Can you genuinely get Manual Vitals in every scenario?

Mitchellmvhs

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Hey everyone looking for some more BLS help and suggestions.

I was supposed to transfer out to AMR riverside and got hired in December, but still have gotten nothing back from them, so I took an opportunity that came up that will allow me to run a lot more 911 in Laguna Beach and I’m looking for help with a skill I still struggle with a lot.

Is it realistic and possible to get an accurate set of manual vitals in every scenario regardless of how hypo or hypertensive a pt is?

I genuinely have been trying my best to try and take manual BPS at every opportunity, but sometimes I still struggle a lot with it. I even bought a Littman cardio III stethoscope to help me auscultate, but my biggest fear is being asked by a medic for a manual and not being able to hear it or even palp it and looking like a complete idiot because I can’t get a BP. Or getting something that’s completely inaccurate and my pt dies bc of my incompetence. I’ve done so much research and readings on the best methods to getting them. But are there cases where you really just can’t?

I’ve had an idea of even taking a BP cuff and steth to every call even if it’s an IFT and instead of using the monitors in hospitals and just taking manuals in hospital, but I also feel like the nurses and my partner are gonna be like wtf are you doing lol.

Am I struggling due to lack of experience? Or am I really just dumb lol. I really want to be the best provider that I can be, especially since my mom passed away this month due to covid and I made a promise to her and myself that I will be the best provider I can be. I’ve been working for about 8 months now, but I can’t seem to confidently get manual vitals every single time.

I would really appreciate any input.
 

DrParasite

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Yes. practice makes perfect. know your anatomical landmarks
 

luke_31

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Practice, practice, practice. There are times you’ll not be able to get a BP. Don’t guess it, just state I can’t get one. I recently had a call where I couldn’t get a manual BP while I was in the house with the Pt. Pulse was very rapid and thready. When I got to the ambulance and put him on the monitor Pt was in the 80s/50s and treaded down during transport. Pt was shunting so bad couldn’t get a flashback with the IV for blood or a finger stick to get a blood sugar since it was a syncopal episode. Bottom line is not every Pt you’ll be able to get a BP on. I’ve been doing this 17 years now and some patients I just can’t hear it for a multitude of reasons. If you can get a pulse and respiratory rate then at least you know they are alive.
 

DrParasite

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Yes. practice makes perfect. know your anatomical landmarks
I should clarify my previous statement: you can (and should) attempt to obtain manual vital signs on every patient. Are there going to be patients where you can't feel a pulse? or can't auscultate a blood pressure? yes absolutely, but that doesn't mean you shouldn't at least ATTEMPT to get vitals.

I recall one patient where I couldn't auscultate a BP. tried 3 times, couldn't hear anything. hooked up the NiBP on the lifepak 12: 122/70. I didn't believe it, and to this day, even the medic said the machines aren't always accurate.

if you have a hypotensive 20-year-old, who keeps passing out every time she sits up, will you be able to get a radial pulse on her? no, but you should still attempt to obtain one.

In my experience teaching, the vast majority of the time when a new person can't obtain a set of vitals is because they are looking or listening in the wrong spot. practice makes perfect, and know your anatomical landmarks (radial notch of the ulna for radial pulses, using the proper arm position for a BP (with slightly flexed elbow and held at heart level) and blood pressure cuff positions, as defined by the American Heart Association), and your lung areas).

However, if you are unable to palpate a pulse, or obtain a BP, and you are confident you are looking in the right area, then that should tell you something too.
 

MMiz

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Absolutely not. What's a pedal pulse in the field?

Like anything, it becomes easier with experience.

Sometimes you have to stack the cards in your favor. Assess vitals before the rig is in motion, position yourself to minimize outside distractions/noise.

If I were actively working in EMS I'd be more willing to ask for my experienced partners to help me better assess vitals of challenging patients.

Good luck!
 

