Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Ms. Woods: from a practical standpoint, you are quite correct. However, one of the big points to be made is that if EMS wants to become a professional progression, then we must do much more in terms of educating *everyone* in the system, from the lowest field providers on up to the docs who work with them. this includes, most especially, the whys as well as the hows. and this is the kind of case where a paramedic who recognizes the problem can get the attention of the ED attending and his medical director in a positive way. ck In a message dated 6/12/2010 01:54:15 Central Daylight Time, amwoods8644@... writes: In the end, yes, it's a mystery as to why she's stroking out, but I can't treat it on scene. Knowing her meds and history would be nice, but transport to definitive care is really the name of the game. But that's just me, treating it a little more scenario-like. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 Ms. Woods: from a practical standpoint, you are quite correct. However, one of the big points to be made is that if EMS wants to become a professional progression, then we must do much more in terms of educating *everyone* in the system, from the lowest field providers on up to the docs who work with them. this includes, most especially, the whys as well as the hows. and this is the kind of case where a paramedic who recognizes the problem can get the attention of the ED attending and his medical director in a positive way. ck In a message dated 6/12/2010 01:54:15 Central Daylight Time, amwoods8644@... writes: In the end, yes, it's a mystery as to why she's stroking out, but I can't treat it on scene. Knowing her meds and history would be nice, but transport to definitive care is really the name of the game. But that's just me, treating it a little more scenario-like. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 you will, eventually. ck In a message dated 6/12/2010 02:07:20 Central Daylight Time, amwoods8644@... writes: Thankfully, I have seen no reason to attempt to obtain a femoral pulse on a call. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2010 Report Share Posted June 11, 2010 you will, eventually. ck In a message dated 6/12/2010 02:07:20 Central Daylight Time, amwoods8644@... writes: Thankfully, I have seen no reason to attempt to obtain a femoral pulse on a call. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 You ask some good questions, though I'm not sure all emts will understand what a catecholamine is. I would not be surprised at a regular heart rate. Blood pressure and heart rate, while connected in some ways, are not in others. Look at benzodiazepines. Lower bp, higher heart rate. Catecholamines work. Unless they don't. CNS depressants, chronic CNS depression (such as with neurological damage) instantly spring to mind. Or acute depression, from trauma or infection. But this is just a tangent, demonstrating that you cannot always count upon a physiological response. Because that response is always there until you find the patient where it isn't. Now, if this were my scene, upon finding no radial pulse, and no bp, I'd move to the legs. If that didn't work, I'd assume a bp of less than 80 (and suspect it to be below 70) over palp, would leave that area blank on the run form, and would load and go, because, even though I don't know what's going on, she's got AMS, slurred speech, and the Cincinnati stroke scale says it's a CVA. if I were on a basic unit, I'd ask for an ALS intercept, if the hospital was > 5 min away, and the closest ALS unit could meet me partway with enough time for them to have the Pt for about 5 min, because while I can't be certain, I suspect the only greater level of treatment they could give (provided she did not deteriorate) would be to get an iv ready for the ER, which they should be able to do en route. Heck, depending upon my gut feeling at the scene, I might even load her up before trying the BP cuff on her leg. In the end, yes, it's a mystery as to why she's stroking out, but I can't treat it on scene. Knowing her meds and history would be nice, but transport to definitive care is really the name of the game. But that's just me, treating it a little more scenario-like. Alyssa Woods, FF/NREMT-B Sent from the itty bitty keyboard on my iPhone > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 And, in response to another one of your questions - yes, I have obtained a blood pressure from someone's leg. Fortunately, I've never had to use a pedal pulse to palpate one. (knock on wood!) However, if we're just talking about pulses... if I can't find a radial pulse I check the carotid pulse. If it is there, carry on. If it's not there, start CPR. I have before attempted to obtain a femoral pulse, but that was simply as a " Hey, think we can do this? " while sitting around a fire station. I was, of course, unsuccessful. Thankfully, I have seen no reason to attempt to obtain a femoral pulse on a call. Alyssa Woods, FF/NREMT-B > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 And, in response to another one of your questions - yes, I have obtained a blood pressure from someone's leg. Fortunately, I've never had to use a pedal pulse to palpate one. (knock on wood!) However, if we're just talking about pulses... if I can't find a radial pulse I check the carotid