Observations Part 1 – Pulses
This was prompted by a duty a while back where I and another person ended up doing an impromptu lesson in patient monitoring to half a first aid post. Not a promising start to the duty, but we were told afterwards by quite a few of the members that they appreciated the help.
Observations. Obs. Pulse and Resps. Vital Signs.
Whatever you call them, they’re important. And too many of us (myself included) are really bad at remembering to do them.
I was checking over a report for a patient I had treated, where I had come cycling down to back someone up. Something simple, but significant enough to require a reasonable amount of writing to prove we’d tried to think of everything. As I scanned through the notes, I noted that they’d put down: “patient apparently stable”. I glanced over at the observations box: empty. Now I agreed that the patient was stable (they wouldn’t have wondered off five minutes ago if they weren’t), but if you look at that form there was nothing to back us up. Nothing showing that the patient’s obs were normal, or at least returning to normal, and not shooting off somewhere unpleasant.
Repeat after me: if it isn’t written down, it didn’t happen.
To prove that something isn’t changing significantly, you need at least two data points. One tells you nothing. And they need to be reasonably spaced out. Two sets of obs done in two minutes tells us nothing. A lot of things that could go very wrong happen over a relatively long period of time (at least at first). Getting two sets of obs should be simple: one when they arrive, and one when they leave. Obs every ten minutes or so works well, if you can (obviously life-saving stuff needs to come first). It should only take a minute or so to do, and we don’t have to be getting precise numbers every time. We just need to know what’s going on, and then use that information to help us make decisions (such as, do I take my time and finish tidying this bandage, or do I want to have a paramedic with me yesterday…)
Taking a pulse is a simple technique, anyone with a couple of fingers on one hand should be able to do it, but it does takes practice. However, in my experience, it doesn’t seem to be covered as much as it should by our training. Everyone just assumes that everyone else knows what they’re doing. I’ve been caught out a number of times in training where someone has told me they don’t know what they’re doing. And I’ve caught out a number of people trying to cheat in an assessment by making things up (and holding the wrong part of my wrist…)
This is the method I use on a conscious patient:
- Decide which wrist you’re going to use. Make sure it’s comfortable for the patient, and the arm isn’t squashed beneath them or against something (and cutting off the blood supply).
- Make sure your patient knows you’re going to do a pulse. Like with any technique, if you do this without consent you could technically be assaulting your patient.
- Take the hand as if you are going to shake hands, and gently rotate it around so that their palm is up. Don’t let go, but consider resting it on a hard surface (a leg works well if it isn’t shivering). This means you have control of the arm, and you can keep it still.
- Using the first three fingers on your other hand (never your thumb, which has its own pulse), place your fingers on their wrist, beneath their thumb, next to their radius. You are trying to (gently!) press their radial artery against a bone. Hopefully you should feel their pulse. Don’t push to hard (you may cut of the blood supply, or your patient may just hit you because it hurts), and be prepared to hunt for it. It’ll always be on the thumb side of the arm, but sometimes you’ll have to search (and sometimes it is quite hard to find).
- Count the pulse for 15, 20 or 30 seconds, and then multiply it up. You don’t need to count for an entire minute, we’re not after exact numbers here, this should give you an acceptably accurate number. A normal pulse in an adult is about 60-80 bpm1 (though remember this depends on the patient’s fitness and what they’ve just been doing), and expect a child’s to be faster (and a baby’s faster still). Also pay attention to the quality and regularity of the pulse. Are they strong or weak? Are they skipping beats? Is it a regular pulse (or regularly irregular, or just plain irregular)? All things that are important.
If you can’t find the radial pulse, try the brachial. This one is on the inside of the elbow. It can be quite challenging to find, so practicing this one is a very good idea. If you ever learn to do manual blood pressures (which I hate doing, but we can’t use automatic BP cuffs) you’ll need to know about this one, as this is the one you listen to. As a last resort you can use the carotid (in the neck, next to the trachea on both sides), but this is not very comfortable for a conscious patient (take it from someone who has played at casualty as many times as I have: it is NOT fun). The First Aid Manual has some good pictures on where you can find pulses (page 53).
Keep in mind that if you expect your patient’s blood pressure to be very low (for example when shock is starting to get bad), pulses do start to disappear (radial first). It is worth noting if you can’t find a pulse (don’t be embarrassed or afraid to say you can’t do something), and it is very important to note if a pulse disappears.