Aprz

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My first set of vital signs on almost every call, even "critical calls", is manual. The only time I don't do it is cardiac arrest. That's my county's protocol and it is just a part of my routine. Personally, I think Lifepak 15 are garbage at getting vital signs so my manual heart rate and blood pressure will be the most accurate. It may be the coiled blood pressure cuff tubing? Then the pulse ox always struggles to work "Poor perfusion! Poor perfusion!" even when I crank it up to high sensitivity. Ugh. I think the only time that darn machine doesn't give me a bizarre number like 202/186 (it really is dumb and give me phony bologna numbers like that) is when the patient has coded... Then it'll be 120/80, your dead patient is OK. Kinda reminds me of The House of God law XII. "If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there." (https://en.m.wikipedia.org/wiki/The_House_of_God) Just switch it up to "If the Lifepak 15 can get a normal blood pressure and the experienced paramedic/firefighter can palpate a carotid pulse, there can be no pulse." Something like that, haha. Same thing with Philip MRx monitor, RBBB, and STEMI, haha. Dunno why, but MRx always thought normal RBBB was a STEMI and would frequently miss the STEMI/proximal LAD occlusion with RBBB, Hahaha.

Anyways, it's rare I cannot get a blood pressure. So rare that I usually use the blood pressure to auscultate the heart rate instead of palpate. I find it easier to auscultate a blood pressure instead of palpate a pulse. I usually inflate the cuff, listen on the way up to know when it goes away (that is my systolic), then deflate the cuff slowly (you'll hear the systolic again), and usually 10-20 mm Hg below systolic, when the Korotkoff sound is loudest, I stop bleeding air out. I count the heart rate I hear for 15 seconds (or 6 seconds if the heart is really fast multiply by 10 or "perfect 1 beat per second" then I just insta say 60 bpm without listening more), then deflate more to get diastolic. I actually do count respirations and notice people do miss brady/tachypnea a lot because patients will not appear dyspneic, but have abnormal rates, especially now with COVID 19. I am pretending to still get your blood pressure, stethoscope in my ear, cuff on, and count your respiration pretending to get your blood pressure still. I used to test students on vital signs, and when I was a student myself, I got tested on vital signs. Auscultating the heart rate during the blood pressure was my method of confirming my heart rate, and eventually, I just ditched palpating the pulse rate while working in the field because of how easy it is for me to auscultate and get all my vitals while "auscultating the blood pressure".

I think people get psyched when patients are hypotensive, but it shouldn't really be quieter or harder to get, but rather just lower mm Hg than usual when you do finally hear it. I think people just give up when they don't heart it at <90 mm Hg, but it is still there and probably easier than getting a palpated pulse. Like it'll still be loud enough to hear even if the blood pressure 60/40 or something crazy low. I don't find any association between loudness and how high/low blood pressure is, which it seems people do, but I think that is a mental thing. They are used to hearing the sound go away at 90, 80, 70 mm Hg (their diastolic) when now a hypotensive patient systolic is 90, 80, 70... mm Hg and they think since they normally lose the sound there that it is hard to hear or expect to lose it there, but they shouldn't. I think it's a mental thing personally. I've heard soft Korotkoff sounds at 180 mm Hg on hypertensive patients and noticeable/louder Korotkoff sounds at 80 mm Hg on hypotensive patients. That's my personal experience with doing a manual blood pressure almost every single call for a decade (only for 1 year, I didn't take manual vital signs, and that is because I was an EMT on an ALS 911 unit where ambulance drivers I mean EMTs weren't allowed to tech calls :/).

I prefer auscultating the heart sound than palpating a pulse, if I cannot get it via when I get a blood pressure. I find it easier to palpate a brachial pulse than radial or carotid. I do not find carotid/femoral pulse easy or reliable at all. Maybe it is just me, but carotid/femoral sucks even in healthy patients in my opinion. I think my sense of feeling is extremely poor. I do not like palpated blood pressures at all. I can do brachial no problem. Radial, dorsalis pedis, and posterior tibialis harder. For CMS (or whatever variation you use eg PSM, CSM, CMSTP), if I cannot palpate dorsalis pedis or posterior tibialis, cap refill or warmth is an alternative I document. I'll sometimes try using a pulse ox pleth wave as an alternative (especially in restrained patients, proof I feel the restraint had good circulation/wasn't too tight). Popliteal is difficult as well, and counterinuitively easier to do with the knee flexed/bent.