pulse. If it is there, carry on. If it's not there, start CPR. I have before attempted to obtain a femoral pulse, but that was simply as a " Hey, think we can do this? " while sitting around a fire station. I was, of course, unsuccessful. Thankfully, I have seen no reason to attempt to obtain a femoral pulse on a call. Alyssa Woods, FF/NREMT-B > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 Howdy Alyssa! Thanks for your post and your excellent questions and comments. Let me address some of your questions and comments below, please. Gene Re: Scenario You ask some good questions, though I'm not sure all emts will understand what a catecholamine is. GG: I'm aware of that, but it's sad. Since Basic EMTs in Texas are allowed to use EpiPens, they should have had some training in basic pharmacology. I know that many EMT=Basic " education " programs do not address that, but they should. I would not be surprised at a regular heart rate. Blood pressure and heart rate, while connected in some ways, are not in others. Look at benzodiazepines. Lower bp, higher heart rate. GG: Benzos can lower heart rate in some situations, particularly cocaine and meth ingestions, and they can reduce anxiety and thus catecholamine release, but they generally are not potent BP lowering drugs. Beta blocking drugs lower heart rate and nitroglycerines, and some alpha/beta blockers like labetalol, can lower both. Catecholamines work. Unless they don't. CNS depressants, chronic CNS depression (such as with neurological damage) instantly spring to mind. Or acute depression, from trauma or infection. But this is just a tangent, demonstrating that you cannot always count upon a physiological response. Because that response is always there until you find the patient where it isn't. GG: What you're essentially saying is that all patients are different, and caregivers must be conversant with the varying presentations. I agree. Now, if this were my scene, upon finding no radial pulse, and no bp, I'd move to the legs. If that didn't work, I'd assume a bp of less than 80 (and suspect it to be below 70) over palp, would leave that area blank on the run form, and would load and go, because, even though I don't know what's going on, she's got AMS, slurred speech, and the Cincinnati stroke scale says it's a CVA. if I were on a basic unit, I'd ask for an ALS intercept, if the hospital was > 5 min away, and the closest ALS unit could meet me partway with enough time for them to have the Pt for about 5 min, because while I can't be certain, I suspect the only greater level of treatment they could give (provided she did not deteriorate) would be to get an iv ready for the ER, which they should be able to do en route. Heck, depending upon my gut feeling at the scene, I might even load her up before trying the BP cuff on her leg. GG: You would be right to move to the legs but only enroute. Think about this: What would knowing that she has an auscultatable BP in her legs cause you to do differently? I suggest nothing. She needs to be in a hospital ASAP. Also, in a stroke case, there is no ALS intervention that will affect the outcome, is there? So move your patient to the appropriate hospital ASAP. Forgetabout the ALS intercept. Any findings that you can do such as " no BP in the upper extremities but 70/40 in the left popliteal " is helpful to the ER doc. Helps them to get right to the problem. In the end, yes, it's a mystery as to why she's stroking out, but I can't treat it on scene. Knowing her meds and history would be nice, but transport to definitive care is really the name of the game. GG: You are correct. It's always a mystery why they're stroking out for us because we don't have CT scanners on the bambulance. We can say that our patient has failed the Cincinnati Stroke test, or the LA stroke test, but in either case, what we need to do is get them to the place where something can be done to fix them. We cannot fix anybody with a stoke in the field, no matter how tough we are. LOL. But that's just me, treating it a little more scenario-like. GG: You're thinking. That's good. Alyssa Woods, FF/NREMT-B Sent from the itty bitty keyboard on my iPhone > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 Howdy Alyssa! Thanks for your post and your excellent questions and comments. Let me address some of your questions and comments below, please. Gene Re: Scenario You ask some good questions, though I'm not sure all emts will understand what a catecholamine is. GG: I'm aware of that, but it's sad. Since Basic EMTs in Texas are allowed to use EpiPens, they should have had some training in basic pharmacology. I know that many EMT=Basic " education " programs do not address that, but they should. I would not be surprised at a regular heart rate. Blood pressure and heart rate, while connected in some ways, are not in others. Look at benzodiazepines. Lower bp, higher heart rate. GG: Benzos can lower heart rate in some situations, particularly cocaine and meth ingestions, and they can reduce anxiety and thus catecholamine release, but they generally are not potent BP lowering drugs. Beta blocking drugs lower heart rate and nitroglycerines, and some alpha/beta blockers like labetalol, can lower both. Catecholamines work. Unless they don't. CNS depressants, chronic CNS depression (such as with neurological damage) instantly spring