases such as the Simple mastectomy where just the breast tissue is removed, the lymph nodes may not have been dissected. Unless I a totally positive about that, I use another site. Any procedure with the word _radical _ will have lymph node involvement. Compression on the affected arm will set them up for Lymphedema.  Lymphedema may become a life long battle for them


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## VentMedic (Jul 19, 2007)

No BP over a PICC line.


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## eggshen (Jul 19, 2007)

Also you should not take a B/P in an arm containing an active shunt, i.e. one used for dialysis. You can bugger up the shunt requiring placement of a new one. Now this is a good thread on b/p taking. ALL legitimate questions and useful answers.

Egg


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## BossyCow (Jul 19, 2007)

eggshen said:


> Now this is a good thread on b/p taking. ALL legitimate questions and useful answers.
> 
> Egg



We couldn't have done it without you!


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## eggshen (Jul 19, 2007)

Rhiiiight not sure how to take that one. 

Egg


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## MedikErik (Jul 19, 2007)

monkeyfeet said:


> how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?



I almost had a heart attack when I read that. Most definitely do NOT do it directly over an iv/pic, and just to be on the safe side I don't do it on that limb if I don't absolutely have to.


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## monkeyfeet (Jul 19, 2007)

thanks for the replies, everyone! i got a lot of inconsistent answers from ppl at work, so i'm reassured by the general sense of agreement here.


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## Ridryder911 (Jul 20, 2007)

Not just being able to obtain an accurate blood pressure is essential, knowing what it means and as well understanding the physiological occurrence of what is occurring is just as essential. How many actually understands the * mean* pressure and reports it ? [(2 x diastolic)+systolic] / 3) 

Just obtaining the numbers is only one part of the equation..


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## eggshen (Jul 21, 2007)

Just out of curiosity, how does the MAP affect how you run your call?

Egg


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## Ridryder911 (Jul 21, 2007)

* Just an FYI:*
Yes, we all are taught to watch our patients blood pressure, and then to take it at least every 5-10 minutes on critical patients. But very few if any pay enough attention to the mean arterial pressure (MAP)? Many see it as that tiny innocent little number that is usually placed in brackets or hiding off to one side of the monitor screen of electronic blood pressure cuffs or on the cardiac monitors.
.
So what the heck is that number? Is it important? Should I record it?
YES ! 

MAP is defined as the average arterial blood pressure during a single cardiac cycle. The amount of stroke volume (blood ejected from the ventricle) cardiac output (blood perfusion).

The reason that it is so important is that it reflects the hemodynamic perfusion pressure of the vital organs. In other words how much blood supply is reaching or going through your patient. 

So what if we do not have a electronic B/P cuff, can we still obtain a MAP reading ? YES !

If so, how can we calculate it?
The simple way to calculate the patients MAP is to use the following formula:
MAP = [ (2 x diastolic) + systolic ] divided by 3. (i.e. 155/85 the MAP would be 108)

The reason that the diastolic value is multiplied by 2, is that the diastolic portion of the cardiac cycle is twice as long as the systolic. Or in other words, it takes twice as long for the ventricles to fill with blood as it takes for them to pump it out….. that is at a normal resting heart-rate.

In bradycardia or tachycardia conditions; in a patient this relationship between systolic and diastolic values may have some changes, and the formula may not be as always accurate, but still is an important.

One may see the use of invasive monitoring of BP (using an arterial line) in the ER and especially in ICU/CCU settings. This gives a true and only real accurate blood pressure reading (single digit). This uses a complex formula and real time value, very few understand the formula for this method.
Okay, if you want to know ...it is obtained via Fourier analysis of the arterial waveform, or as the time-weighted integral of the instantaneous pressures derived from the area under the curve of the pressure-time. 
Understand it ?.. me neither....LOL  okay a little bit...

Does EMT's need to watch it MAP?
Definitely. I would describe MAP as that as the RPM or oil pressure in an automobile.
A MAP of at least 40-60 is necessary to perfuse the coronary arteries, brain, and kidneys. The normal range is around 70 - 110 mmHg.

