Basic Vitals??

[intraining]

as some of you know i recently (about four months ago) completed my EMT-B course.... i recently became a Volunteer Firefighter at one of our local stations and since i do not have my FF1 certification i cannot help on fire calls really, but since i am an EMT i can do MVA's etc.... my question is, what do you usually do as far as basic vitals for your concious (sp) alert patients??

for me it is BP, HR, Pulse, Oxygen Level, Breathing Rate, and obviously the basic questions.. since i have only gone on a few calls so far (what can i say, we're a slow station! :( ) i am still suffering from my jitters.... any recommendations on anything else i should be checking or a better way to overcome the jitters.. i know they will go away with time,but didn't know if anyone had any tips..... thanks in advance... :)

[MiamiMedic]

I check all the following if time permits:
symptoms
Resp rrq
lung sounds
pulse rrq
bp
skin
cap refill
o2 sat
and I keep an eye on the lifepak, if needed.

[kghemtp]

If you can follow as much of the patient assessment checklist you studied for the test, you will gain comfort from doing all of your assessments the same, and that side of thing will become second nature. When you're relaxed, you can see more of the picture and think more about where the patient's condition and/or treatment might be heading. On your fire company, since you're the eager new pup, you may be relied upon for heading the EMS side of things. You're also most recent out of class and more up on the changes in EMS, so you can offer a lot to your department. As for the scene, what you've described sounds great. No matter how much $#!t is dealt to you, try to keep calm & remember A,B,C's are what matter most. Good luck!

[IAMedic]

This is my suggestions (in order so I can remember the steps while typing them out)

Scene Size-up
Initial Assessment (what does my patient look like)
A,B,C's
Manual Stabilization til a C-Collar can be fitted
Is Rapid Extrication needed
Treat Life Threatening injuries
Oxygen, if possible
Get vitals, if possible

These are the things I would focus on once the patient has been placed into my care:

Oxygen
B/P
P
R
SA02
Lung Sounds
Physical Examination
Monitor Vitals
Expose and treat injuries

[hageremtp]

What I do with each patient is different. They are unique and so are their medical emergencies. Never forget your ABC's as far as taking vitals goes, BP, Pule, and resps at least. Attempt to get a past medical history, current medical history (as far as this event goes) Allergies, and Medications. This is usually what our First responders out in the county can get before we arrive...if you need to fill time, remember what you were taught in EMT-B classes, do your assessemnt.......Trust me you will make alot of ambulance services happy when they walk in the door and you hand them a sheet or paper with all the of your vitals and assessment findings.

[twocuts]

I see that many of you include SA02 on your assessments. I have to tell you that when I train folks I usually don't let my cadets use this tool. The fact is that many people use a pulse ox as a crutch. Instead of relying on their assessment techniques, senses etc, they rely on the pulse ox. I think that is wrong.

If they need the pulse ox they have to tell me why that piece of equipment will tell them what they cannot find through other means. Granted, there are times that the pulse ox is needed.

I see it as a liability issue as well. Ok, grandma called because she has a stubbed toe. She has a history of emphysema but that is not her problem today. Now, we put the pulse ox on and her sats are 88%. I do not transport grandma because I was able to wrap her toe, etc. Now I am documenting a SA02 of 88% on a refusal. Not that I cannot write my paperwork to reflect the problem, but, why make more of a hastle than you have to.

My pet pieve is going into a house and a person puts a pulse ox on a patient before even shaking their hand or introducing themselves.

Ok, thats my soapbox.