to mind. Or acute depression, from trauma or infection. But this is just a tangent, demonstrating that you cannot always count upon a physiological response. Because that response is always there until you find the patient where it isn't. GG: What you're essentially saying is that all patients are different, and caregivers must be conversant with the varying presentations. I agree. Now, if this were my scene, upon finding no radial pulse, and no bp, I'd move to the legs. If that didn't work, I'd assume a bp of less than 80 (and suspect it to be below 70) over palp, would leave that area blank on the run form, and would load and go, because, even though I don't know what's going on, she's got AMS, slurred speech, and the Cincinnati stroke scale says it's a CVA. if I were on a basic unit, I'd ask for an ALS intercept, if the hospital was > 5 min away, and the closest ALS unit could meet me partway with enough time for them to have the Pt for about 5 min, because while I can't be certain, I suspect the only greater level of treatment they could give (provided she did not deteriorate) would be to get an iv ready for the ER, which they should be able to do en route. Heck, depending upon my gut feeling at the scene, I might even load her up before trying the BP cuff on her leg. GG: You would be right to move to the legs but only enroute. Think about this: What would knowing that she has an auscultatable BP in her legs cause you to do differently? I suggest nothing. She needs to be in a hospital ASAP. Also, in a stroke case, there is no ALS intervention that will affect the outcome, is there? So move your patient to the appropriate hospital ASAP. Forgetabout the ALS intercept. Any findings that you can do such as " no BP in the upper extremities but 70/40 in the left popliteal " is helpful to the ER doc. Helps them to get right to the problem. In the end, yes, it's a mystery as to why she's stroking out, but I can't treat it on scene. Knowing her meds and history would be nice, but transport to definitive care is really the name of the game. GG: You are correct. It's always a mystery why they're stroking out for us because we don't have CT scanners on the bambulance. We can say that our patient has failed the Cincinnati Stroke test, or the LA stroke test, but in either case, what we need to do is get them to the place where something can be done to fix them. We cannot fix anybody with a stoke in the field, no matter how tough we are. LOL. But that's just me, treating it a little more scenario-like. GG: You're thinking. That's good. Alyssa Woods, FF/NREMT-B Sent from the itty bitty keyboard on my iPhone > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 Hey, Alyssa. You're a thinking medic. Thank you! It's hard to get a " leg " BP isn't it? I am so glad you have been able to do this. Please teach others how to do it as well. I have never used one of the pedal pulses to try to get a BP either, but it's an interesting problem, isn't it? I would suspect that the readings would have to be adjusted since the systolic pressure should be less the lower one goes, but I don't have any studies to support that thinking. Now, I would suggest this, and I KNOW you already know this. Even if you can't get ANY pulses, look at your patient. If your patient is able to talk and tell jokes, then he's not dead no matter if you can feel his pulses. The one thing I have learned in 30+ years of this, is that every patient is different. The great medic, of whatever level of training, recognizes differences from the norm and reacts. The bad medics have no idea what the norms are. GG Re: Scenario And, in response to another one of your questions - yes, I have obtained a blood pressure from someone's leg. Fortunately, I've never had to use a pedal pulse to palpate one. (knock on wood!) However, if we're just talking about pulses... if I can't find a radial pulse I check the carotid pulse. If it is there, carry on. If it's not there, start CPR. I have before attempted to obtain a femoral pulse, but that was simply as a " Hey, think we can do this? " while sitting around a fire station. I was, of course, unsuccessful. Thankfully, I have seen no reason to attempt to obtain a femoral pulse on a call. Alyssa Woods, FF/NREMT-B > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 Hey, Alyssa. You're a thinking medic. Thank you! It's hard to get a " leg " BP isn't it? I am so glad you have been able to do this. Please teach others how to do it as well. I have never used one of the pedal pulses to try to get a BP either, but it's an interesting problem, isn't it? I would suspect that the readings would have to be adjusted since the systolic pressure should be less the lower one goes, but I don't have any studies to support that thinking. Now, I would suggest this, and I KNOW you already know this. Even if you can't get ANY pulses, look at your patient. If your patient is able to talk and tell jokes, then he's not dead no matter if you can feel his pulses. The one thing I have learned in 30+ years of this, is that every patient is different. The great medic, of whatever level of training, recognizes differences from the norm and reacts. The bad medics have no idea what the norms are. GG Re: Scenario And, in response to another one of your questions - yes, I have obtained a blood pressure from someone's leg. Fortunately, I've