This should be taught as another vital sign for all EMT'sto monitor. It should be monitored anytime the patient has a potential problem with perfusion of their organs. For example (and there are many more):

Shock : especially  pt.'s with septic shock and are on vasopressors (Levophed, Dopamine, etc). 
CHI :head injured patients, and those with suspected ICP. 
Cardiac patients on vasodilator med.s such as NTG, Nipride drips 
Patient with a suspected dissecting abdominal aneurysm (AAA)> They need to have their BP controlled within a narrow range so as not to cause increased bleeding or tear.
In the head injured patient, the brain is at risk of ischemia injury if there is  insufficient blood flow if the MAP falls below 50. On the other hand, a MAP above 160 reflects excess cerebral blood flow and may result in raised intracranial pressures (ICP).

So, one can see obtaining a blood pressure is important but just getting the numbers is not the real purpose. What those numbers reflect is the *main* importance. This is why, I am so picky of my blood pressure readings. *It is much more than just pumping up a sphygmometer up and listening to some lubb.. dubbs... *Any idiot can do that!... Being able to distinguish the true sounds, having the knowledge of what is going on inside your patient is the whole point.

How will this affect my call.. this can lead to a more accurate diagnosis as well as knowing how well my patient is being perfused .... What kills most patients is multiple end organ perfusion.. being secondary to shock, sepsis, post arrest.. what ever. Having a knowledge of thorough assessment, just by understanding the basics of numbers ... can make one understand the "big picture". 

Hopefully this answered your question + some...


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## RedZone (Jul 21, 2007)

monkeyfeet said:


> while i'm starting to feel pretty skookum on the actual process of taking bps, i do have some bp-related questions i was hoping some of you folks could help me out with...
> 
> if a pt has a distal iv, can you still take a bp on that arm so long as the line is closed/capped?
> 
> ...




PERIPHERAL, VENOUS IV: No problem, take it on that arm.  Put the damn cuff over the line if you have to.  Sure, blood's gonna back up if it's open, but just keep an eye on it in a real situation.  Blood doesn't back up into the IV bag.  Or, yes, you can close it (or it's a saline lock).  But you technically must understand the minute risk of losing IV patentcy.

Common sense: Trauma patient gets two IV's.  Probably one in each arm.  Would you even think of not getting a BP?  And if his BP is 70/P, a leg won't do.

PICC Line: Personally, I can't think I've ever seen one that wasn't proximal to the biceps.  The catheter terminates in, or close to the thorax.   What is the contraindication to taking a BP???

Dialysis access: If the WORKING dialysis access is in the arm.... that arm is off limits to anyone but a licensed dialysis tech or a nephrologist.

Hemiparesis: PREFEREBLY use the working arm.  I look at this as a relative contraindication unless it would cause severe pain to the patient.

A BP is only a tourniquet for a few seconds with good technique.


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## RedZone (Jul 21, 2007)

Oh yeah, the mastectomy thing:

The last ruling I got was NO BP on that side if it is a recent one.  I don't know how recent that is... I don't do it at all unless it would be a matter of life or death. 

Like rid said, WHY are you taking the BP???  Stable pt on a non-emergency?  Well, there's plenty of signs besides BP to give you an indication of perfusion status.  

Post-arrest of a bilateral mastectomy?  Guess what, in that unlikely event, where's my BP cuff going?


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## VentMedic (Jul 21, 2007)

RedZone said:


> Oh yeah, the mastectomy thing:
> 
> The last ruling I got was NO BP on that side if it is a recent one.  I don't know how recent that is... I don't do it at all unless it would be a matter of life or death.



Lymph node removal is permanent. It doesn't matter the length of time. Any compression or trauma (including needle sticks) to that arm at any time during that person's (male or female) life will cause potential damage.


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## Ridryder911 (Jul 22, 2007)

Both of you brought up some very important basic points in obtaining blood pressures. What many think of is okay or the opposite of being taboo may not be the case. 

Usually, one can obtain a blood pressure in the other extremity. Yes, even over burned areas.. etc. Personally, I attempt to stay away from line site areas especially PICC lines since the do usually originate in the A/C area and are pretty thin catheters. But, as Vent described.. use common sense and if need has to be; outweigh the consequences and use it. 

As well many are not familiar with taking radial pressures in lieu of brachial ones. I do this often on obese patients that you cannot find a cuff large enough to circumference the upper arm. Thigh cuffs are great, just remember the accuracy may be altered or need adjusted do to the distal location (don't alter the numbers) and be sure to document location as well. 