[intraining]

Originally posted by twocuts
I see that many of you include SA02 on your assessments. I have to tell you that when I train folks I usually don't let my cadets use this tool. The fact is that many people use a pulse ox as a crutch. Instead of relying on their assessment techniques, senses etc, they rely on the pulse ox. I think that is wrong.
.

i understand what you mean about using the pulse ox, but to be honest it plays maybe 1% in the actual size up of our patients, we do not base anything off of it, but rather use it as a tool for more info.

i understand and agree with the steps provided by IAmedic, but i guess what i meant was what do you do for your alert patients as far as vitals, not what will i find in my emt book :p , that is a perfect textbook of what i would do for every situation, but to be honest most of the calls we go on are usually not life threatining (knock on wood) but are calls for minor MVA's, gas leaks, minor fractures, older patients, etc..... fortunately (or unfortunately if ya want more experience) most of the time when it is a large accident or life threatening situation, our paramedics are there first or arrive soon after...

i mean what do you personally do or what have you done in the past as far as taking vitals on your everyday patients. i guess what i am looking for is a concensus (sp?) on what to take on scene from those that are out there, not from the books (that being said, i do realize i probably should follow exactly what the books say, i just have this problem with asking too many questions and asking for too many opinions :( )

[Weruj1]

I agree with Hager about each patient being different and sometimes they get treated the same but you take different ways of getting there.........you have the general idea and always always ask the patient their first name........then use the appropriate surmane ...for me through the years it has been one of my greatest things.....I hate the honeys, mams and hey yous ...TREAT the pateint like you would want to be both medically and as a person ...............over and out !

[smurfe]

I see that many of you include SA02 on your assessments. I have to tell you that when I train folks I usually don't let my cadets use this tool. The fact is that many people use a pulse ox as a crutch. Instead of relying on their assessment techniques, senses etc, they rely on the pulse ox. I think that is wrong.


I have to TOTALLY agree with this. I wish I could figure out someway to lobby to outlaw these devices. I have seen them cause more harm to a patient than I have ever seen them help a patient. To many people trust the Pulse ox over good competent basic patient assessment. Bad Product bad!!!!!!!!! Some-days I just show my age I guess where we had to use our 5 sense's to treat a patient. The biggest irony is that as I have learned more, have more high tech equipment and skills, I have more patients die, go figure.


Smurfe:D

[IAMedic]

SAO2 can be beneficial in certain circumstances and with the proper training. You don't need a SAO2 on every patient. I find them useful for a baseline for SOB, Chest Pain, and other symptoms. I like knowing what they were compared to how they are now. Do I base my treatment on it?? Nope!! My MD would kick my ***** if he caught me "treating a machine".

[ALSfirefighter]

Where were all you anti pulse ox guys when I was being ambushed on the pulse ox threads? Just kidding.

Anyway, basic vitals are exactly what they are..vitals. Pulse ox readings (which, intraining, you wrongly called oxygen level) are not vital at all. Vital Signs are called vital because you can't live without any one of the three, you gotta breath, you gotta have a heart beat and you have to have blood movin' round.
Anything else is part of the assessment process and that all comes down to what type of patient, etc.

[ABMedic]

Hey what is with the bashing of SpO2, someone stated they actually would want to ban the technology (laughing) - as with an test, the result has to be considered in light of the patient presentation. I honesty believe "that it has its significant benefit as one part of the total assessment and a trending value in the management of critical patients".

But hey all you anti-tech people, there is a device out there that appears to have the same problem with its proper utilization by some people, it's called a car ... maybe we should go back to walking?

Solve the education problem, don't blame the technology!

ABMedic

[smurfe]

Hey what is with the bashing of SpO2


Can someone PLEASE give me a pertinent theory of the value and reliability of this tool? I don't "bash" technology when technology has a pertinent purpose and a viable use. Yes, I am an EMS dinosaur, I admit that and I don't accept change too well unless it hits me over the head with "pertinent value". I just see this industry trending toward "educated" paramedics who let machines do all their assessment for them. I have precepted hundreds of paramedic students in my advanced years and I am seeing weaker and weaker assessment skills being displayed. For years we have been screaming and demanding respect in the medical community and it has always been touted that education will cure that. "Send me degreed paramedics and I will show you a true EMS professional" I find little truth to this statement.