never had to use a pedal pulse to palpate one. (knock on wood!) However, if we're just talking about pulses... if I can't find a radial pulse I check the carotid pulse. If it is there, carry on. If it's not there, start CPR. I have before attempted to obtain a femoral pulse, but that was simply as a " Hey, think we can do this? " while sitting around a fire station. I was, of course, unsuccessful. Thankfully, I have seen no reason to attempt to obtain a femoral pulse on a call. Alyssa Woods, FF/NREMT-B > First, let me say that I appreciate Wes's taking the time to > formulate and post the scenario. It is an excellent learning tool. > If some do not see it as such, there is a key on the upper right > part of the computer keyboard marked " delete " that is quite easy to > use. > > Now, on to the scenario. > > I've been thinking about this, and two things to ask come to mind: > (1) If BPs cannot be obtained in either arm, can a BP be obtained in > one or both legs? (2) does the physical examination reveal any scars > from prior surgical procedures? Also, in taking a history from this > patient, what questions would you ask that have not been asked yet? > > I think Wes is working tonight and may not be able to respond > immediately, but do any of you find these questions pertinent? Why > or why not? > > If BPs were obtainable in the legs, what conclusions would one draw? > What surgeries might result in inability to obtain BPs in either > arm? What conditions could lead to this situation? > > And just to be a cranky old man (which I am) , for those who are > " only " Basic EMTs, and I say that with the greatest admiration for > what you do and in no way intend to denigrate you, what questions > would a Basic EMT have if a patient had a heart rate of 72, radial > pulse of 72, regular, and full, but no obtainable BPs in the arms. > What would you do? See if there were radial pulses? See if there was > a carotid pulse? See if there was a femoral pulse? Take a BP in the > leg? Ever tried that? It's hard but can be done. You need the > " elephant cuff " to do it, however unless you use one of the pedal > pulses. Anybody ever tried that? > > Further, does it seem odd that a patient with no auscultatable BPs > in either arm but with a responsive LOC might have a regular heart > rate of 72? Wouldn't a patient with such profound hypotension as to > have no obtainable BPs in either arm be compensating with > catecholamine release resulting in an increase in both systolic and, > in particular, diastolic BP? > > Just some questions that come to my mind as I Google to try and find > the answer to this. > > Gene Gandy, JD, LP, NREMT-P > Bujia EMS Education > Tucson, AZ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 I in no way meant to insinuate that the scenario should not be discussed, nor that creating a differential is not immensely useful, nor that knowing what's going on with the patient (especially if you get that " Aha! " moment) isn't good. I love playing the mystery diagnosis game, much to the chagrin of everyone around me. I was merely asked what I, as a basic, would do with the patient. I said what I would do. Now, on the other hand, I got chewed a new one for (properly, I'll note) diagnosing a patient, and tactfully noting my suspicion to a doc. Because apparently, that does nothing but make me " look like a know-it-all or better yet a smart ass and cause the doc to disregard everything that comes outta [my] mouth in the future. It gives [me] and everyone work with a bad rep. So [i should] just hand in [my] report and learn [my] place. " Or, let's go with the more concise: " You don't have an opinion until you're a doctor. " So, while I do enjoy this game, and it delights me to see others take pleasure in it, I feel I must find balance between the two extremes (those who like it and those who ban me from doing it). And to be honest, I don't have much faith in my fellow emts. When I came out of my class of 20-some-odd, I was one of two who knew how to spike a bag and place a 12-lead. The others didn't find it necessary to learn. One even forgot after I had taught her. I have had an emt ask me what a liver is. Hell, I had a paramedic ask me what a benzodiazepine is. So, really... I don't trust them to know a damn thing till they prove it. Ergo, since we are not taught in our book about catecholamines, I seriously doubt any field-emt would know it. Even I am familiar mostly with the effects of catecholamines neurologically, though I do have a basic understanding of their excitatory role on the CNS. As for educating everyone in the field, I absolutely agree. That's why I think basics should try to understand basic pharmacology and disease processes. However, again, I must balance this with being yelled at, because suggesting what drug they mightve OD'd on is above my patch level. Different BPs in each arm (here defined as a difference of 20 points or more) can be caused by AAA, and heart disease, but those are the only ones that spring to mind. I shall find more tomorrow. And don't get me wrong, there's a lot for me to learn, and I'm eager to learn it, and it's stimulating to see all of you brain storm. And yes, I am curious. Once I've gotten some sleep, more brain power shall go into it. Alyssa Woods, FF/NREMT-B Sent from the itty bitty keyboard on my iPhone > Ms. Woods: from