True mastectomy patients should not receive peripheral sticks, B/P, and IV since the thoracic duct is usually removed and circulation is altered. It is *not okay* to do this.... as I have heard many medics describe. This just shows their ignorance by proceeding. 

For the A/V shunts or dialysis grafts, avoid if possible as others stated. Yes, very few times I have cannulated one for emergency procedures, but would never recommend it to ones not educated and specially trained to do so. However; you might see it performed in severe crisis situations. 

I realize we in EMS usually go for the biggest and most easiest vein. If possible though, and the situation allows, attempt to initiate IV''s more distally. It is not just a "nurse" thing. The patients will appreciate the IV location, leaving other potential sites. Yes, in severe emergencies one has to do what they can. 

There are so many associated things to blood pressure. The same could be stated about pulses, respiratory and yes... even temperatures. This is why they do call it * vital signs* for a reason. 

I do not believe most EMS personal understand the need of obtaining and reporting vital signs, and a brief  H & P. Yes, I will judge you upon certain things. Give me inaccurate vital signs, and poor history, assessment, one looses creditability with me from then on. Simplistic things like vital signs should be a "give me". If one has trouble obtaining, then inform me of such.. .. there maybe a reason. However; you give me a very false reading... 
now, that's a different story. Honesty is a big part of being a professional as well as possibly affecting the patients treatment and outcome. 

Remember, blood pressures as well are one of the last vital signs to change. Awaiting for the numbers to drop or increase will increase your patients risks. Become educated and learn other symptoms to inform you of potential problems before relying upon the decompensation of the patient. 

Be safe, 
R/r 911


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## VentMedic (Jul 22, 2007)

There are so many things about blood pressure that still have not been discussed indepth which Rid mentioned by example in his previous posts.

Orthostatic Blood Pressure
Pulse Pressure
Pulsus Paradoxus
Bilateral Systolic Blood Pressure Significance

Getting proficient at taking BP and all other vital signs is a must. 

Paying attention to the medications and how they can skew the whole picture concerning BP and HR is also important.


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## Ridryder911 (Jul 23, 2007)

Do you know how to stop a topic in EMT Life? Add more general education to it... 

R/r 911


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## RedZone (Jul 23, 2007)

Ridryder911 said:


> Do you know how to stop a topic in EMT Life? Add more general education to it...
> 
> R/r 911



I think this topic was actually covered pretty thoroughly.  The original and *very specific* concerns were debated, and several opinions were offerred.  I'll send you a pm.


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## VentMedic (Jul 23, 2007)

Actually we have barely skimmed the surface of BP.

Nursing Assistants and Patient Care Technicians in the hospital setting spend many hours learning class room things about BP before they are allowed to do an actual BP in the hospital. Accuracy and knowledge about the different indications and contraindications are stressed.  The CNA's textbook is over 800 pages of "general" education and skills. To become a PCT, it is another 400 page text book and more training.  All of the things mentioned in this thread, including MAP, are found in these textbooks. There is no heresay or "opinions" for some of the basics. 

Yes, there are exceptions in some emergencies.  But, you should know the basics so that you know when you are making an exception. 

I am beginning to think that being a CNA or PCT should be a prerequisite to the Paramedic program.


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## Ridryder911 (Jul 23, 2007)

VentMedic said:


> I am beginning to think that being a CNA or PCT should be a prerequisite to the Paramedic program.



Wow! That would be interesting... instead of being a basic for one year, require being a CNA... hmm?

I would start another thread on different areas of B/P, but that would involve many multiple posts and threads; again all regarding the same topic..blood pressure.

R/r 911


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## VentMedic (Jul 23, 2007)

I made the remark based on the actual number of BPs an EMT or EMT-P  may do per shift or even in a week as compared to the RN, CNA, PCT or ER Technician per shift. 

Yes, getting to do "ride time" is important, but what if they did 40 hours (and that is a conservative number) of just taking vitals, basic assessment skills and documentation all day long on a hospital floor or busy ER?


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## Airwaygoddess (Jul 24, 2007)

Not to mention the number of patient contacts with multi system health problems, and  learning how to work with sick patients, medical and trauma.