EMS is a simple business, it it common sense and the skill to think and pay attention. I don't see medics "talking" to patients anymore short of stumbling their way through a marginal assessment and then watch their machines. Old timers, please tell me what the introduction of 12 leads in the field have done to change your mode of treatment for chest pain? What has the Pulse ox changed your treatment of an asthma patient with bilateral wheezes or the CHF patient with Rales who are "satting" 98% but gasping for air? Do you with hold treatment because the "sat's" are 98%? Do you not treat the chest pain because the 12 lead shows Normal Sinus without any ectopy or pertinent changes? Do the ER's say "your 12 lead is good enough, no reason to do another"?

Have we really "earned" respect because of all our "technology" or have we earned respect from excellent basic assessment skills and proper treatments due to the patients signs and symptoms?

Do I use pulse oximetry and 12 leads? Yes, because my protocols require it, do I value the machines "value"? Not at all! Have I seen improper or poor treatments from technology? Absolutely. Have I seen poor treatment from poor assessment skills? Absolutely. Have I seen poor treatment from good basic assessment skills? Can't say I have.

Now, most are reading this as I am bashing technology and I am not. What I am truly bashing is the trend in paramedic education that relies so heavy on technology and little on common sense. Todays paramedics know the body inside and out and can answer any "test" question that you throw at them. Who do they look at when the $*#& hits the fan for guidance on a bad call though? Us dinosaurs!

I dunno, I guess I am just rambling here and these are only my opinions and they don't mean anything to anyone but me. It just saddens me that while I to have dreamed of and worked hard to earn respect in the medical field that I see regression of quality. And to the original author of this post I apologize for having absolutely nothing to say about your original question in this post.

That is all. I will shut up now


Smurfe

[RoryEl]

First your gonna have to pry my finger off of my, ugh, gu, I mean Spo2 monitor. Well said, ABMedic

[tazmedic69]

What about level of conciousness as a vital sign?

I usually take:

LOC (using GCS)
Pulse (rate and strength)
Resp (rate, quality, and maybe Spo2)
BP
Cap refill/skin colour temp.

[7U4Free]

Maybe there is a disconnect here. Those questioning the technology of the pulse Ox, and to some degree the 12-lead, seem to ask "Do you base your treatment on it". I'd offer that, "No, I don't base my treatment *solely* on that", but it is just one more piece of the puzzle. I often pop the SpO2 on, it takes amost NO time to do, it's hands free, and it provides one point of information without much of my time or intervention, leaving me free to talk to the pt, get a better Hx, etc. By the same token, would you treat "only" on lung sounds? I had rales bilaterally for 2 weeks, but no SOB, and an occasional cough, no thanks on the nitro and the Lasix for me. I know that sounds a bit extreme perhaps, but I would offer that none of us base treatment on a single factor. I've seen the pulse ox tip people off to focus on other areas at times, for example, ours blinks with the pulse, along with displaying the rate. Now, it's not exact, and it's not a substitute for the monitor or even the "two fingered ECG", but a steady blink that suddenly became erradic in a pt that otherwise gave no cardiac signs did help direct things. Just an example outside of the obvious.

As for the 12-lead in the field, I have never had the ER not do it's own when I got there. However, I have had the Md come to me as I wrote a report and tell me that there were no elevations in any lead, and I was able to hand him my initial 12-lead, done in the house asap, that had 2+mm elevations in 3 leads. Now, cardiac enzymes, and pt hx would have told the ER that I'd brought them an MI, and that our MONA helped resolve that incident, but what would have told them WHERE the MI was? My training stressed that our Pts are dynamic, and that having these things early may capture information that is not available later.

I don't think it's the technology, but the over-focus on it, or the lack of training around it that is the problem. These things are tools, not magic wands. Never treat the machine, but then my BP cuff and stethoscope are just machines too, and I bring them every time.

Not a rant, but maybe a different perspective....

[smurfe]

I don't think it's the technology, but the over-focus on it, or the lack of training around it that is the problem.

Yes, I agree, I guess you summed up my long-winded 2 AM ramblings in one sentence and you hit it on the head. Like I said, I am not Anti-technology. I put the blame on todays teaching styles. I still wanna slap many medics upside the head when they slip the pulse ox on someone and it says 98% and they shove it in their face and tell them to "quit the dramatics, you are getting plenty of air" and do not listen to lung sounds due to a good pulse ox reading.

