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EMS Medical Equipment Tips



The Ambulance Driver's Perspective
by Kelly Grayson

Blood pressure reading tips and tricks for EMS

One of the things I'm most often asked by students and rookie EMT's is, "Kelly, how am I supposed to hear a blood pressure in the back of the rig?"

My reply is usually to cup my hand behind one ear and shout, "What?"

Much to my chagrin, few of them take the hint, but honestly, I'd rather deal with those kids than the ones who take a pressure, drape the scope around their neck, and confidently announce, "120/80…"

… for every patient.

Old, young, fat, thin, pink or pale, everybody has a suspiciously normal blood pressure that always ends with a zero. Just as bad are those who hesitantly stammer, "Uhhhh… 135/79?"

My ears may suck, but my eyes are still pretty good, and try as I might, I've yet to be able to find those odd-numbered markings on a sphygmomanometer gauge. Thus, I'm forced to conclude that my rookie either has preternaturally sharp hearing and eyesight, or he's pulling those numbers out of his rectum. Judging from the uncertainty in their tone, I usually go with the latter.

Being a guy with a measurable hearing deficit in both ears – too much shooting as a kid without adequate ear protection – I've learned a few tricks over the years to allow me to hear what I need to hear in the back of the rig. Sometimes, when the sounds I'm listening for are in the high frequency range where most of my hearing loss is, I have to resort to things like assessing tactile fremitus, or rely on the ears of a trusted partner.

Luckily, Korotkoff sounds are low-frequency enough that I can still pick them out over the rumble of the road beneath my feet, but it takes a lot of practice and sometimes a few tricks to be able to distinguish the real stuff from the road noise. Here's a few of the tricks I've learned:

  • Isolate the patient's arm from everything else. When you wrap the cuff around his arm, cup your non-dominant hand under his elbow, and tuck his palm beneath your elbow. Lift his arm off the mattress, stretcher rail, or whatever it's in contact with. If you like to lay the patient's arm across your lap while you auscultate a BP, lift your feet onto tiptoes to minimize transmission of road noise through the soles of your feet.
  • Use the bell of your stethoscope, not the diaphragm. I spent 18 years in EMS without learning that trick, and it took a Stethoscopy For Dummies class from Bob Page for me to see the light. The bell of your stethoscope works better on those low-frequency sounds. Try for yourself, and you'll see.
  • Use a good stethoscope. While you're on that initial gear-buying spree right after graduation from EMT school, say no to the spring-loaded window punch, Swiss army knife trauma shears and the glove holster, and treat yourself to a nice stethoscope instead. A few hundred bucks spent in the beginning will pay a career's worth of dividends. And whatever ‘scope you buy, take off the stock diaphragm and replace it with a disposable antimicrobial diaphragm. They're cleaner, safer for your patient, and they're much more acoustically sensitive.
  • Turn your cuff upside down. You know those hoses that bump annoyingly against the head of your stethoscope? You can get them out of the way by turning the cuff upside down. It won't affect the accuracy of your findings, as long as you make sure the artery markers are still lined up correctly.
  • Learn to palpate. It's not optimal, but sometimes you just can't hear a pressure. In all my time in EMS, I've only met one person that can get an accurate systolic and diastolic pressure from palpation, but unless your name is Liz Hyde, you'll just have to do like the rest of us mere mortals and settle for a rough systolic pressure.
  • Turn off all the crap in the back of the rig. Being spec'ed for use in Louisiana summers, our rigs are equipped with air conditioners that keep the module a comfy 72 degrees – or at least that's the rumor. But however well they cool or don't cool, hearing anything over them is like straining to hear the whispered words of a lover over an F5 tornado. Except in the case of blood pressures, you can't lip read, smile and nod.

If you're one of those EMTs whose ears threaten to betray you when you need them most, try some of these BP tricks. Hopefully, they'll take some of the pressure off of getting a pressure.


About the author


Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (www.facebook.com/theambulancedriverfiles), or email him at kelly.grayson@ems1.com.