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## Airwaygoddess (Jul 24, 2007)

*a second thought*

I also think that it would be the best training of both worlds in the field and in the clinical setting.


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## Arkymedic (Aug 14, 2007)

Ridryder911 said:


> * Just an FYI:*
> Yes, we all are taught to watch our patients blood pressure, and then to take it at least every 5-10 minutes on critical patients. But very few if any pay enough attention to the mean arterial pressure (MAP)? Many see it as that tiny innocent little number that is usually placed in brackets or hiding off to one side of the monitor screen of electronic blood pressure cuffs or on the cardiac monitors.
> .
> So what the heck is that number? Is it important? Should I record it?
> ...



This is a very well put and articulated post. I also think that MAP should be another v/s taken and monitored and wished we had discussed it in more greater detail in my medic course.


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## triemal04 (Aug 22, 2007)

So, aside from RN's that work in clinics and for doc's in private practice, (and often a lot aren't even nurses) I don't honestly know when I last saw an RN, CNA, LPN, ER Tech or anyone who works in a hospital take a manual blood pressure.

That's all well and good that CNA's have to spend all that time learning HOW and WHY to take a blood pressure, but in the end they take it using a machine.  Almost every medic I know (and most I's, and a lot of Basics) can tell you all about a BP, including what the MAP is why is matters. 

I guess my point is...if you know how to take a BP, are good at it (which will ONLY come from practice, not from reading about it) and know what the little numbers mean...who cares how long it took you to learn, or how often you take one.


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## VentMedic (Aug 23, 2007)

triemal04 said:


> So, aside from RN's that work in clinics and for doc's in private practice, (and often a lot aren't even nurses) I don't honestly know when I last saw an RN, CNA, LPN, ER Tech or anyone who works in a hospital take a manual blood pressure.



Actually, if you notice next time you are in the hospital setting, there are still manual BP cuffs everywhere. If they are not mounted on the wall by the beds, there are usually at least one in each section of the ED and definitely on the med-surg wards. Most of our med-surg rooms have at least one in each room. The ICUs will usually have a manual cuff at each bedside. Per policy for all including PCTs, CNAs and RNs, if there is a discrepency between the last set of vitals, the BP must be confirmed manually. The manual cuff is available for all emergency situations when the machine just won't do the job.  Part of being a good clinician also involves knowing when the numbers on the machine and the patient's appearance don't appear to match. 



triemal04 said:


> That's all well and good that CNA's have to spend all that time learning HOW and WHY to take a blood pressure, but in the end they take it using a machine.  Almost every medic I know (and most I's, and a lot of Basics) can tell you all about a BP, including what the MAP is why is matters.



I would say you know an elite group of people. Not all paramedics have the same educational background. MAP to many is a formula mentioned somewhere in paramedic school and then forgotten.  

CNAs/PCTs are relied upon to provide accurate information to the licensed staff.  They also spend the most time during a 12 hour shift with the patients doing direct care. Part of their training is knowing when a patient is not tolerating certain basic activities. Obtaining vitals at the time of some change can provide valuable information for the patient's overall care. It's not just about "taking a BP" but relating it to the patient's overall activity tolerance and condition at that particular moment in time.  



triemal04 said:


> I guess my point is...if you know how to take a BP, are good at it (which will ONLY come from practice, not from reading about it) and know what the little numbers mean...who cares how long it took you to learn, or how often you take one.



Technology has made some manual skills weak. Even those that have had excellent skills get used to using technology and their skills start to suffer.  I see this frequently when someone is asked to do a manual BP during an emergency.  They get that stunned and fumble moment. This can be anyone with any credential.  

Reading and continuing to learn/review can enhance your overall awareness in different patient presentations.  There is so much to learn from those "little numbers".


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## VentMedic (Aug 23, 2007)

> Originally Posted by triemal04
> Almost every medic I know (and most I's, and a lot of Basics) can tell you all about a BP, including what the MAP is why is matters.





VentMedic said:


> *I would say you know an elite group of people. *Not all paramedics have the same educational background. MAP to many is a formula mentioned somewhere in paramedic school and then forgotten.



I did mean that as a compliment. Educational BASICS vary in different areas. If the prehospital providers in your area have a thorough understanding of BP and MAP, then it is a good achievement for your EMS education system.


