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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What Makes A Good EMT?

I get a bunch of E-mails from people just starting their EMT education who want advice on how to excel in their programs. “How should I prepare? What books do you recommend?” The questions vary but their is always the familiar flavor of enthusiasm and the same basic question, “How do I do this well?”

Success in this field is fairly predictable. Use the right recipe and you’ll get there. I think the hierarchy of EMS success looks like this:

1.) Attitude

2.) Motivation

3.) Tolerance for repetition

4.) Goal orientation

5.) Strategy and tactics

6.) Performance

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5 Things My Kids Taught Me About EMS

I’m blessed with two kids. They are amazing. My kids changed my whole perspective on the world. They re-framed my purpose. It’s wonderful, the way a few minutes with your kids can put an entire bad day in perspective. They also force you to evaluate some of your own behaviors. (If you’re lucky.)

Here are a few of the more valuable lessons I’ve learned from my kids.

1.) Test Your Limits.

Kids know this instinctively. The moment you create a boundary they begin testing it. There is no running in this area. How fast is running? Can we just walk really fast? What about jogging?  It’s like they just instinctively know that life is more fun when you’re testing the limits.

Sure there are boundaries that we all have to live within but when was the last time you gave them a little test or maybe tried to actively redefine them? “OK, are you saying that I can’t attend this training or that you’re not willing to pay for me to attend this training? So are you saying we can’t use the conference room for an EMS journal club or we can’t use it during business hours?”

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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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Six Techniques To Nail The IV Every Time

Did you get the IV?

Sometimes it seems like your performance on the whole call can be reduced to the success or failure of the IV start. Rarely does the successful treatment of the patient hinge on a successful IV placement but sometimes it can certainly feel that way.

The best way to ensure that you’re ready when that make or break it IV start does come your way is to start a lot of them when the pressure is not on. If you wait until game day to practice, you’re a whole lot more likely to fail.

The single biggest factor that separates the IV virtuoso from the weekend hacker is practice and experience, so when the patient could use an IV, jump in there. The patient’s a kid. … Get in there. The patient is a frail, elderly woman on Coumadin. … Get in there. IVs are nothing to fear. Start practicing these six IV start tips. Before you know it, you’ll be an IV starting superstar.

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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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4 Sloppy IV Mistakes You Should Avoid

One of the nice perks I’ve found to blogging is that every now and then I get to rant. This piece might fit into that rant category. Not necessarily the full blown, foot stompin’, leave the caps lock key on, kind of rant, but a rant none the less.

I’ve started a bunch of IVs. Some were really good. Some were, I can’t believe I got that, there must have been some divine intervention involved, good. Of course I never say anything like that at the time. I tape it down nonchalantly and act like I get the hard ones all the time.

I’ve had my share of bad ones as well. I’ve missed IVs in veins so big that I should have been able to throw the needle dart style and still hit the vein. I’ve chased veins across peoples arms and left them with bruises to remember me by for weeks to come. I’m not proud of it, but I’ll take ownership of it. IVs aren’t my favorite thing to do. I didn’t become a caregiver because I liked causing people discomfort with needles. (Though some of my patients have seemed convinced otherwise.)

Along the way I’ve picked up some pet peeves about starting IVs and I’d like to share them with you. This is a list of my top four, please don’t do this, IV pet peeves.

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