It’s an important moment because it’s an opportunity to make a very real, human connection with our patient and leave them with a positive impression of their experience with us and our service organization.

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There’s an interesting little bit of behind-the-scenes information about how I started the tradition of saying these two things before I left a patients room. I picked up the idea of always saying that I was glad to be of service to the patient early on while working at Pridemark Paramedic Services.

Jeff Forster, the organization’s CEO, was the first EMS leader I encountered who really challenged his people to take their service level up a notch and maintain a patient-needs-first focus.

Years later I had a partner named Will Dunn. Will went on to be a popular EMS instructor in the mid-west region as well as a paramedic supervisor and education coordinator for Eagle County Ambulance District.

Years after our partnership, Will and I were having lunch together when he brought up how he’d picked up on my habit of leaving each patient with a hand-shake and warm goodbye. He told me that he had been doing it ever sense our partnership. I respected Will as an excellent paramedic and I was proud to know that I had influenced his care in that way.

Then he told me about how he always asked if there was anything he could do for the patient. I really liked the idea and started trying it out immediately. I’ve been doing it ever since.

I was influenced by Jeff, then Will learned something from me and then I learned something from Will and now, perhaps, you can learn something from all of us. It’s amazing the way we influence each other, isn’t it? I hope you’ll try this out and I hope you enjoy the video.

Leave a comment and let me know how it goes. It’s been a pleasure being of service to you today.

I can disclose much about the different methods and results that the engineering team experimented with, but I will tell you this, if you want to drop someones core temperature fast, nothing is quite as effective as a quick, two litter bolus of  cold saline. This is why most therapeutic hypothermia protocols begin by inducing hypothermia, not with some fancy cooling blanket or external cooling device, but an infusion of 37 degree saline.

With that thought in mind, how important should it be to keep the saline we infuse into our patients whom we want to keep warm at something close to body temperature? I hadn’t really given the question much thought until I got an email from Scott.

Scott’s one of those SWAT medic types. He works with his local SWAT team to provide on site medical interventions if the need arises. Scott had an interesting experience with an accidental infusion of ice cold saline. I’ll let Scott take it from here:

“I am on a tactical medic team.  The temperatures here have dropped recently (as they always do this time of year). We recently had a call out. Most all of our medics have an entry bag that stays in their vehicle and a main bag that stays in the response vehicle. As you can imagine, neither of these are heated or cooled, “temperature controlled” environments.”

“On this call out, we had an officer who was walking through the neighbors yard to provide perimeter security when he obtained a fairly significant laceration on his lateral right leg. As most officers would, he brushed it off, vowing to deal with it after the incident. After about 45 mins he finally called for a medic. We replaced him with another officer and escorted him back to the command post. “

“The officers leg from the laceration down was soaked with blood, pant leg, sock, everything. This officer was being particularly hard headed and said he would go get it looked at in the morning and asked us to simply bandage it for him. My partner was able to talk him into an IV because of the blood loss. I was focused on bandaging his leg while my partner started a 500 cc normal saline bag. I left to go back to the perimeter after finishing with the bandage and my partner stayed back to monitor him and finish his IV. “

“I was at the perimeter for all of 20 minutes when I was called back to the command post for assistance. When I got back the officer was lethargic, his extremities were cold to the touch his teeth were chattering, and he was slightly confused. “

“My first thought after, “Oh shit!” was shock, but I had a brief moment of sanity before the panic set in. I took my partners glove off and told him to grab the IV bag. As you guessed it was freezing cold to the touch. He had put the officer into hypothermia by giving him a sub-zero fluid bolus. “

“We quickly called for a unit, covered him up, took vitals and proceeded through our hypothermia protocols. “

“It had not even occurred to my partner that his IV equipment has been in his freezing cold trunk all night, and even when the patient went down hill, he didn’t see the obvious signs of hypothermia. In treating this officers laceration he nearly caused a more serious medical emergency. “

“Most agencies keep their trucks in a climate controlled bay or have a solution to heat their units or bags. However there are some that don’t. I thought this might be worth sharing with you. “

Thanks for the story Scott. And yes, it is worth sharing. I’ve mentioned before the importance of keeping trauma patients warm. As winter sets in here in Colorado, I can imagine all kinds of scenarios where this mistake could play a significant role in the patients outcome. Our medic units use warming plates for our IV bags, but the one in the kit remains unheated.