Personally, stethoscopes don't make a difference for me and I am practically deaf I feel like. I kept losing/breaking my fancy stethoscopes at work so I used the cheap toy ones provided at work. When I decided to make heart sounds/tone routine for me, I got a fancy stethoscope again, but it isn't necessary. One of my previous EMTs said he noticed a difference, but I don't.

I guess my advice is to put the blood pressure cuff high up on the arm, not so low that the bottom part is touching the antecubital (inner elbow where IVs are usually started). I make sure it is snug on the patient, somewhat tight like how tight I'd velcro shoes on or tie shoe laces on my shoes. Should be snug. For accuracy sake, make sure the cuff is the right size (white line should go between the limit on the cuff, there is like a range printed on the cuff and a white line that should go betweem the printed range... most people don't notice it). For accuracy sake, make sure the artery line on the blood pressure cuff (I think it is the middle of the bladder that inflates when you take a blood pressure) is over where I'd palpate the brachial pulse.

I do not tuck my stethoscope under my blood pressure cuff, which I see a lot of people do.

With cheapo stethoscopes, the bell (small side that people think is for pediatric patients) usually is better at getting low frequency sounds like blood pressures and heart tones, in theory I guess, and the diaphragm (big side people think is for adults, the side most people use) is better for high frequency sounds like breath sounds. I personally don't notice a difference, but maybe it'll give you the edge you need, if you use a cheapo. Littman doesn't care which side you use, but how hard you press. Lightly apply the stethoscope for low frequency and more pressure for higher frequency. Most common issue is people pressing up their stethoscope too much into the patient's skin thinking it'll help them when it does the opposite.

Location for me matters somewhat. The brachial, which is easier for me to palpate than the radial or carotid (I do not palpate mid shaft humerus, but at the antecubital, look at the picture attached) is more medial. I have the elblow completely extended and hand supinated (facing up towards the sky) when I auscultate blood pressures or palpate brachial pulses. To help keep the hand supinated on uncooperative patients, I'll usually put my elbow (with a chuck folded between my elbow and the patient's hand) in the palm of the patient's hand and hold it down that way, if I can. For me, having the hand supinated makes it eaiser to auscultate the blood pressure and palpate the brachial personally and I consider it an important step for me, but not absolutely necessary, just easier. I just put the bell/diaphragm of the stethoscope directly over where I'd palpate the brachial pulse (look at picture attached) and again not tucked under the blood pressure cuff. The brachial pulse is usually located in the same spot you'd visually see veins to put an IV in so that can be a quick easy way to find the right location to palpate and auscultate, if you can see the veins (like you can see in the picture attached, my vein is very visible since I am see through like a ghost, haha).

In a moving ambulance, I usually rest my feet on the side of the gurney or under carriage, and the patient's arm on a chuck resting on my lap (I cannot believe how many people take blood pressures without chucks, gross!). I find that helps eliminate most of the sound of the moving ambulance. Probably my leg, being fatty/muscular, eliminating most of the vibration of the ambulance.

I'm sure with time, it'll click. Personally, as a medic, I only trust me and my best friend (my EMT partner for like 4 years now?) with manual vitals/blood pressures. I imagine most medics who listen to EMT vital signs are just being nice, but usually somewhat hesitant to believe it or don't care. For me, even though I do manuals and only trust me and my best friend, vitals are usually just something I check off in my to do list rather than something I really care about. I work in an area where paramedics are practically EMTs, very limited scope, so the only meds that matter with blood pressure is Nitroglycerin and Morphine (for me, Morphine causing hypotension is over dramatized/overstated, and I am very lenient with giving Morphine... I cannot think of a time I've seen hypotension due to Morphine and even borderline hypotensive patients still tolerate it well, in my experience). My protocol cares about blood pressure for Nitro and Morphine (and TXA, they have to have SBP <90 mm Hg for us to give it, I've yet to give it) nothing else. Otherwise vital signs are like quantative findings, something to check off my list of things I am suppose to do, look busy, rather than life or death treatment stuff for me. So don't be too stressed out about vital signs. :)
 

