The Art of The Pulse Check

   Fast or Slow, Strong or Weak, Regular or Irregular

I’d like to teach you how to take a pulse in three seconds or less. Yes it’s possible.

I am, quite possibly, about to contradict everything you learned about taking a patients pulse in your EMT class. Hear me out on this one.

In general, I think we overemphasize the importance of coming up with a set of numbers that represent the patients vital signs and we underemphasized the importance of placing the patients vitals in context for their condition. The pulse is a prime example of this dynamic at work.

The patients pulse holds a wealth of clinically significant information. The exact heart rate isn’t one of them. Sometimes, we get this misconception lodged in our brain that the purpose of feeling the patients pulse is to determine how many times their heart is beating each minute. We will dutifully devote 15 seconds, 30 seconds … yes some even advocate taking a full minute to make sure this number is perfectly accurate.

I disagree. You can determine everything you need to know about the patients pulse in three seconds and then move on. The next time you kneel to take a patients pulse, consider these four, clinically relevant findings instead of staring at your watch.

1. Estimate the heart rate.

That’s right, just take a guess. The more you practice this, the better you’ll get. You should be able to guess the patient’s heart rate to within four beats-per-minute in either direction. That’s as close as you need to get. Get in the habit of grabbing a pulse and estimating the rate before you look at the monitor or count it off a watch. You’ll be surprised. This isn’t as tough as it might seem.

2. Is the patient’s heart rate to fast or to slow?

Start thinking like Goldilocks. You know … from the nursery rhyme? Everything was either too much or too little or just right. Once you have an estimated idea of the pulse rate ask yourself, “Is that too fast for this patient, too slow for this patient or just right? Knowing whether the pulse is too fast or too slow in the context of this particular patient is much more important than having an exact number.

3. Is the patients pulse strong or weak?

Imagine the heart as a pump (it is) sending a wave of pressure through the arteries and out to your gloved fingers. Is it a strong pump or a weak one? Does the pulse bound strongly or is it thready and weak? This is significant.

A quick note on weak pulses; don’t spend to long searching for a pulse you can’t find. We tend to doubt ourselves when we are unable to find a pulse so we keep searching, and searching … and searching. If you can’t feel a pulse, check quickly at the brachial artery and then grab your blood pressure cuff.

If you find that the blood pressure is adequate you can always come back and search around for that pulse, but don’t delay the continued assessment of a possibly hypotensive patient to search for a pulse.

4. Is the patients pulse regular or irregular?

Does the pulse have a nice regular cadence to it or does it occur irregularly. An irregular pulse will present in gallops and pauses. It can be subtle or obvious. In some cases, an irregular pulse is not clinically important finding. In some cases it could be medical emergency. Note the regularity or irregularity of every pulse you check.

What I’d really like you to take away from this is that the exact heart rate is pretty low on the clinical significance scale. We tend to spend far too much of our time, energy and focus on obtaining a highly accurate heart rate and not enough time or focus on the things that are very significant about the patients pulse. Is it too fast or too slow? Is it strong or weak? Is it regular or irregular? There will be time later to get the heart rate nailed perfectly. And if there isn’t … it probably wasn’t that important anyway.

So what do you think? How much time do you spend taking a patients pulse on scene? Do you agree or disagree with my thoughts on the importance of that task? When is it very important to have an exact heart rate? Is it ever? Leave a comment and let me know.

        

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Comments

  1. I’m a first aider. If I took 3 seconds guessing a pulse, they’d flay me alive. I already got in trouble for counting breaths and pulse at the same time (ie, count pulse while counting breath in the same 15 secs, as opposed to 15s on one, and then 15s on the other).

    That being said, I think you’re dead on the money, and I’ve made the argument in class a few times. But it’s pretty entrenched in our instructors’ minds.

  2. Steve Whitehead says:

    And so it begins … this is an idea that’s bound to meet with some opposition. Both here and in the field. Maybe you could ask your instructors to explain … or even ask one of them to come here and explain to all of us … why is an exact pulse rate so important early in the patient care process?

    Thanks for coming by Newt.