I also consider how many times I’ve started IV’s on the side of the road in a snow back or deep in the back-country. IV bags get left outside on special events and coverage situations like the one Scott describes here all the time. The next time you’re outside in the cold or pulling an IV bag out of a kit, don’t forget to feel that solution. Induced hypothermia does have its applications, but most of our patients will benifit from warm fluid.

Thanks for the tip Scott.

Send me your contribution and, if  you make the final cut, you’ll see your advice immortalized right here in a future post. This is your chance to contribute to the ever-growing database of EMS knowledge that is The EMT Spot. I’d love to put your name right here, along side many of the industry’s top educators and EMS practitioners.

Send your IV starting advice to steve@theemtspot.com, send me a tweet @SteveWhitehead or click on the comments section and add your advice right here and now.

This post won’t be awesome without you. What are you waiting for?

Here are a few things to consider before you run your next obstetrical call.

1) At full term, pregnant females have a heart rate 10-15 beats per minute faster than when they were prepartum. (Psst…Before they were pregnant.) They also have 25%-30% higher stroke volume and 30%-50% higher cardiac output.

2) Pregnant females will tolerate significant blood loss before they become symptomatic. Once they are symptomatic, they will decompensate rapidly.

3) The official obstetrical term for the mother’s water breaking is “rupture of membranes”. It can be documented with the abbreviation ROM.

4) Unlike the Glasgow Coma Score, you can’t just guess that a healthy baby gets an automatic 10 on the APGAR score. Most healthy babies are born with a score between 8 and 10. In some regions of the United States very few babies are ever scored a 10 at birth.

5) You won’t remember the APGAR score when you’re holding a newborn baby in your hands. Write it on your OB kit.

6) All things considered, moms tends to be the best judge of when labor is eminent.

7) In your EMT class we drilled on the idea that mom should be laid on her left side. More recent research has indicated that getting mom on her side is the important part. Whether she’s on her left side or right side makes no real difference.

8.) Designate the person with the least to do as the official time keeper. Make sure they have access to the most accurate clock available.

9) 600 ccs of blood pass between mom and baby every minute. Mom can loose 1,000-1,500 ccs of blood before she becomes symptomatic. Typical postpartum hemorrhage should be in the neighborhood of 500 ccs.

10) Delay transport if delivery is eminent. Don’t delay transport for delivery of the placenta. It can take hours. Once baby is out, package for transport.

11) Aggressive (uncomfortable) fundus massage is still the best method to slow postpartum hemorrhage.

12) Cut the cord between the clamps. (Seriously…it happens.)

13) When delivering twins, both babies will deliver first. Both placentas will deliver after. Any other ordering is an obstetrical emergency.

14) Fetal trauma cannot be ruled out in the prehospital setting. Lack of vaginal bleeding or pain on palpation does not rule out fetal trauma. Pregnant mothers who have suffered any significant mechanism to the abdomen should be transported for evaluation. (They will typically be observed for 12-24 hours.)

15) Don’t forget to prepare for two patients.

Now it’s your turn: What OB tips would you add to the list?

More Goodness:

Trauma Care, 2 Minutes, 2 Hours, 2 Weeks

How to Double Your EMT Income

Heart Attack Symptoms and Women

The Protocol / Skill Breakthrough

Four Steps to Moving Past Medical Mistakes

“It’s the space between the bars that holds the tiger.”

-Zen Koan

How does anyone become really good at what they do? Is there a magic recipe?

From the opposite side of the bars, an adult Bengal tiger studied me from his resting spot. He was big, topping out just over five-hundred pounds. He was also strong. Pound for pound a tiger is four times stronger than a man.  Our guide explained this to me while she pointed out some of the finer elements of the great cats stalking behaviors.

The Feline Conservation Center in Rosamond, California, isn’t like a typical zoo. There are few barriers that prevent guest from reaching inside the cages if they chose to be so foolish. Hence our watchful guide. At the observation end of the enclosure, thirteen bars kept me from becoming tiger lunch. Once the great cat fixed on me, they seemed hardly adequate.