a practical standpoint, you are quite correct. > > However, one of the big points to be made is that if EMS wants to > become a > professional progression, then we must do much more in terms of > educating > *everyone* in the system, from the lowest field providers on up to > the docs > who work with them. > > this includes, most especially, the whys as well as the hows. > > and this is the kind of case where a paramedic who recognizes the > problem > can get the attention of the ED attending and his medical director > in a > positive way. > > ck > > > In a message dated 6/12/2010 01:54:15 Central Daylight Time, > amwoods8644@... writes: > > In the end, yes, it's a mystery as to why she's stroking out, but I > can't treat it on scene. Knowing her meds and history would be nice, > but transport to definitive care is really the name of the game. > > But that's just me, treating it a little more scenario-like. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 I in no way meant to insinuate that the scenario should not be discussed, nor that creating a differential is not immensely useful, nor that knowing what's going on with the patient (especially if you get that " Aha! " moment) isn't good. I love playing the mystery diagnosis game, much to the chagrin of everyone around me. I was merely asked what I, as a basic, would do with the patient. I said what I would do. Now, on the other hand, I got chewed a new one for (properly, I'll note) diagnosing a patient, and tactfully noting my suspicion to a doc. Because apparently, that does nothing but make me " look like a know-it-all or better yet a smart ass and cause the doc to disregard everything that comes outta [my] mouth in the future. It gives [me] and everyone work with a bad rep. So [i should] just hand in [my] report and learn [my] place. " Or, let's go with the more concise: " You don't have an opinion until you're a doctor. " So, while I do enjoy this game, and it delights me to see others take pleasure in it, I feel I must find balance between the two extremes (those who like it and those who ban me from doing it). And to be honest, I don't have much faith in my fellow emts. When I came out of my class of 20-some-odd, I was one of two who knew how to spike a bag and place a 12-lead. The others didn't find it necessary to learn. One even forgot after I had taught her. I have had an emt ask me what a liver is. Hell, I had a paramedic ask me what a benzodiazepine is. So, really... I don't trust them to know a damn thing till they prove it. Ergo, since we are not taught in our book about catecholamines, I seriously doubt any field-emt would know it. Even I am familiar mostly with the effects of catecholamines neurologically, though I do have a basic understanding of their excitatory role on the CNS. As for educating everyone in the field, I absolutely agree. That's why I think basics should try to understand basic pharmacology and disease processes. However, again, I must balance this with being yelled at, because suggesting what drug they mightve OD'd on is above my patch level. Different BPs in each arm (here defined as a difference of 20 points or more) can be caused by AAA, and heart disease, but those are the only ones that spring to mind. I shall find more tomorrow. And don't get me wrong, there's a lot for me to learn, and I'm eager to learn it, and it's stimulating to see all of you brain storm. And yes, I am curious. Once I've gotten some sleep, more brain power shall go into it. Alyssa Woods, FF/NREMT-B Sent from the itty bitty keyboard on my iPhone > Ms. Woods: from a practical standpoint, you are quite correct. > > However, one of the big points to be made is that if EMS wants to > become a > professional progression, then we must do much more in terms of > educating > *everyone* in the system, from the lowest field providers on up to > the docs > who work with them. > > this includes, most especially, the whys as well as the hows. > > and this is the kind of case where a paramedic who recognizes the > problem > can get the attention of the ED attending and his medical director > in a > positive way. > > ck > > > In a message dated 6/12/2010 01:54:15 Central Daylight Time, > amwoods8644@... writes: > > In the end, yes, it's a mystery as to why she's stroking out, but I > can't treat it on scene. Knowing her meds and history would be nice, > but transport to definitive care is really the name of the game. > > But that's just me, treating it a little more scenario-like. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 and that is why I insist that the *docs* also need to have further education in the professionalism of EMS. and I was half way to a BS in Bio/minor Chem when I first passed the NREMT-A test, so I was already educated about basic anatomy and physiology at a level far beyond the Orange Book 2nd Edition that was our textbook at the time. ck In a message dated 6/12/2010 04:38:05 Central Daylight Time, amwoods8644@... writes: Now, on the other hand, I got chewed a new one for (properly, I'll note) diagnosing a patient, and tactfully noting my suspicion to a doc. Because apparently, that does nothing but make me " look like a know-it-all or better yet a smart ass and cause the doc to disregard everything that comes outta [my] mouth in the future. It gives [me] and everyone work with a bad rep. So [i