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## triemal04 (Aug 23, 2007)

VentMedic said:


> Actually, if you notice next time you are in the hospital setting, there are still manual BP cuffs everywhere. If they are not mounted on the wall by the beds, there are usually at least one in each section of the ED and definitely on the med-surg wards. Most of our med-surg rooms have at least one in each room. The ICUs will usually have a manual cuff at each bedside. Per policy for all including PCTs, CNAs and RNs, if there is a discrepency between the last set of vitals, the BP must be confirmed manually. The manual cuff is available for all emergency situations when the machine just won't do the job.  Part of being a good clinician also involves knowing when the numbers on the machine and the patient's appearance don't appear to match.
> 
> I would say you know an elite group of people. Not all paramedics have the same educational background. MAP to many is a formula mentioned somewhere in paramedic school and then forgotten.
> 
> ...


Not to be a jerk or anything...but not every ER is the same as the one in the hospital in which you work.  Yes, some do have manual cuffs in each room, sometimes mounted on the walls.  And a lot don't.  Including many that I have seen.  As far as taking a manual to check discrepencies...same deal.  Things are different everywhere  (this is ignoring the part about how people will not follow their protocolls in some situations...whole 'nother topic), and a lot of people rely way to much on a machine to take vitals for them.  My point was that just because someone has an RN, CNA, LPN or whatever after their name doesn't make them more proficcient in something than an EMT.  Ever.

Far as the MAP goes...it's part of the medic curriculum here.  Everyone learns about it.  Most seem to remember it.  And to relate the automatic BP's...most machines I've seen will also display the MAP...and most people I know want to know what the equipment they use tells them.    

But, you are absolutely right, taking vitals isn't the end, it's looking at those vitals and knowing if they are accurate based on what your pt's presentation is.  This will come in part by reading a book, but again, the ultimate way to know is to go out there and DO IT.  Again and again and again.  Like I said, it has nothing to do with what your cert is or where you work, but how much you do it, and how much you practise.


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## VentMedic (Aug 23, 2007)

Actually I get to see a lot of hospitals on two different coasts. Both areas are prone to disasters, earthquakes and hurricanes. Having manual cuffs and other equipment readily available for disasters, power failures and for just regular emergencies is a must. I do like working for hospitals that are well prepared. 

I would hate to see anyone try to defend NOT doing a manual BP if there was doubt in the machine reading in court. 

But you are right some hospitals just like some professionals just barely meet minimum standards. Hopefully with the raised JCAHO standards, these hospitals will get their acts together.  



> My point was that just because someone has an RN, CNA, LPN or whatever after their name *doesn't make them more proficcient in something than an EMT. Ever. *



Now that is a strong statement and could definitely be up for debate.     There are definitely things that each of these professions do more proficiently than an EMT. Of course, there are prehospital things that an EMT has definitely got more proficiency in.   The average CNA in our hospital will take a minimum of 50 BPs/shift and those are just the scheduled ones. Some are manual and some are by machine.  They get very proficient at what they do.  Not many paramedics will have the same indepth understanding of MAP as an ICU RN.   Healthcare is very diverse with many different skilled and educated professionals. There are things every professional can learn from other professionals.


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## triemal04 (Aug 23, 2007)

VentMedic said:


> Now that is a strong statement and could definitely be up for debate.     There are definitely things that each of these professions do more proficiently than an EMT. Of course, there are prehospital things that an EMT has definitely got more proficiency in.   The average CNA in our hospital will take a minimum of 50 BPs/shift and those are just the scheduled ones. Some are manual and some are by machine.  They get very proficient at what they do.  Not many paramedics will have the same indepth understanding of MAP as an ICU RN.   Healthcare is very diverse with many different skilled and educated professionals. There are things every professional can learn from other professionals.


It's a true statement though.  Sure there's going to be people that work in hospitals that are better at a specific skill than some EMT's.  And the reverse will be true too; a lot will depend on the individual though, and what system they work in.  But just because some has a certain certification or licence does not mean that they will be better at something than an EMT.  Ever.  I know I'm repeating myself, but I don't know how much clearer I can get.  The only way to get good at something is to do it; if you don't, it doesn't matter what you cert is, you still won't have the skills.  And again, good for the CNA's where you work; again though, it isn't like that everywhere.


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