In truth, they weren’t. Bunch them all close together and the tiger would surely escape. Space them randomly across the gap and you’d get the same result. In fact, even the slightest alteration in the spacing between the bars would produce the same result. Free tiger.

While we tend to pay attention to the bars, it is the space between them that contains the power of the tiger.

If you’d asked me what saved me from becoming a tiger snack, I would have undoubtedly pointed at the bars. We tend to focus on what we can see. We are drawn to the obvious. The necessary perfection of the spacing would have never crossed my mind. And so it is with our job skills.

If you told me about an EMT that you know who is really good at what they do, undoubtedly, you would tell me about how they perform on calls. You would tell me stories about their great patient assessment skills or their ability to ask that just-right question in that just-right moment to bring the whole call together. You might discus the way the interact with people or their superior clinical skills.

You would point to the things they do from the time the call drops to the time they place the patient in a hospital bed.

Hard evidence. Strong proof.

You would point to the bars.

While it is their performance during a call that defines them as great, it is what they do in between the calls that makes them great. We tend to pay attention to what they do during the calls. It’s what they do between the calls that contains the power of their skill set.

The next time you have an opportunity to work with someone you feel is really good at what they do, pay attention to how they use the space between their working time.

Notice if they leave the hospital room immediately after giving a report  or if they linger and listen to the questions the hospital staff ask and talk with the doctor about their impression of the patient.

Notice how they check out their rig before their shift.

Notice how they respond when they encounter information that they are unfamiliar with.

Notice what they do when they make a mistake. (Yes, they do make mistakes.)

Notice if they spend time on continuing education, or research.

Notice the million little things that they do to prepare themselves for the next call.

What they do on the next call will be the thing that people talk about. What they do before the next call is every bit as essential. I imagine it’s the same for just about anything.

What about you? What do you do with the space between?

As we explained in the protocol / skill connection, we are dependent on our protocols to different degrees at different levels of skill development. This is defined by the Dreyfus model of skill acquisition. Misunderstanding this concept leads to some predictable problems.

The problem with our protocols is that they were written with the expectation that everyone would use them the same way.

The problem with our field education is that proficient and expert field providers teach novice and advanced beginner students. These two groups think differently about their protocols.

Let’s look at both of these problems a little more closely.

1.) The problem with our protocols.

Your protocols were developed by a group of physicians who were trying to give direction to a competent EMT or Paramedic provider. Remember the competent caregiver? She’s the one who feels safe operating inside of her protocols and still depends primarily on rules, guidelines and routines.

This Goldilocks approach to protocols is neither too hot nor too cold but it leaves a large segment of caregivers wanting something more. Our novices want more detail. Our advanced beginners want more structure to the prioritized treatment lists. Our proficient caregivers want to be able to operate outside of the protocol with less formality and scrutiny and our experts want to work without the protocol book at all.

This can also create problems if your quality assurance manager has an idea that everyone should adhere to the protocols as if they were an advanced beginner. If the care provider is an advanced beginner, that level of compliance may be entirely appropriate. If the caregiver is proficient, there are going to be some problems.

With both of these situations, the clear answer is to build protocols with detailed direction meant to guide the caregiver through an example of what ideal care might look like with an emphasis on flexibility. Protocols should guide appropriate care; they should not dictate appropriate care.

The necessity of that guidance will change as a caregiver’s skill and knowledge advance. When we are reviewing field care, we should always focus on the appropriateness of the care given, not the strict adherence to protocol directed treatment. If our field personnel are giving appropriate care that falls outside of the protocol, the problem is with the protocol, not with our providers.

2) The problem with our field education.

In the documentary movie Hearts of Darkness, Francis Ford Coppola describes his frustration with actor Dennis Hopper’s improvisation from the script. Hopper would want to enter the scene and just begin filming and see how the scene flowed from there. For a brilliant (Read expert) actor like Hopper, this type of improvisation was appropriate.

There was just one problem. Hopper hadn’t read the script. Coppola and him would have yelling matches with each other where Coppola would lament, “You can’t improvise from the script if you don’t know the script!” Well said Francis.

As new providers enter the field we need to account for the fact that they will be highly dependent on their protocols. They need to learn the script. A certain level of protocol dependence needs to be OK…in fact, in needs to be emphasized.