  3. For estimating I use a 2 second interval. Of course this is only for an initial check which is standard anyways. When doing a trauma assessment, your not looking for an exact number when first making contact.This comes when you actually take a set of vitals. Yet people always spend at least 15 seconds trying to figure things out. I use the following

    1 beat in 2 seconds….somewhere around 30 BPM
    2 in 2 seconds…..60
    3 in 2 seconds…..90
    4 in 2 seconds…..120

  4. Well, when doing Industrial First Aid, your instructors have stopped somewhere around the level of a Basic EMT. They have a lot of experience at their particular level of training, but not much more (and they’re terrified to go beyond that).

    As an example, during my examination, I was given an open chest wound (the patient had a rebar go through his lung). However, his vitals were normal, he wasn’t clammy (no signs of shock, yet), and so I decided to, after doing my initial assessment, to block the wound with esmarch bandages before getting him ready for transport. I failed that part on the spot, because it goes against the book (the instructor mercy-passed me, because she knew my logic was correct).

    In my neck o’ the woods, OFA instructors are very much a “by the book” type of people, who then say that “in the real world, these are only guidelines”. But don’t give any critical thinking skills, just a bit of “how to”.

  5. I’m with you on this one Steve. Like Goldilocks, a pulse guesstimate is good enough most of the time. In the grander scheme of things…does it really matter that the pulse is say 64 or 82? The main thing is that it falls with an acceptable parameter for any given situation. In addition, anything that could discourage ambos from defaulting to the pulse oximeter or non invasive blood pressure monitor for a “pulse”, would have to be greeted with enthusiasm. On a seperate issue, patients find a pulse check a non-threatening form of tactile reassurance.

  6. I have been doing this for years as an EMT and Paramedic, although I never thought it out this far. There have been very few situations (Probably none, but I’m not sure) in which knowing the exact pulse rate changes my treatment.

    I get impatient waiting for someone to count a pulse when all I want to know is if its normal or not and why.

    I also get that “are you stupid” look when someone asks what the pulse rate is and I only tell them its normal. Fortunately, I don’t get that look much being the only paramedic covering a large rural area in a mostly BLS volunteer system.

  7. @Graeme Im glad you agree … (though I was secretly hoping for some disention on this one) And, it’s worth pointing out that there are some cases where being very accurate about the pulse has some clinical value. But those cases (as you say) are few and far between.

    @Tim I think that holds true for a lot of responders. I think most experienced medics do something like this though they may not articulate it even to themselves.

  8. Now just add in “Does every P have a QRS?” “Does every QRS have a P” and you have the basics of primary intervention cardiology. So simple it hurts, yet so effective, well, they’ll never go for it.
    If I determine in 4 seconds a patient is bradycardic, I don’t need an accurate count right now. If I feel 4 beats as soon as I latch on, we’re in trouble as well. Be it 180, 200 or 240, we’re going towards the monitor without the 60 second count.
    And the line counting method…works every time.

  9. I agree, we spend too much time on details that don’t make a difference at the early stage. One point worth adding is that having a ‘number’ early on does help later to access the effectiveness of one’s treatment. That is: “is he doing better now that I did [this or that intervention]”. Changes are significant indicators, what is the O2 sat on room air BEFORE we give O2? Is it improved?
    Still getting a specific number should be less important than gettng the patinet timely interventions. Folks who put too much emphasis on this (I call them ‘protocol nazis’) generally haven’t put the whole ‘patient treatement thing’ together in their heads yet. They are treating signs and symptoms, and not the patient. In time, one hopes they will get there.
    Capt. Tom

  10. I agree- my only problem as a geriactric nurse is checking apicals for HTN meds and cardiac meds- it requires more accurate assessment. I have also found most supervisors and Dr.s only want the “set” of vital signs- I don’t think I have ever heard any comments about the pulse specifically. We DO however, get nailed for describing a pulse rate as “normal” because some elderly are tachycardic on a regulart basis and that is their norm. Others, thanks to the cardiac meds they are on, are closer to 60, and a few even run in the range of high 40″s to 50’s without the meds..In EMS , it is more important to assess the rate more frequently due to the potential for a patient going into shock.

  11. Steve Whitehead says:

    @The Happy Medic Line counting method … big fan.

    @Capt. Tom I can see where you’re coming from, but even with patient improvement or deterioration, don’t you think there are other signs that tend to be better and appear sooner, (ie. skin signs, LOC, distress, effort, systolic BP, etc.

