The Ultimate Guide to EMT Vital Signs

Part 3: The First Rule of Vital Signs

This is probably a good time to bring up the number one rule of vital signs. Remember the movie Fight Club? Everyone knew the first rule of fight club was to never talk about fight club. Now let me give you the first rule of vital signs. Burn it into your memory.

Never lie about vital signs.

Oh, I know. You think you’d never lie about vital signs. You’re an honest person right? Why would you lie about something as silly as vital signs? And yet, it happens…a bunch.

There you are deflating that blood pressure cuff. Everyone’s looking at you, waiting for your report, and you hear . . . . (wait for it) . . . (wait for it) . . . nothing! everyone is waiting. And you did see the needle bounce right around 120 and stop bouncing right around 70. The BP must be normal right? Couldn’t you just make it up and save face?

Don’t do it. It’s hard to admit when you just don’t hear the BP or can’t feel the pulse, especially when you think it’s something you’re doing wrong. It’s easier…and very tempting, to fake it. Don’t do it. You only have to make up incorrect vital signs once to completely blow your credibility.

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Mastering The Head-To-Toe Assessment

You probably practiced your head-to-toe assessment a bunch in your EMT class. Maybe more than any other skill in the EMT curriculum. If your class was or is anything like mine (as a student or a teacher) you performed the head-to-toe assessment again and again.

As much as we practice this skill in EMT class, I often wonder why so many EMT’s have such bad head-to-toe skills out on the street. It seems that, once we get out on the street, the systematic, thorough head-to-toe assessment falls out of favor and quickly gets replaced with the faster, more direct focused assessment.

That works just fine most of the time. If it didn’t, I figure it probably wouldn’t be such a universal phenomenon. (For the record, have you ever worked somewhere where this wasn’t the case? Neither have I.) The downside is that when the patient arrives who really needs a, honest-to-goodness, rapid, complete head-to-toe, we’re not up to the task.

I happen to believe that patient assessment skills are one of the defining qualities of a talented EMT. Here are seven tips to keep your head-to-toe in top form.

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Medicine Between The Frames

One of my favorite bloggers, Seth Godin, recently introduced me to the work of Scott McCloud, an author who’s written several classic books on understanding comic books. Scott dissects the comic medium and explains the ongoing allure of the comic book to the uninitiated.

One of Scott’s observations is that comic books require imagination on the part of the reader because, in all great comic books, the action occurs between the frames. The artist only shows you snapshots of action and dialogue. Most of the story takes place in our heads. The real story is the stuff that we invent that happened in-between the frames.

Medicine works in much the same way. We assess, we ask our questions, we do our head-to-toe and we make a guess (educated) about what’s going on. Then we make a change, and the medicine begins, after we make the change, not before.

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The Non-Conformists’ Guide is Here!

I’ve gone live with the book and newsletter sign up and it appears that everything is running smoothly. I’ve already had a half dozen sign-ups and the link has only been posted for a few minutes.

Thanks for your patience. This writing project took me nearly six months to finish. I had an idea of what I wanted this book to be and I wasn’t willing to stop until I’d succeeded.

The result is The Non-Conformists’ Guide to EMS Success. This is no pamphlet or power point slide show. This is 48 pages, almost 16,000 words, and chapter after chapter of compelling ideas designed to challenge the way you think about your job, your leadership, your life, and your role in EMS. And it’s all free.

If you’re ready to stop listening to me talking about it and get the book for yourself, just click the newsletter sign-up at left. The EMT Spot practices a strict, double opt-in, anti-spam policy. We’ll never reveal your e-mail to anyone, ever.

You’ll receive an e-mail confirming that you really did sign up for Splatter and the e-book. Once you click the confirmation link you’ll received your welcome edition of Splatter and the .pdf version of the e-book will be attached. It’s as simple as that.

The newsletter will also have an opt-out link at the bottom if you’d rather not be on the newsletter mailing list. (But I hope you’ll decide to stay)

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The E-Book is Coming!

OK, I can’t keep this to myself any longer. It’s time for the big announcement. With the final draft still in the mail from my editorial team and the final design still lacking a few details, it would probably be best to just keep this under wraps for a few more weeks, but I can’t wait.

My first E-book is scheduled for release on January 21st, one week from today. The e-book will be free and it will be available right here at The Spot.

The Book is called The Non-Conformists Guide to EMS Success. This book is the culmination of two decades of EMS experiences, mistakes, failures, trials, and errors that lead to my ultimate success. My goal was to write something that would be useful to EMTs at any stage in their career. And I didn’t hold anything back. This is my road map to finding true success and fulfilment in EMS work.

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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.

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Test For Unconsciousness: The Sternal Rub

Ahhh the embattled sternal rub. Revered, reviled … the sternal rub is the Ann Coulter of medical interventions. Abrasive, annoying, loved by many, hated by many more. The subject of the usefulness of the sternal rub is bound to cause controversy in any EMS forum.

In other words … it’s a great subject for The Spot.

Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.

Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.

If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.

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Atypical Cardiac Chest Pain

We taught you what cardiac chest pain looked like, right? You remember.

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

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Understanding OPQRST

After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.

For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.

This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.

Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.

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Test For Unconsciousness: The Hand Drop

After I wrote a recent article on the benefits of the face flick for assessing level of consciousness, I received a string of questions and commentary on the effectiveness of another, more well known assessment for unconsiousness - the hand drop test.

The hand drop test is considerably more well known than its cousin the face flick and it remains a fairly reliable, though somewhat controversial test.

There’s a reason why the hand drop test is so well known. It tends to work. It’s a clever and reliable way to force a patient to make a decision and reveal their true mental status.

When done properly it’s harmless and does not require forcing pain or noxious stimuli on the patient. It also has the advantage of  being appropriate to perform in front of family and loved ones. Unlike the face flick which is a bit to obnoxious for public consumption, the hand drop can be performed anywhere and looks like a fairly standard neurological test. If you don’t have this one in your tool box yet, it’s time to add it. If you do know it, let’s review it. There are some subtle elements to doing the hand drop test accurately and safely.

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