The problem we can run into here is when we take on a new trainee and we have an expectation that they will act as a proficient provider immediately. The new provider needs to know the rule book before they can deviate from the rule book. As field instructors, we can’t rush into demanding improvisation from the script until we have emphasized the need to learn the script.

We need to teach the script. And we need to recognize that it can be hard to teach someone a script that we haven’t been using for years. It’s easier to just say, “Do it the way I do it.” But that is a recipe for disaster.

If we are the new trainee we can also get ourselves in trouble by wanting to eschew the formality of protocols when we haven’t yet developed the skills to do so. This isn’t a field known for attracting people who are willing to take the long slow approach. That just isn’t in our DNA. But skill development in something as dynamic as EMS is a long slow process. It flies in the face of our impatience.

When we put our protocols in the context of the Dreyfus skill acquisition model our view changes dramatically. We change our perspective and recognize that protocols are not a one-size-fits-all endeavor. We change the way we see this essential element of EMS care. Hopefully this model will eventually change the way we write protocols, the way we perform quality assurance, the way we educate our EMS novices and the way we use the protocol book during patient care.

All of these changes can start with you.

What do you think? Are these the two most significant challenges to our protocol use? What are the others? Does the Dreyfus model change the way you see your protocols? Leave us a comment and join the discussion.

Read more stuff like this:

The Protocol / Skill Connection

What is an EMS Nonconformist?

Why Do Bad Ideas Stick Around?

Written Protocol vs. Common Sense

Quality Assurance in EMS

If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow.

Such is the nature of growing things.

It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works.

Stuart and Hubert Dreyfus developed the Dreyfus model of skill acquisition in 1980 at U.C. Berkley. They were working for the U.S. Air Force at the time, an organization who, I imagine, is keenly interested in how people develop advanced skill sets like aerial dog-fighting.

As you develop complex skills, you go through five phases. During these phases you are reliant on rules and guidelines to differing degrees. If I know where you are on the Dreyfus skill acquisition model, I can tell you exactly how dependant you are on your written protocols. I can also tell you whether or not you feel supported or confined by them.

Here are the five phases of skill acquisition.

1) Novice

As novice learners, we demonstrates strict adherence to the rules and the plans that we have been taught. We devote most of our mental energy to recognizing which rule best applies to the current situation and enacting that rule or plan.

When we are novices, we do not exercise discretionary judgment. We don’t like either-or situations and we don’t want systems built with too many user directed preferences. We want to be told what to do.

As you might imagine, in our novice phase, we are dependant on rigid, well defined protocols. We are afraid of the possibility of running into situations that are not addressed by our protocols. At this phase, more rules are better than less.

2) Advanced Beginner

This is the phase when we begin to develop some situational perception. We can recognize that some rules only apply to certain situations and not others. We start factoring in more if-this / then-this types of decisions, but we still follow the prescribed actions religiously.

We also still struggle to prioritize our actions. We know the right things to do, but ordering them appropriately is still something that needs to be emphasized by our rule book.

During our advanced stage we will remain extremely dependant on our protocols and may even wish that they were broader in their scope or more detailed in their descriptions of which treatment options should come first or second.

3) Competent

As we achieve competence, we experience a rush of new skills and abilities.This is when we often feel that we have come into our own with our medicine. In our competent phase we learn to cope with “crowdedness” or what we often call multitasking. We can now remember a list of medications, evaluate lung sounds and keep a watchful eye on the scene at the same time.

We also begin to plan ahead and see several steps into the future, directing our current activities towards future goals. We might set up our intubation equipment at the same time that we prepare a nebulized medication, seeing the two possible futures that lie ahead. Another hallmark of competence is the development of routines. We become particular about how we set up our rigs and our equipment with strong preferences about what goes where.

In our competent phase we begin to first see the inherent weaknesses of our protocol system. We may seek to operate outside of the rule book in some situations. (Hopefully with guidance.) When we are competent, we feel safe within the protocols but we also begin to feel confined, perhaps wanting for more treatments, more options and more protocols to regulate their use.

