Posted by: medicblog999 | October 23, 2009

Over use of our Technology

blood_pressure_cuffI have a pet hate.

No, honestly, for those of you that know me, I am sure this will surprise you, but there is one thing that does actually get my goat sometimes.

This isn’t going to be a rant. In the very first post of this blog, I said I would never use it to vent or rant, and I will stick to that. Instead, let’s have another discussion.

I am very much a hands on paramedic. I like to touch my patients (No, not in that way!!)

I like to feel their skin and actually have tactile confirmation that they are hot, cold, clammy or sweaty. I like to actually feel a radial pulse to ‘feel’ the quality of it. Is it strong, full and bounding or is it weak and thready? I will hold the patients hand to reassure them and comfort them and unless there are bodily fluids about, I won’t be wearing my gloves.

But the main point of this post is the frustration that sets in when I see people who never (ever) seem to take a manual blood pressure reading.

We are becoming far too reliant on the wonderful medical technology that is constantly finding its way onto our ambulances. Some of them are obviously essential such as 12 Lead ECG, Capnography (if you are lucky enough to have it) and blood glucose monitoring machines, but many of them are becoming the standard and default option for patient assessment.

Need to know the pulse – stick the pulse oxymeter on.

Need to know the BP – just put the cuff from the lifepak 12 on.

Need to know how oxygenated the patient is – again the pulse oxymeter.

Don’t get me wrong, these are great bits of kit which I use on a daily basis with my patients, but that is only after I have actually used my own senses to asses the patient first.

What’s the pulse – I know, let’s actually palpate it and find out!

What’s the BP – Let’s put the manual sphygmomanometer on and actually auscultate the systolic and diastolic blood pressure.

How oxygenated are they – lets look at the patients colour, responsiveness, extremities and respiratory effort for signs of hypoxia and cyanosis.

The technology we use has its ‘very significant’ limitations. I have lost count of the amount of times I have stood back and let another paramedic try getting a ‘proper reading’ from an automated BP machine. The patient may be on the stretcher with a horrendous tremor, and the cuff will still go on. Then they wonder why the patients BP comes back at 210/160 (or something equally as unlikely and against the presentation of the patient). I guarantee that I can get a manual blood pressure quicker than any machine, and more to the point, I wont have to query it and ‘just check it manually’ if it doesn’t seem to match what you were expecting.

I only ever use the LifePak 12 for BP monitoring after I have taken my own baseline measurement with my own ears. Then I have something to actually judge a trend on and decide if it is likely to be correct or not (and even then I may try to have a quick listen in on the way if the transport time is anything significant).

The same sort of thing goes for the pulse oxymeter. Great bit of kit, when you have a good signal going to it. But there are so many things that can interfere with the reading and the accuracy, that you have to remember that it is a guide to support your own assessment of the patient. If the SaO2 comes up at 74% but the patient looks a good colour, has no breathing difficulty, and no pre-existing medical condition that may make them chronically hypoxaemic, then it’s probably not the best reading to take as gospel.

We have a responsibility to our patients to ensure that the information that we pass onto the hospital, regarding their presenting condition in the prehospital setting, is accurate. Sometimes it’s really beneficial to go right back to basics and use your senses for patient assessment instead of microchips and circuitry.

So, how frequently do you get the manual sphyg out?

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Responses

  1. Hi Mark,I'm with you on that one. I do get carried way sometimes with our gadgets, but (luckily?) we don't have too many – no automated BP Cuff for example. Unless it's a noisy environment I always auscultate rather than palpate a blood pressure for baseline obs. Our SP02 probe has atrocious readings a lot of the time too, not always reliable. Having said that, I do use the heart rate reading off the Sats probe, but only after I have checked the pulse with my own fingers on the radial that both of our reading have the same rhythm.Nice to read you take your job seriously!

  2. I hear you. I wake up screaming in the garage at night, such is my frustration on the our over reliance on technological wizardry! For example, on encountering a time critical patient with acute cardiogenic pulmonary oedema, who is doing a really good impersonation of a gold fish in trouble, a colleague will reach for the “mighty pulse ox” and NIBP, instead of implementing expedient definitive care. They will muck around trying to get a BP with a NIBP, when a palpated systolic pressure with a sphyg cuff would do the job in 30 seconds. An in extremis patient readily determinable without the need for a second opinion with a pulse oximeter. I agree with you. We need to relegate technology to the realm of useful adjunct and regain the lost art of clinical acumen.