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mgr22

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I prefer auscultating the heart sound than palpating a pulse, if I cannot get it via when I get a blood pressure.
I realize I've picked only one sentence out of a very long post, but it's the one I understood the least.

To me, palpating a radial pulse (fast/slow, weak/strong, regular/irregular) while making eye contact with a (conscious) patient and observing respiratory effort should be done while beginning most patient interviews in the field. I think those initial tactile and visual clues are usually harder to find with equipment.
 

Akulahawk

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Genuinely get manual vitals in every scenario? Sure... COMPLETE vitals? Not a chance. Some people just won't allow you to get a full set. There will be times that I can't get a manual BP. That's OK as long as you attempt to do it and document (somewhere) the attempt was made. Same with pulse and resp checks. I've done THOUSANDS of manual vitals over the years. I've got reasonably decent ears and a good stethoscope. If I can't get a manual BP, something's not right. However that usually means that I can't get a palpated blood pressure either. A BP of 124/P is perfectly OK, if that's all you can get. Getting a palpated BP is also an art but it's not as difficult to learn. Mostly you have to learn NOT to smash the artery with your fingers and to be super sensitive to the pulse when it returns. Getting that feel just takes practice.

I do something similar to Aprz in that I listen on the way up. That lets me know I'm in the right place and gives me an idea of what the SBP is before I start actually listening for the BP. I don't do pulse rates via BP cuff though. By the time I'm doing a BP, I've already done the pulse check and I've got the breathing rate done by then too. The auto cuff is nice but sometimes it doesn't work as well as I'd like. In the setting of afib, they can be (sometimes) a bit off.

I find that by palpating the pulse, I get skin signs, can get an idea of mental status, pulse quality, and so on. It helps me do my sick/not sick determination. I've had a few patients over the years (not many) that I've decided to GO based on that initial check and just quickly got a BP right before leaving the scene.
 

Aprz

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I realize I've picked only one sentence out of a very long post, but it's the one I understood the least.

To me, palpating a radial pulse (fast/slow, weak/strong, regular/irregular) while making eye contact with a (conscious) patient and observing respiratory effort should be done while beginning most patient interviews in the field. I think those initial tactile and visual clues are usually harder to find with equipment.

If I cannot get a manual blood pressure, what does that say about the patient's blood pressure? If it was due to movement, do you think I'll be able to auscultate heart sounds or palpate a pulse? Are there other things I can use, probably more reliable, like awake and oriented patient? Their skin signs?

What does a weak/strong pulse indicate? Would I determine it when I ausculate the blood pressure?

Can you not hear the regularity/irregularity of the pulse when auscultating heart sounds or the blood pressure?

Can you not hear the rate (fast/slow) when you auscultate the blood pressure or heart rate?

Am I not touching the patient when I get manual blood pressures? Can I not feel their warmth or coolness?

For me, I used to palplate a pulse and then auscultate it as a confirmation. I found I was getting the same info with auscultation, found it easier, and more reliable.

If the patient is combative, it is gonna be hard to get any vital signs with most method, machine too, but my strength is usually auscultating the blood pressure and I am more likely to get all my vital signs auscultating it, I can auscultate it waaaaay quicker than the machine making it more ideal for combative patients. I can get almost a full set if the patient sits still for 6 seconds (multiply by 10 instead) versus just getting a pulse rate if I palpate the pulse. So to me, auscultation just seems more rewarding and it is easier for me.

