I usually put my feet on the gurney (the left foot on the undercarriage and right foot on the back part of the gurney). I'll then rest the patient's arm extended on my leg with the palm facing up towards the ceiling of the ambulance.
I've failed to auscultate a blood pressure because the cuff wasn't tight enough around the patient's arm. Make sure the cuff fits their arm like yoga pants or whatever, lol. It's not too tight, but it is pretty much attached or form fitting.
I put the diaphragm/bell of my stethoscope where I would palpate the brachial artery. I notice that there seems to be two to three different ways people palpate the brachial artery.
I often see people palpating it near the mid shaft of the humerus like in
this image. On an adult patient in a moving ambulance, I imagine that would be absurd or insane to try to palpate.
I palpate the brachial artery distal to that around the antecubital area (the bend of the arm, opposite side of the elbow) and medial (the part that is closest to the attached body when in the anatomical position / palm up). Here is an image of what I am describing (also taken from Google. The image link goes to
this website).
Some images/books I've seen show it in the center of the antecubital (example is
this), but I have never felt it in the center.
If you're going to palpate it, it is easiest while the arm is extended with the palm faced up.
I've always successfully palpated the brachial artery in the antecubital area and medial part of the arm. The bell or diaphragm of the stethoscope covers such a large part of that arm that any variation in where the brachial artery is easiest to palpate doesn't really matter. For this reason, I skip palpating the brachial artery and just place the bell or diaphragm at the antecubital and medial part of the arm.
Another issue I've notice people doing is tucking part of the stethoscope under blood pressure cuff. Some cuffs are even made with stethoscopes already attached doing this.
Here and
here is an image of what I am talking about. To me, it seems like you'll hear a lot more extraneous sounds like people talking, the ambulance vibrating, etc. when you do it this way. I avoid putting the bell or diaphragm of the stethoscope under the cuff as much as possible. The two are rarely touching. Here is an example of what it should look like to me (the image is taken from
this website).
A lot of people buy fancy stethoscopes. I didn't buy my first fancy stethoscope until I started my paramedic clinicals (if I were actually a paramedic, lol). I had the hardest time getting a blood pressure with them. Turns out that some of them are so fancy that whether it is easier to hear low or high pitch sounds depends on how hard you are pressing the bell or diaphragm. On a normal cheap-o stethoscope, you'll hear low pitch sound like blood pressures, heart tones, and bowel sounds using the smaller side called the bell (it's not actually for pediatrics like most people mistakenly believe) and high pitch sounds like breath sounds using the larger side of the stethoscope called the diaphragm.
Image is taken from
this website.
Anyhow, I was probably pressing pretty hard initially when trying to get a blood pressure. I'd press harder and harder trying to hear something thinking maybe I didn't have a good seal. Nope. Pressing harder was a bad idea.
In my opinion, although you should technically hear the Korotkoff sounds better using the bell of the stethoscope, which is what the AHA recommends, I don't think it really makes a difference with the cheap-o stethoscope. I usually use the diaphragm still because I don't personally hear a difference and people thought I was clueless for using the "pediatric" side. Got tired of being called out and then explaining it (if they even allowed me to explain it). I did find a significant difference with the fancy stethoscopes pressing harder. Be careful too cause some of them look like the standard bell/diaphgram, but they are actually pressure sensitive (eg Littmann Cardiology III, the one I bought).
Hope some of that helps.