  3. Mark,You truly are a member of the crusty “old school” of paramedicine! An, apparently transoceanic, movement of old-fart medics who understand what “treat the patient not the technology” really means.How about this: any medic right out of school should only have access to Lifepak 10 (or equivalent – and know how to use modified chest leads for STEMI identification), a good stethoscope and a manual BP cuff for a period of 1 year. If they learn how to do a decent exam with those tools, then they can graduate to the techno-toys. Meanwhile they will have to listen to us crusty ones tell war stories of “back in the day” when NIBP and pulse oximetry were science fiction, while cussing them out as young whippersnappers! Glad to know there's kindred spirits out there – keep it up…

  4. Touching the patient also allows you to engage with them, you can feel abnormalities in the pulse, and if youre clever enough you can spend 30 secs doing the pulse and 30 secs doing respiratory rate and they wont ever know you were doing it 😉

    I also prefer to use a manual sphygmomanometer.

  5. Hospitals are even worse, do they even have manual sphygs in A&E departments? Particularly with AF patients the Lifepak is very unreliable, so I'll always do a manual BP. Then you turn up at A&E, they do their set of obs and get a completely different BP. I'll then be met by utterly blank looks when I suggest the BP is unlikely to have changed dramatically on a stable patient in the last ten minutes and perhaps it's because the machine can't deal with AF?

  6. I've seen this from the other side. Registering at a doctors' surgery, the nurse took my BP with whatever gizmo. Came back 140/110, and, as politely as possible, I told her that was nonsense (having spent an evening a week or so before with a bunch of nurses and nursing students learning how to use sphygs). She just ran the machine again, got the same result. Doctor checked it later and found it 110/70.

  7. Over in the good 'ol USA thats what we have lowly firefighter/EMTs for…….right? I was always told treat your patient and not the machine. We will always get a manual reading whenever we show up and then after that I will put them on the automatic NIBP, however those things are notoriously unreliable i.e Manual reading 142/86 automatic reading 58/32 the pulse ox we had was rubbish too pulse 200 sats 42% and the patient would be sitting up and having a good 'ol chat with me, now that you mention it I thought it was weird how blue she was……..oh well.

  8. Well I've just been rudely awakened from my sleep by a phone call and once awake Mrs999 decided to pounce and go into great lengths about how wrong I am on this issue. She won't comment so I thought I would put her view forward.She states that there is a place for all of these gadgets and gives the example of turning up at an RTC alone and having to deal with a critical patient. With all the noise and multiple things to deal with she states that this is when the NIBP comes into it's own as it can free the paramedic up to move onto other interventions. My argument is that many times you will get back readings that you dont believe anyway so wouldn't it be quicker to just do it manually, once?I will however agree that there are always times when it is your only option, maybe due to patient positioning or lack of full access to the patient. But I would want to get a manual to verify the readings as soon as possible.Thank you dear wife, for your comments.

  9. Mike,Congratulations!!!You are the first person to ever call me crusty and old school!I guess in this case though, sometimes it's good to keep some 'traditions':-)

  10. Funny!!!It's nice to have a laugh when I am sleep deprived in between my night shifts and just can't get back to sleep.Cheers mate!

  11. strongly agree, I also try and get one manual reading before turing the lifepak on, but sometimes the lifepak doing the bp saves you a couple of minutes whilst you can be doing other things, especially when your a single responder

  12. It never comes out because we don't ever use them (first aid, not some sort of awful ambulance trust)We aren't trained to do them at all, and only in enhanced courses do we even get taught how to do them. I'd love to be able to learn how to take a manual BP – for one, would you prefer someone treating you to go “right, gonna slap this machine on you and see what it says” or “Right, I'm just gonna take a quick reading” and do it manually? From a patients perspective, I'd say the latter looks way more professional…

  13. I'm a CFR and supposedly trained in advanced techniques. Unfortunately, we're not allowed to measure BP either manually or by the diabolical machine. I can, though, give GTN to a patient with chest pains. Then I'm playing the will he/won't he collapse game. My only guide is that if there is a discernable radial pulse, systolic is 90mm+. For every patient?A few years ago I found out how reliable the automatics are. My GP was a bit concerned that my BP was high, so he lent me a machine so that I could record BP at different times of the day over two weeks.Sometimes – often, in fact – it would return a reading that suggested the top of my head was going to blow off! Taking the advantage of the fact that we had a nurse on shifts at work, I got my BP tested using an old mercury sphyg at the same time as the machine. The machine was reading 80% too high!Incidentally, I have my own sphyg and I'm just looking for one of our friendly paramedics to give me some unofficial instruction.

  14. I always make my basic partners ascultate a BP. my service does not have the auto BP on our lifepak 12s. When a partner throws the pulse oximeter on I ask for the quality of the pulse. I agree, I am a fan of tactile information. We get countless calls from nursing homes for low SpO2 sats, only to find a patient with pink warm & dry skin, no respiratory distress just cold hands.