should] just hand in [my] report and learn [my] place. " Or, let's go with the more concise: " You don't have an opinion until you're a doctor. " Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 and that is why I insist that the *docs* also need to have further education in the professionalism of EMS. and I was half way to a BS in Bio/minor Chem when I first passed the NREMT-A test, so I was already educated about basic anatomy and physiology at a level far beyond the Orange Book 2nd Edition that was our textbook at the time. ck In a message dated 6/12/2010 04:38:05 Central Daylight Time, amwoods8644@... writes: Now, on the other hand, I got chewed a new one for (properly, I'll note) diagnosing a patient, and tactfully noting my suspicion to a doc. Because apparently, that does nothing but make me " look like a know-it-all or better yet a smart ass and cause the doc to disregard everything that comes outta [my] mouth in the future. It gives [me] and everyone work with a bad rep. So [i should] just hand in [my] report and learn [my] place. " Or, let's go with the more concise: " You don't have an opinion until you're a doctor. " Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 actually, the blood pressure in the 'lower' extremities will vary much more than those in the upper, depending on position. if the patient is fully supine, then there will be little difference between the two *as long as the anatomy is intact.* In fact, we use this detail to perform a test called the 'ankle/brachial index,' to evaluate for adequacy of lower extremity arterial blood supply. if the patient is even somewhat upright, then the pressures in the lower extremities should be *higher* than those in the upper, by the effects of gravity- which is part of the reason that veins have valves and arteries do not. it's also the reason that Aquacise classes are one of the recommended forms of exercise for folks with venous stasis problems. ck In a message dated 6/12/2010 04:39:46 Central Daylight Time, wegandy1938@... writes: It's hard to get a " leg " BP isn't it? I am so glad you have been able to do this. Please teach others how to do it as well. I have never used one of the pedal pulses to try to get a BP either, but it's an interesting problem, isn't it? I would suspect that the readings would have to be adjusted since the systolic pressure should be less the lower one goes, but I don't have any studies to support that thinking. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 actually, the blood pressure in the 'lower' extremities will vary much more than those in the upper, depending on position. if the patient is fully supine, then there will be little difference between the two *as long as the anatomy is intact.* In fact, we use this detail to perform a test called the 'ankle/brachial index,' to evaluate for adequacy of lower extremity arterial blood supply. if the patient is even somewhat upright, then the pressures in the lower extremities should be *higher* than those in the upper, by the effects of gravity- which is part of the reason that veins have valves and arteries do not. it's also the reason that Aquacise classes are one of the recommended forms of exercise for folks with venous stasis problems. ck In a message dated 6/12/2010 04:39:46 Central Daylight Time, wegandy1938@... writes: It's hard to get a " leg " BP isn't it? I am so glad you have been able to do this. Please teach others how to do it as well. I have never used one of the pedal pulses to try to get a BP either, but it's an interesting problem, isn't it? I would suspect that the readings would have to be adjusted since the systolic pressure should be less the lower one goes, but I don't have any studies to support that thinking. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 12, 2010 Report Share Posted June 12, 2010 Let me clarify: ER docs have been nothing but kind to me (with the exception of one neurologist at 0030, but that's forgiveable, given the time of day). I've gotten to see some really cool things, and learned a lot of valuable information from ER docs. All of the aforementioned comments were partners, supervisors, and teachers. Alyssa Woods, FF/NREMT-B Sent from the itty bitty keyboard on my iPhone > and that is why I insist that the *docs* also need to have further > education in the professionalism of EMS. > > and I was half way to a BS in Bio/minor Chem when I first passed the > NREMT-A test, so I was already educated about basic anatomy and > physiology at a > level far beyond the Orange Book 2nd Edition that was our textbook > at the > time. > > ck > > > In a message dated 6/12/2010 04:38:05 Central Daylight Time, > amwoods8644@... writes: > > Now, on the other hand, I got chewed a new one for (properly, I'll > note) diagnosing a patient, and tactfully noting my suspicion to a > doc. Because apparently, that does nothing but make me " look like a > know-it-all or better yet a smart ass and cause the doc to disregard > everything that comes outta [my] mouth in the future. It gives [me] > and everyone work with a bad rep. So [i should] just hand in [my] > report and learn [my] place. " > > Or, let's go with the more concise: " You don't have an opinion until > you're a doctor. " > > Quote Link to comment Share on other sites More sharing options...
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