4) Proficient

As we transition from our competent phase to our expert phase we need to go through a prolonged period of proficiency. As proficient caregivers we are able to sense a holistic view of the situation. Our brains conceptualize how all the parts have come together to create the scene before us. We master prioritization of actions and we see when and how deviation from the prescribed course is desired.

It’s important to note that we don’t desire to deviate from the rules because of a sense of rebellion or a desire to break the rules. We want to deviate because we can see that there is another, better path for the patient. We recognize that placing this particular patient on a c-spine board is simply the wrong course of action. We know that nitroglycerin isn’t going to help this particular patient; in fact, it may hurt them. We know that the book says it’s time to give Lasix, but that course of action is useless. (Not contraindicated…that’s a rule. Useless as a concept.)

As proficient caregivers, we often process much of our decision making on an unconscious level so we may not be able to describe why we wanted to do what we wanted to do. We may fall back on axioms like “Skin doesn’t lie” or “When the Glasgow is less than eight, intubate.” to explain what was actually a very complex mental assessment.

This is the phase when we truly want less protocol driven treatment. We want to take the tools we are given and use them as we see fit. When the patient fits the protocol, we treat them by protocol, not because of the protocol, but because the protocol is correct. At this phase, protocols can only serve to confine us and we see less and less importance in their existence.

5) Expert

When we become experts we transcend the rules and the guidelines and the axioms and we act out of our intuitive understanding of the situation. Very few of us will ever fully move from competence, through proficiency to expert. When we do, our protocols are no longer necessary. Not only do we treat from our tacit understanding of the patient’s condition, we have learned the mechanisms to safely provide the treatments required within our scope of practice.

When we achieve the expert level of skill we can see what’s possible and analyze new treatments and approaches, applying all that we know to unknown situations and developing the best course of action. When we are experts we can write the next protocol. We create the rules for others to follow. We see the importance of our protocols from a different light. We see why they are necessary for the next provider that comes along.

And now you see too.

Next time, I’ll tell you why all this can be such a problem for EMS educators and EMS bloggers in particular. But first, I’d like to know what you think about all that. Where are you on the skill continuum? Does the Dreyfus model apply to EMS? Leave a comment and let us know.

Read More Stuff:

Too Much Information

Where Do You Put The Fear?

6 Reasons Why You Should Be A Better EMT

The Ultimate EMS Protocol

What Makes a Good EMT?

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.

Report a 120 over 80 blood pressure to your partner when it’s really 60 over nothing just one time and your credibility as a caregiver is shot. Tell the hospital the patient has a strong pulse at 84 bpm when it’s really weak and irregular at 136 bpm just one time and it will be a long time before they trust your hand-off report again. Medicine is harder when your colleagues don’t trust you.

Everyone has had the experience of not being able to feel a pulse, or hear a lung sound or a blood pressure. Practice your vital signs. Take them diligently and then tell the God’s honest truth about what you find.

Now it’s your turn: Have you ever been tempted to lie about the vital signs? Have you ever done it? What happened?

Read more EMS stuff:

Medicine Between The Frames

Beyond the 1-10 Pain Scale

You Can’t Give Away What You Don’t Have

Waiting Is Serving

Self Destruct

I love teaching each new EMT class cycle how to take a blood pressure. It’s fairly simple and strait-forward, but there’s also a real art to it. Folks who are good at it wield their blood pressure cuff like a teppanyaki chef wields his knife. You can tell they’re good by watching the confidence in their movements, the order that they perform the steps, and the attention they give to the details.

There’s a big difference between the guy who chops vegetables down at the local Denny’s and the chef at the Benihana. Same tools, different level of skill. You see what I mean right? If your blood pressure skills are still somewhere in between the short order cook and the teppanyaki chef, here are some tips to getting better.

1) The blood pressure starts with a pulse, not a cuff

Most folks put the cuff on the patients arm without much thought to the location. Sure, you were taught how to place the cuff correctly back in school, but, hey, you’ve been doing this a long time so…

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.

Now place the cuff with the artery label directly above the brachial pulse with about an inch between the pulse point and the cuff. Oh, and this is a good time to make sure you have the correct size cuff. If you have trouble getting a good seal on the Velcro you may need to move up to the big boy cuff. To much overlap may mean you need the Lilliputian size.