By the same token, would you treat "only" on lung sounds? I had rales bilaterally for 2 weeks, but no SOB, and an occasional cough, no thanks on the nitro and the Lasix for me.

Another excellent point. And as you said to the extreme level, I see this regularly to. Remember in my post where I said I don't see medics talking to the patient besides stumbling through a sub-par assessment. They don't talk to the patient. Did the patient call for SOB and now says they feel fine or did they call for hemorrhoids and on assessment they hear Rales and BAM, shove the drugs on the patient. How many COPD patients have you seen the nebulizer shoved in their mouths due to rhonchi is heard and a SPO2 is 88%? Is that the patients normal condition? Do they feel the same today as any other day? How many exacerbated COPD patients have you seen treated as CHF and had the MS pushed on them when MS is contraindicated in COPD? I see many students that don't even know what Rhonchi is and think if they hear any abnormality it is fluid. How many have protocols to give Lidocaine for 6 or more PVC's in a minute and see it given for that reason when the patient is totally a-symptomatic? I see EMS has evolved to "What I get to do to the patient" vs "What can I do for the patient to help them"

I guess I am asking you all to guide me to the "benefits" of these technological wonders and change my point of view! Yes, I guess I am a bit dramatic at times and I see marginal benefits of 12 leads although my treatment is never changed or based on them as I don't trust the machines in the field, but I have absolutely no value, faith, trust or anything in a Pulse OX.

Smurfe:D

[twocuts]

I am all for technology. I never meant for my post to be misunderstood as that I am anti-technology. Smurfe, if you do not see a great benefit in 12-leads then it makes me think that you do not understand them. They are a great tool. You do not just use them for chest pain. And, yes they do change your treatment. (see the right sided MI discussion) I see the pulse ox as a crutch. I think medics rely on it and I personally do not use it unless I have a good reason. I would venture to say that 10% of my patients get a pulse ox. Schools do not teach their students to use their god given senses anymore, and, I have to fix their bad habits when they come through my academy.

[smurfe]

Smurfe, if you do not see a great benefit in 12-leads then it makes me think that you do not understand them.

It isn't as much I don't understand them as it is I don't trust them. I have had many episodes where I have ran one and seen an MI, then ran one again just to be sure and get a perfectly normal reading. I see most of the problem as type of electrodes used personally. If you don't have perfect placement and perfect skin adhesion you will get different readings. But overall, I have to say no, I am not anywhere near an expert or totally comfortable with interpreting a 12 lead. My training on 12 leads has been ALL self taught.


Smurfe :D

[ABMedic]

I think the mistake made with SPO2 monitors is that practioners don't understand the technology or purpose of the technology. A single SPO2 value is usually of limited value, rather the device is intended for monitoring, ie trending the saturation. Used in this fashion, it can lead to early identification of episodes of desaturation, often prior to clinically apparent signs and symptoms. This is the clinical utility of the technology, allowing the practioner to search for the potential cause and intervene in a timely manner prior to decompensation.

Yes, there are limitations, as with an technology; however the information is another component of the total aspect of on-going assessment of patients. No device or technology must in and of itself drive the management of patient care, nor replace the critical thinking or common sense of the end user of technology.

In the anesthesiology literature, studies demonstrated the value of the technology in providing early warning, prior to clinical awareness of the anesthetists that were blinded to the SPO2 value. See the literature of the 80's and 90's for the studies, as this technology has been around a long time. The results demonstrated that regardless of your expertise (anethetists) their ability to note early episodes of hypoxia was significantly poor. My question - would yours be better - I think not!


ABMedic

[ABMedic]

smurfe - we will let you keep your car (laughing)

ABMedic

[smurfe]

smurfe - we will let you keep your car (laughing)

Thank you cause my horse died and my chariot has square wheels LOL


Smurfe :D