Comments
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Steve Blethyn Steve Blethyn Saturday, December 03, 2011 3:22:54 AM Or, put Dr Nikolai Korotkoff's sounds to one side for a moment, watch the needle on your sphygmomanometer's dial, you will see it 'double-tap' This tapping starts as blood flow resumes in the artery and stops at the same moment that the sound, were you able to hear it, would stop. This method does not require the ability to hear at all, a useful little trick were you to find yourself under fire for example. Ask any combat med tech. or wilderness medic :o).
Rob Nash Rob Nash Friday, December 09, 2011 6:21:26 AM One of my many peeves, seen on more calls than not. Faked vitals. Tips above so spot on. Good scope with good fitting eartips, the entire eartip holes should project into your ear, not 80% occluded. Hard plastic eartips, not soft rubber. Headset will only seal in one orientation to your head, keep this consistant. Scopes with any moving parts/replacable tubing/rotating heads will leak or inhibit air movement. Above is true about bell and lower frequencies, but this is a rotating head scope concept. Bell users, keep head pressure light, or you have a diaphram. Flex the elbow a tiny bit, again avoiding the taut skin from becoming a diaphram. Release cuff pressure slowly. No patient talking. Cuff size. I carry 5 cuffs and 2 scopes. And a good doppler. My report has lots of B/P notes. Faking numbers is the beginning of a very bad relationship with our craft. I take my own B/P measurements right away. Bozo earlier numbers are obvious to me. Auto B/P systems are screening devices only. Find an ICU patient with an art line and check your technique against those numbers. Thanks for the article.
Joanne T. Johnson Cmrs Joanne T. Johnson Cmrs Thursday, January 05, 2012 9:06:05 PM wow...first time I have seen others had problems hearing...thought it was just me!
David Doc Krebs David Doc Krebs Friday, January 06, 2012 6:04:58 PM It's good to see these tips in print. A senior medic I worked with in 1989-1990 taught me the same techniques. I was skeptical at first, being a rookie, I thought he was just making me look silly, but it worked! He taught some really good IV starting techniques and how to brew an exxcellent espresso. A pity he dead now. He would have made a great instructor.
Diane Nikfar Diane Nikfar Monday, May 14, 2012 10:07:28 PM Great advice! Thanks, Kelly!
Anita Lindsay Anita Lindsay Wednesday, May 23, 2012 8:57:28 AM These are great tips for auscultating blood pressures. Some I have also used in the past 20 years. Something to add is to find the brachial pulse and place the stethoscope over it when auscultating. If the patient's B/P is difficult to find making sure the bell or diaphragm of the stethoscope is placed right over the patient's brachial pulse helps tremendously. Not everyone had a good strong pulse in the ac fossa. I do this every time I take a B/P and rarely do I have a problem hearing. I also teach this trick of the trade to my students, they love it.
Shirley Karst Shirley Karst Monday, October 29, 2012 6:37:37 PM 120/80.....that made me chuckle and remember fondly all of the young EMS people that came through the service where I worked. I haven't worked EMS now for 5 years, and from time to time I miss it...this was one of those moments. Thanks!
Morgan Young Morgan Young Tuesday, February 12, 2013 1:23:04 PM Bob Page was my Paramedic instructor!
Dan Vachon Dan Vachon Tuesday, February 12, 2013 7:38:43 PM I put my feet up on the stretcher rail, which rests on rubber wheels. I find this helps absorb some of the vibration. When a B/P is critical though, pull over and do it.
Dave Bloom Dave Bloom Friday, March 01, 2013 9:07:11 AM There were a couple of new tricks this "old dog" learned from this article.
Dominick Walenczak Dominick Walenczak Wednesday, June 12, 2013 9:46:08 AM Forget fancy rescue gear, radios, dodads and gizmos. The MOST IMPORTANT possession of any good provider is a quality scope. It makes a difference... whether your trying to hear a faint gallop in a CHF patient, listening for basilar rales in the MI, or just taking a blood pressure. Make sure your priorities are straight and you have a quality scope before you go out an buy all the other "Ricky Rescue" toys.