2) The stethoscope comes next

Don’t start inflating that cuff yet! Often, folks get the idea that the next move is to start pumping the cuff up to the 200 mmHg range. Hold off their camper.

Place your stethoscope on the patient’s arm and place a bit of pressure on the bell. Now start inflating. Since you placed the cuff and the stethoscope first, now you can listen on the way up. Pay attention to when you start to hear those whooshing Korotkoff sounds. Are they regular or irregular? do they sound fast or slow? Are they loud or soft?

You’re going to know when to stop inflating the cuff because you’re going to hear when the sounds stop. Now you can tailor your cuff inflation to your patient. No more guess work.

3) Nice even drop

With practice, you’ll figure out which needle drop rate is right for you. Too fast and your systolic reading may come out inaccurately low. Too slow and everyone on scene will start tapping their foot waiting for your results. Nice and even.

You’re listening for the first clearly audible whoosh (Or thump…pick your poison.) and the last whoosh before silence. The first clear whoosh is your systolic pressure and the last one represents the diastolic pressure.

There’s some debate over whether the true diastolic pressure is represented by the transition to the fourth Korotkoff sound (deep whoosh) or the fifth korotkoff sound (silence). Don’t worry about it. The current common practice is to use the transition to silence as the true diastolic pressure.

If you want to get fancy you can also grab a quick six-second pulse by counting the korotkoff sounds. Freeze the needle in between the systolic and diastolic pressures, glance at your watch and count how many whoosh sounds you hear in six seconds. Multiply by ten and then continue dropping the needle. Now you’ve got a fairly accurate pulse and a blood pressure all in one.

4) Listen for a blood pressure; don’t look for a blood pressure

The bumping of the needle often seen on the sphygmomanometer (the gauge) during the needle drop may or may not coincide with the audible blood pressure. You can’t take an accurate blood pressure by simply watching the needle. Let me repeat that last line.

You can’t take an accurate blood pressure by simply watching the needle.

It doesn’t work. Believe me, if it was that simple, I’d tell you. The truth is, you may see needle jumps 20 mmHg above the audible systolic pressure or 20 mmHg below. There’s just no reliable correlation. So don’t get fooled.

5) No sound? What now?

OK, so you didn’t hear anything. Don’t panic. It happens to everyone. Start from your ears and work toward the patient.

• Are the ear pieces angled forward into your ear canals or backward against the side of your ear canals? Angle them forward.
• Are there any kinks in the stethoscope tubing?
• Is the bell on the stethoscope turned toward the correct side? Everyone gets fooled by this one occasionally. Tap the business side of the stethoscope and see if you hear clear crisp tapping.
• Feel for the brachial pulse again and place the stethoscope bell directly over it.
• Are you putting too much pressure on the bell of the stethoscope? Don’t let the bell ride to far up under the BP cuff or you’ll invert the bell when you inflate the cuff and muffle the sounds. You want gentle pressure on the bell.

Now inflate the cuff and try again. If you still can’t find it consider trying the other arm or palpating the blood pressure. If the patient is unstable, consider that they may not have a viable pressure. Quit fiddling with the BP and treat for shock.

6) Palpation, how do you do that?

Palpation allows you to quickly get a rough estimate of the systolic pressure without the use of a stethoscope. When monitoring critical patients, when time is of the essence and trending vitals is a frequent task, palpating the pressure is a great tool.

Correctly apply the BP cuff and grab a radial pulse. Inflate the cuff until the radial pulse goes away and then slowly deflate the cuff. When the radial pulse returns, that’s a fair estimation of the systolic pressure. it’s worth noting that palpated pressures tend to be about 8-10 mmHg lower than the true systolic. when documenting palpated pressures note the systolic pressure as assessed and replace the diastolic pressure with the letter “P”.

There you have it. The basic blood pressure technique is just like the basic vegetable chop. But there’s a lot more skill to taking a solid accurate blood pressure than initially meets the eye. Just like there’s a lot more to chopping vegetables than just the basic slice. Just ask any teppanyaki chef.

Now it’s your turn: What are your favorite blood pressure tips and tricks?