    @Nancy. I think you’re in a situation where accurate vitals are far more important. You’re tracking long term care needs and you have more time since you’re usually not managing a medical emergency. Now, if you walk in to the room and the patient is having a medical emergency, I think the 3 second pulse now applies.

  12. Good post!

  13. I have only been in EMS for about 2 years now, and I had realized this quite a while ago. I really started out as an EMT doing transport, and so spent a lot of time working on my vitals skills, so that I could get a really accurate BP in the back, and count out a halfway decent pulse while the driver found every pothole in the road. It was then that I realized that I could get a very accurate guesstimation of HR without counting for the full 10, 15, 30, or 60 seconds. The only time I really stop and take a long time getting a pulse is when it’s very irregular, and a semi accurate count become more difficult. When I do this, I try to remember to not say the pulse is ‘about ___’ just give a number. I had a couple partners/medics who would reply is it ‘___’ or ‘about ____’. (my response is usually that the HR is between such and such, closer to which number, and then ask if they really want me to get something more accurate. they usually don’t) Now there are very few medics I work with that question me when I tell them ‘the HR is about 70 and irregular, like a-fib irregular, not PVC irregular’ (or opposite).

    I wonder how many people ever get a pulse count from the bp cuff. (manual, not automatic). When the patient is stable enough when I arrive on scene, I will check the bp first, and tell whoever is writing that bp is 126/78 and pulse sounds like 80, regular/irregular etc. Then I usually do a quick 3 second check to confirm “yep, about 80” and also get a strength measurement. This method also helps me when the patient has an irregular heart rhythm to get an idea of what i’m going to be feeling, and makes that recheck a bit quicker.
    How do you feel about doing the same thing for respiratory rate? My question is usually is the patient breathing too fast, too slow, or right about where they should be, and is it adequate. If my initial look tells me something is abnormal, then I will get a more accurate count.

  14. Steve Whitehead says:

    @Cathrine I feel like I can hit the respiratory rate pretty close, but it’s harder. And I think we chronically under-guess at the rate. I do the same guesstimation early on but I always recheck myself later.

    You’re going to run into some folks who get really uptight about the exact numbers. It’s interesting to ask them why they felt an exact number was clinically significant at that moment. You’ll get an answer regarding the importance of accurate documentation and proper hand-off, but bring them back to the “clinical significance” question. Perhaps it was significant, but make them explain why.

    It can be helpful to describe heart irregularity as regularly-irregular (Many PVC’s, Wenckebach) and irregularly-irregular (A-fib). Instead of trying to guess the underlying rhythm, your just describing exactly what you’re feeling. (Which also allows you to take a guess)

  15. EMTBella says:

    Funny enough, I began doing the “2 second pulse check” a couple of months ago (except, I do it twice over 4 seconds for a better guess-timate) and i found it easy to get used to, especially on EDP’s and peds calls. Reading it here put it in a much better perspective.
    If only I could eye-ball a BP, I’d be golden… but we’re not going to try that. 🙂

  16. I have been using the “hold the wrist and stare at my watch” trick as a way to get 30 seconds of peace at a scene. I have found that people won’t bother me while when I’m in that position. It will establish me as a trained caregiver if I’m not in uniform and gives me a chance to size up the scene and situation. Sometimes it also calms the scene a bit, kind of a reset.

Trackbacks

  1. […] The Art of The Pulse Check […]

  2. […] The Art of The Pulse Check […]

  3. […] actually pretty low on my pulse check priority list. Before that, I primarily want to know if it is fast or slow, strong or weak, regular or irregular. Most of the really important stuff can be figured out in the first three seconds of your pulse […]

  4. […] I disagree. Cuff placement is important. Start with the brachial pulse. If you have trouble finding the brachial pulse, you can review the location here. The location of the brachial pulse can vary considerably from patient to patient. Don’t assume you know where it is. Find it and place a finger on it while you grab your cuff with the opposite hand. while you’re here, note if the pulse is strong or weak, regular or irregular, fast or slow. […]

  5. […] When it’s time to take a real-deal, documentable respiratory rate, find a moment when you can delegate a task to another provider, then step back and watch. I know that it’s common to teach people to pretend that they’re taking a pulse while they watch the respirations. This patient care head-fake always seemed a bit awkward to me. I just feel like I’m giving the appearance of taking a ridiculously long time to take a pulse. (Remember that I’m the guy that advocates for the three second pulse check.) […]