That's just me. I suppose it is just a preference just like choosing a miller vs mac for intubation, how you backboard, prefer monitor, etc. I feel I get the same info, more accurate, and more quickly by auscultating, and I feel palpating is a waste of seconds for me and more likely to be unreliable. That could be due to poorer sense of touch with me. Who knows? Preference I guess. I know people like palpating a pulse. I don't.
 
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mgr22

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If I cannot get a manual blood pressure, what does that say about the patient's blood pressure? If it was due to movement, do you think I'll be able to auscultate heart sounds or palpate a pulse? Are there other things I can use, probably more reliable, like awake and oriented patient? Their skin signs?

What does a weak/strong pulse indicate? Would I determine it when I ausculate the blood pressure?

Can you not hear the regularity/irregularity of the pulse when auscultating heart sounds or the blood pressure?

Can you not hear the rate (fast/slow) when you auscultate the blood pressure or heart rate?

Am I not touching the patient when I get manual blood pressures? Can I not feel their warmth or coolness?

For me, I used to palplate a pulse and then auscultate it as a confirmation. I found I was getting the same info with auscultation, found it easier, and more reliable.

If the patient is combative, it is gonna be hard to get any vital signs with most method, machine too, but my strength is usually auscultating the blood pressure and I am more likely to get all my vital signs auscultating it, I can auscultate it waaaaay quicker than the machine making it more ideal for combative patients. I can get almost a full set if the patient sits still for 6 seconds (multiply by 10 instead) versus just getting a pulse rate if I palpate the pulse. So to me, auscultation just seems more rewarding and it is easier for me.

That's just me. I suppose it is just a preference just like choosing a miller vs mac for intubation, how you backboard, prefer monitor, etc. I feel I get the same info, more accurate, and more quickly by auscultating, and I feel palpating is a waste of seconds for me and more likely to be unreliable. That could be due to poorer sense of touch with me. Who knows? Preference I guess. I know people like palpating a pulse. I don't.

The questions you're asking -- are you looking for answers or just being rhetorical? I'm only checking because your bio says you're a paramedic.

Maybe we're not understanding each other. When you say you don't like palpating a pulse, that sounds to me like a pilot saying "I don't like to look outside the cockpit" -- more radical than a personal preference.

I'm suggesting you approach your patient, grab a wrist and palpate a radial pulse, look at the respiratory effort, and get a sense of alertness -- all while starting a conversation. It would take you 10 seconds. The patient wouldn't even notice most of what you're doing. Don't count anything yet, just get an impression. Auscultating takes longer and makes multitasking harder. You could do that later.
 

Aprz

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The questions you're asking -- are you looking for answers or just being rhetorical? I'm only checking because your bio says you're a paramedic.

Maybe we're not understanding each other. When you say you don't like palpating a pulse, that sounds to me like a pilot saying "I don't like to look outside the cockpit" -- more radical than a personal preference.

I'm suggesting you approach your patient, grab a wrist and palpate a radial pulse, look at the respiratory effort, and get a sense of alertness -- all while starting a conversation. It would take you 10 seconds. The patient wouldn't even notice most of what you're doing. Don't count anything yet, just get an impression. Auscultating takes longer and makes multitasking harder. You could do that later.
Oh, I'm not really a paramedic.

Y'know, when I was in EMT school a million years ago, I heard people doing the pulse thing. Y'know? Multitask, ask questions, get a respiratory rate all while feeling a pulse. Do you really county respiratory rate at the same time as pulse? Are you really listening to your patient when counting the pulse or even just trying to get basic info like fast vs slow, regularity, and strength? The times I've seen it done, it was very unnatural, the patients did notice (they get very distracted when touched, sometimes annoyed when you haven't told them you were gonna do it), and the info obtain was not accurate. I kinda doubt that is something people actually do. It is like something that is said among teachers/firefighters/new people, but rarely executed, and I don't think I've ever seen it done well where they did obtain all that info while palpating a pulse.

From what I've observed, most paramedics (perhaps in my area) don't do manual vital signs pretty much ever unless their equipment failed to get one or gave a bad one. So the times I've seen it done, it is like flying with visual flight rules in inadvertent instrument meteorological conditions (pilot looking out their window instead of at their instruments in bad weather). Definitely see some paramedics end up like John F Kennedy Jr too.

