When it comes to one facet of the “rescue” half of our SAR duties, acting as a medical responder can be one of the toughest aspects of the job. Learning the EMR skills is one thing, but keeping those skills fresh and in practice is another. To help with that, some of the more experienced members of the team (who also have EMT, nursing or other medical credentials) have offered some tips they use for a critical basic skill: taking vital signs.
The following are collected from Jeremiah Dees, Jim Gay, Chris Nichols, Catrina Christian, Frank Moschetti, Tom Bates, Alan Mathews and Dawn Curran:
• To count breaths, observe the rise and fall of belly/chest movement.
• Ask a teammate to count the respirations (by observation) while you take other vitals.
• Misdirect the subject so he doesn’t alter his breathing by telling him you are taking his pulse. Fold the subject’s arm back to his chest, holding it there while taking the pulse, with your watch facing you so you can count. This can then segue into counting the respirations as you feel your arm rise and fall.
• Note not only the number of respirations (normal is 12 to 20), but the quality: normal/quiet, gasping, shallow, labored, wheezing, etc.
• Take the arm closest to you. Slide your first two or three fingers over the top of the radial artery (below the thumb pad on the inside of the wrist, just below the bend). Count the beats for 15 seconds and multiply by four.
• Some prefer using only the fingertips; others say using more of the pads of your fingers can help with finding the pulse as you cover more surface area. Never use your thumb as it contains a radial pulse and you may confuse your own with the patient’s. Practice to see what works best for you.
• Reaching your fingers around from the top of the wrist and curling the fingers toward the underside can be a more comforting way to take a pulse than grabbing the wrist. This also works well when holding the arm to the chest to count respirations.
• If you can’t find the pulse at first, adjust the pressure. Press harder and then ease up. Some pulses are deeper than others.
• In certain cases, particularly trauma events, checking the pulse for bilateral consistency (both arms) is advisable.
Blood Pressure – Auscultation
• It can help to ask the subject what he thinks his blood pressure is. That can be a useful starting point. Pump up the cuff about 15 to 20 points above the expected systolic (first) number. You should not be able to hear the pulse.
• When putting on the blood pressure cuff, locate the “artery” notation and place that just above the interior side of the elbow over the brachial pulse. Be sure the cuff is put on snugly.
• Place the stethoscope diaphragm on the inside of the elbow at the bend and below the cuff.
• Position the subject’s arm so that it is fully extended. One field technique is to secure their hand in your armpit in order to stabilize the arm extension.
• Do not inflate the cuff until you are ready to take the reading. Make sure the earpieces are in your ears (angled toward your nose), the diaphragm is properly placed (test for sound first), and the cuff is snug before you begin inflation.
• Close the thumb valve on the bulb (right) before inflating, but not so tightly that you can’t loosen it with just a twist of your thumb and forefinger.
• If you hear the Velcro begin to pull apart as you inflate, recheck the cuff; you may have it on backwards.
• Don’t partially inflate and then deflate the cuff and try to re-inflate it. If you begin to deflate it, go all the way, and if you need to start again, start from the beginning.
• Open the thumb valve on the bulb (left) in order to slowly and smoothly deflate the cuff in one continuous process. Pay attention and note the number when you first begin to hear the pulse (systolic) and again when the sound of the pulse fades completely (diastolic).
• Note the subject’s position at the time of the reading: sitting, standing or lying down.
• Do not rely on any visual needle “bounce” as an accurate reading indicator. Generally, the needle may “bounce” during the period the pulse is strongest, but does not react to the first pulse sounds and ends before the last. Don’t be afraid to ask those around you to be quiet so you can listen for the beats.