Read more EMT skills stuff:

The Ultimate Guide to EMT Vital Signs Part 1, The Pulse

The Art of Using Trauma Shears

Remembering The Glasgow Coma Score

Beyond The 1-10 Pain Scale

5 Assessment Findings That Should Concern You

There are few things that EMT’s should claim as their domain. There are certain skills that the EMT provider should simple dominate. Vital signs are one such skill. No medical provider anywhere should be able to hold a candle to the EMT when vitals signs are the name of the game.

Vital signs are, to the EMT, what sharp shooting is to the sniper; what the fast ball is to the closing pitcher; what swordsmanship is to Zorro. It’s the EMT bread-and-butter skill. And yet…so many EMTs fumble through vital signs like it’s amateur hour. No more. Over the next few weeks we’re going to break down vital signs here at The Spot and make every one of our trusted and loyal readers a vital sign virtuoso.

Are you ready? Carnegie Hall awaits. Let’s start with the pulse check.

Some EMT’s can take 30 seconds to a minute to check a pulse. When they’re done they have one single piece of clinical information to pass on, the heart rate. Others can feel a pulse for 3 seconds and tell you much, much more about the patient’s cardiovascular status. What’s the difference? Practice and focus. If you’d like to be the second EMT, here’s how.

1) Know where to check for a pulse. (And why)

There are a bunch of places to obtain a pulse and good reasons to use each one. Here, our collapsed young runner shows us the seven primary pulse points that every EMT should know.

Recall that the pulse is felt when we trap an artery between our finger (or fingers) and a bone lying beneath the vessel. There is some technique to this. It requires a firm, gentle, accurate touch. There’s only one way to develop this skill. Take a lot of pulses. Let’s look at each one of these pulse points in a little more detail.

We’ll start at the top and work our way down.

The Carotid Pulse

The carotid pulse is found by palpating the external carotid artery on the side of the neck on either side of the trachea. The carotid is a very central pulse and should be easily palpated with somewhat deep pressure. Feel for the side of the trachea and then press posterior into the neck.

This is the classic CPR pulse check site and well known to the lay public. It is often used by runners and athletes to assess their own heart rate. A palpable carotid is the current tipping point for rapidly deciding if external chest compressions are indicated. Until a more definitive measure of cardiac output is available, in the absence of a carotid pulse, CPR is indicated. (Presuming the patient is unresponsive.) This site can also be used to assess the effectiveness of CPR. During adequate chest compressions, a carotid pulse should be palpable. If not, it might be time to switch rescuers.

The Brachial Pulse

Felt on the inner aspect of the arm on babies and small children and commonly found on the medial aspect of the antecubital fossa in adults, the brachial pulse should be the starting point for each blood pressure check you perform. Find the brachial pulse and line the artery arrow on the BP cuff up with the pulse point about one inch above the elbow joint.

The brachial is the primary pulse check point for infant CPR, it’s also often overlooked as an easily accessible pulse point when the radial pulse is inconvenient or painful to use. Feeling a brachial pulse requires a bit more pressure than the average radial pulse. Brachial pulses are often present even when a radial pulse is not discernible. If you are ever unable to palpate a radial pulse, the brachial should be your next stop.

The Radial Pulse

Conveniently located and easy to palpate on the anterior / lateral portion of the wrist (thumb side), the radial pulse tends to be the classic point for checking heart rate and rhythm in the conscious patient. More convenient than a carotid, less personal than a femoral, the radial pulse is far and away the most common pulse location in use.

The absence of a radial pulse is a fairly reliable indicator that the systolic blood pressure has fallen below the 80 mmHg mark. Unequal radial pulses can signify a variety of conditions, including aortic abnormalities, vascular compromise, atherosclerosis and compartment syndrome. In the presence of shoulder or upper arm injuries, an accurate blood pressure can still be auscultated at the radial artery, providing that the cuff is properly fit to the forearm and applied correctly over the artery.

The Femoral Pulse

After the aorta passes through the retroperitoneal cavity of the abdomen it branches into the left and right femoral arteries. These arteries can be palpated in the crease between the upper thigh and the lower pelvic area, where the lower abdominal quadrant joins the leg. Palpate deeply in the crease about midway between the iliac crest and the groin.