I am under the impression that most major airlines fly with instrument fight rules mostly, and what they see out the window is just a nice view, night time view, some drizzles or clouds that isn't severe hopefully, and not really heavily relying on visual flight rules. Just kinda a glance out the window maybe. Of course, I am not a pilot either so perhaps I am way off on that. To me, auscultating a pulse is kinda like flying with instrument flight rules and that I am still taking a good glance out the window cause I am talking to my patient, touching them, doing a head to toe (something else I don't see many medics doing). The analogy is not great cause vitals aren't the only thing I am doing, it doesn't give me a great view of the patient (lets say you only do vitals, whether palpated or auscultated, could you use to identify your patient problem most of the time? Is it useful most of the time?) so saying I am using my vitals, auscultated or palpated, to keep my plane flying seems kinda silly.
 
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johnrsemt

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I love when people say that if a patient has a low BP then you can't palpate a radial pulse.
I walk around on a normal day at 80/40 and walked into the Blood Center to donate at 72/30 and always have a good strong radial pulse.
I have had a patient with BP's at 160/100 that we couldn't palp a pulse anywhere, and thought he was dead except for he was breathing.
There is no correlation, and my old medical director always wanted to find out who started that idea so he could beat him. lol
 

dutemplar

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There are a few times when you cannot get vital signs.

Basically, when they don't have them Say: cardiac arrest, chainsaw massacre or all limbs blown off, they're glowing and the hazmat team is still trying to decon, before they've been brought of of the snake pit at the zoo, while you're treating 100 patients at a time from an MCI. Or if the person is way too morbidly obese for any cuff to fit (no, seriously, we could not get an obese cuff around someone's forearm once...)

Yes, you essentially can. As they all said - practice. Know your landmarks. Feel for pulses (especially brachial), and put the steth on the right spot.

Whether the pilot of IFR, or VFR, they use the window and the gadgets to keep the plane from slamming into something. Vitals kinda help us do the same thing.
 

RedBlanketRunner

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To me, palpating a radial pulse (fast/slow, weak/strong, regular/irregular) while making eye contact with a (conscious) patient and observing respiratory effort should be done while beginning most patient interviews

One set of vitals is interesting. Two sets allow for a comparison.
For me, a very informative, instructive maybe a minute and a half - full EMT patient assesment course.
Patient brought in, ambulance, unconscious. Elderly frail female. Nurses having trouble with vitals including BP monitor and intermittent artifact irregular ECG. RT was called in, supervisor responded.
Upon entering the room he slow walked. A study in study. Feet, skin condition, toe nail beds, close inspection up the legs, general body stare, checks hands, A&P, nail beds, wrists as he checked for radial, moved up to brachial as he studied the woman's face, eyes, then ear almost touching her nose watching the chest, tried carotid, went back to brachial, stared at clock then announced "fifty to sixty, respirations ten. Steady.".
(There were numerous reasons why vitals were so difficult to monitor)
 

Jon

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I realize I've picked only one sentence out of a very long post, but it's the one I understood the least.

To me, palpating a radial pulse (fast/slow, weak/strong, regular/irregular) while making eye contact with a (conscious) patient and observing respiratory effort should be done while beginning most patient interviews in the field. I think those initial tactile and visual clues are usually harder to find with equipment.
I echo this as well.

I’ll admit that I’ve gotten spoiled by my automated BP cuffs of late - but there’s something to be said for being able to at least palp a quick pressure - and that is something I developed because of years of experience.

to the OP - I’ll give you the same advice I’ve given to some other partners I’ve seen over the years. Please don’t cheat yourself looking for the easy out. Don’t take blood pressures by just watching the needle bounce. Don’t estimate B/P’s based on presence of a radial pulse, and make sure you’re setting yourself up for success by not doing silly things like rounding to the nearest 10 points.
 

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