  15. My dilemma is that I'm new to the service and work alongside many disgruntled 'old hands' that I presume are just seeing out their time until they claim their pension. So as much as I'd like to get 'hands on' and practise the skills I've been taught it's usually not an option as many senior clinicians subscribe to the trend that ALL patients go to hospital and in a 'scoop and run' style.Until I'm a trained tech I'll have to sit tight and bite my lip.

  16. Mark, I'm with you. As a first responder I don't have enough hands (or for that matter always a LP12) to take all the gadgets with me, so it's manual readings all the way. I trust my eyes and ears a great deal more than the gadgets, as like you say, they are often unreliable. I do have to agree with MrsM999, that they do have their uses, and are sometimes an extra pair of hands, it's just a question of knowing when and where to use them, and when to disregard them. Matt, one of the other commentors, has said it already – treat the patient. Not the machine!

  17. Let me fully agree with you on this matter. I'm a technology kind of guy. I love new gadgets and gizmos. I build my own computers and spend my time trying to get every bit of power that I can from them. However, all of that stops when it comes to patient care. All my initial vitals are always done manually because those pretty machines are just going to tell me numbers and tell me slower than I can do it manually. The funny thing is that my usual partner is about as technologically illiterate as they come, but always is firing up the NIBP and Pulse OX to get his vital signs.(Of course he also thinks ABC means Address, Birthdate and Cards for Insurance). I'm working with him, but he is old and set in his ways. Keep up the good work and enjoy your visit to the USA.

  18. Let me fully agree with you on this matter. I'm a technology kind of guy. I love new gadgets and gizmos. I build my own computers and spend my time trying to get every bit of power that I can from them. However, all of that stops when it comes to patient care. All my initial vitals are always done manually because those pretty machines are just going to tell me numbers and tell me slower than I can do it manually. The funny thing is that my usual partner is about as technologically illiterate as they come, but always is firing up the NIBP and Pulse OX to get his vital signs.(Of course he also thinks ABC means Address, Birthdate and Cards for Insurance). I'm working with him, but he is old and set in his ways. Keep up the good work and enjoy your visit to the USA.

  19. Oh yeah can't agree with you enough on that one. I was a Paramedic and am now just finishing up my Registered Nursing and Midwifery and I don't know how many times taking a manual BP and pulse have saved the pt's (and my own) bacon! One in particular springs to mind. Was doing a stint in the A&E just recently and was looking after a gentleman who just 'didn't look right' (my own diagnosis). Monitor says he's fine, Sa02 99, auto BP machine says he's good at 130/80, pulse is normal, neuro obs are normal but the pateint is not as responsive as I think that he should be and is very restless. Auto readings say that he is fine but he really does look to be early stage hypoxic. Just to be safe I start taking manual obs. Manual BP 170/90. Wait??? What??? take it again 175/90, pulse 105. Press the big red button for dial-a-crowd (call a code) and it turn out to be massive APO – cardiogenic in nature. So yeah! Can't agree with you more on that one! Very interesting blog by the way, brings up lots of good points!

  20. Oh yeah can't agree with you enough on that one. I was a Paramedic and am now just finishing up my Registered Nursing and Midwifery and I don't know how many times taking a manual BP and pulse have saved the pt's (and my own) bacon! One in particular springs to mind. Was doing a stint in the A&E just recently and was looking after a gentleman who just 'didn't look right' (my own diagnosis). Monitor says he's fine, Sa02 99, auto BP machine says he's good at 130/80, pulse is normal, neuro obs are normal but the pateint is not as responsive as I think that he should be and is very restless. Auto readings say that he is fine but he really does look to be early stage hypoxic. Just to be safe I start taking manual obs. Manual BP 170/90. Wait??? What??? take it again 175/90, pulse 105. Press the big red button for dial-a-crowd (call a code) and it turn out to be massive APO – cardiogenic in nature. So yeah! Can't agree with you more on that one! Very interesting blog by the way, brings up lots of good points!

  21. Oh yeah can't agree with you enough on that one. I was a Paramedic and am now just finishing up my Registered Nursing and Midwifery and I don't know how many times taking a manual BP and pulse have saved the pt's (and my own) bacon! One in particular springs to mind. Was doing a stint in the A&E just recently and was looking after a gentleman who just 'didn't look right' (my own diagnosis). Monitor says he's fine, Sa02 99, auto BP machine says he's good at 130/80, pulse is normal, neuro obs are normal but the pateint is not as responsive as I think that he should be and is very restless. Auto readings say that he is fine but he really does look to be early stage hypoxic. Just to be safe I start taking manual obs. Manual BP 170/90. Wait??? What??? take it again 175/90, pulse 105. Press the big red button for dial-a-crowd (call a code) and it turn out to be massive APO – cardiogenic in nature. So yeah! Can't agree with you more on that one! Very interesting blog by the way, brings up lots of good points!


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