The femoral artery is a very central section of vasculature which makes it a popular point of access for insertion of cardiac stents and other invasive procedures that require surgeons to operate within the vasculature. It is also a great spot to check the effectiveness of CPR compressions. Due to its location, femoral pulse checks are reserved for unconscious patients. Like its centrally located brother, the carotid, femoral pulses can sometimes be felt at systolic pressures as low as 50 mmHg.

The Popliteal Pulse

Possibly the hardest to locate of the bunch, the popliteal pulse is useful in assessing vascular compromise in the presence of a knee or femur injury. In significant leg injury it can assist in determining the location of vascular compromise and is a good secondary location for distal circulation checks when using a traction splint, which covers both of the primary pedal pulse locations.

The popliteal artery can be felt behind the knee and is easiest to reference when the knee is slightly bent. Place both of your thumbs on the knee cap and feel in the pit behind the knee at the mid-point with the fingers of both hands.

The Dorsalis Pedis Pulse

While its location can vary considerably, the dorsalis pedis pulse can often be felt on the dorsal (top) region of the foot just medial to the bony prominence above the instep.

The dorsalis pedis is the most commonly used pulse when assessing for distal circulation in lower limb injury.  Once you find it, mark it with a pen for future reference. (Note the “X marks the spot” markings on the feet of the patient at left.)

The Posterior Tibial Pulse

Due to the infinite variations of splinting options in lower limb injuries, it’s often helpful to have an alternate spot for distal circulation checks. The posterior tibial pulse is located behind the bony prominence on the distal end of the tibia. (The medial ankle bone.)

It’s also a handy location to check is the sometimes elusive dorsalis pedis pulse cannot be located. Often patients with a difficult to locate dorsalis pedis pulse will have a strong posterior tibial pulse and vice-versa.

2) Know what you’re checking

As previously stated, there’s a lot more to that pulse check than heart rate. Circulation compromise, cardiovascular status as well as acute and chronic conditions can all be assessed if you’re paying attention to the rate, quality, rhythm and equality of the pulses.

An exact heart rate is 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 check.

3) Put the pulse in context for the patient

This is often overlooked and one of the harder things to grasp for newer EMTs. The pulse, just like everything else you assess, needs to be placed in the context of the overall clinical picture.

An EMT student might ask, “What if I can’t find a radial pulse?” Hoping for some definitive response to the “no pulse” situation. The answer is always the same. “What’s the patient’s mental status? What does their skin look like? Do they have a brachial pulse? Do they have a radial on the opposite side?” The answers to these questions and a bunch more will determine the proper next step.

A friend of mine recently assisted a dentist who was doing CPR on a conscious combative male who had collapsed at a local pool. The fact that he couldn’t feel a carotid pulse was the only thing that mattered to him. The rest of the clinical presentation, including the victim’s cries of protest, didn’t matter to the dentist. He insisted bystanders help restrain the patient while he continued CPR. Sometimes, even people with advanced medical training have a hard time considering the whole clinical picture.

The presence or absence, rate and rhythm, equality or inequality, strength or weakness all need to be put into the greater context of the patient presentation. They don’t stand alone.

4) Really take a pulse

I don’t mean take a long time. I mean focus. Pay attention to that pressure wave beneath the skin we call a pulse. We check pulses so routinely, we often fall into the habit of not paying attention to other stuff while we check a pulse. Allow me to elaborate.

Have you ever checked your watch and had someone else who saw you checking ask, “Hey, what time is it?” …and you have no idea? That’s because you were performing a routine. You weren’t really focusing on the time, you were just checking because that’s what you do.

We do the same thing with pulses. We check it, we find it, we hold it for a few seconds and then we move on. If someone sees us check and asks, “What was the pulse like?” we might know, we might not.

Don’t get stuck in that rut. Feel the wave. Visualize the heart beating withing the patient, sending a wave of pressure through the vessels. Feel for its regularity, equality, strength and rate. Ask yourself what it means. Now you’re on your way to becoming a virtuoso.

Now it’s your turn: What’s your favorite pulse check trick?

Read more skills stuff:

Mastering The Head-To-Toe Assessment

CPR Right Now

The Art of The Pulse Check

Get Anyone To Go With You To The Hospital

How To Make Sure Your Hand-off Report Gets Heard

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