Get used to making this one of the first things you do for a patient (after your primary survey, of cause). Not only does it give you a baseline to work from later, but it starts to tell you something of what is going on, and it makes you look like you know what you’re doing (and you have a plan). Finally, if you’re patient is distressed, the act of taking their hand can be very reassuring (I know this one from experience).
Naturally, be alert for people who aren’t comfortable with you touching them (holding hands can be seen as being quite personal) and be prepared to alter your technique to fit. If they won’t let you take a pulse, note that down and move on. It’s not worth alienating someone over. First aid is all about taking the perfect solution and the real world injury and making the two fit.
And don’t do what someone did in an assessment, and move a ‘broken’ arm to take a pulse. Needless to say, they got an earful from their casualty.
The most important things are, in my humble opinion, practice, practice and more practice. Every time you get a patient who’s with you for any length of time (we’re not talking the plaster dispenser ones here), take a pulse. Every time you do a scenario in training, take a pulse. Pester your friends to let you practice on them. Develop your own method of taking a pulse, one that works for you (or pinch mine, that’s what I did). Whatever it takes to get yourself confident in taking pulses.
I’ll cover respiration rates in my next post. These are more difficult to get, but form the other part of the most basic observations we can all do as first aiders.
CPR Saves Lives
The title says it all, really.
CPR is easy, simple and saves lives. And that’s all there is to it. Everyone should feel they can do something if someone stops breathing.
I know I’m late to this particular party, but this is easily one of the best first aid awareness campaigns I have seen in a long time:
Courtesy of the British Heart Foundation.
If you have to do CPR, you can’t really make things any worse. You won’t get sued. You won’t get arrested. Just go for it.
Cycle Response Training–Part 2
The first day of training was to prove that we could control the bikes, and that we were safe enough to be let loose on the roads. The second day was for demonstrating that would could cycle safely in real traffic, and the fitness tests.
First up was the cycle in traffic. As campus is on the top of a hill, this first involved a cycle down the hill. Oh, and the glorious weather yesterday had turned in to pouring rain.
I was riding one of the response bikes. Complete with an almost full load-out of equipment (including a full O2 cylinder). Down a steep hill. A wet, steep hill. That was an interesting experience.
To save time, our instructor combined the endurance test with the proficiency assessment. The requirements changed depending on age and gender, but we were all aiming for 10km in 40 minutes, the young male target. This is a fairly comfortable patrol speed, and even before allowing for the traffic and the rain, we did fine.
We had a lunch-break in town, just about hiding from the rain while keeping a close eye on the response bikes.
The next assessment was a 1km sprint, followed by a six-minute scenario including CPR. Except, this had to take place on campus, where we wouldn’t have as much traffic to deal with.
Remember that hill. We were now headed the other way. With our bikes, so no cheating by taking the bus.
Four of us tried to ride our bikes up the hill, two on response bikes (me and one other) and two on their own bikes. Everyone else decided not to even try to cycle, walking up instead.
It was a slog, more so considering the fact that I was already soaked through, and was lugging a gas cylinder. And I made it. Once I’d got my breath back, and decided I wasn’t about to have a heart attack, I was very pleased with myself. I’ve never managed that hill before, but this bike had a decent set of gears.
Of cause, I then had to do the sprint. Along a road on campus, and up and down another one, including two hard turns and an automated barrier to navigate. I had to aim for 2 minutes 40 seconds, from the end of the radio call. Oh, and still have enough breath to do CPR for six minutes, and enough sense through the adrenaline to run an AED without ‘killing’ myself.
I made the time, just about. Felt like I was going to keel over when I skidded to a halt by the ‘patient’, but some how managed to survive.
The scenario wasn’t textbook. I forgot to check if the patient was breathing, but otherwise did okay.
Only then did we find out that we didn’t need to do the manoeuvres again (a great relief), and we had all passed. After a small amount of paperwork, a quick round of presentations, and then we headed home. Dripping wet, absolutely knackered, but pleased, and more importantly, now all qualified Cycle Responders.
Oh, and that hill climb… I felt that one for days.
Related articles
- Cycling First Aid (walkingplasterdispenser.wordpress.com)
Cycle Response Training – Part 1
A few weekends ago, I attended a two-day course to become a Cycle Responder for the Organisation. As promised, I’ve written a bit to describe the course.
The first day was pretty relaxed. The obligatory introduction to a course. A quick bit on the various levels of Cycle Responder in the Organisation, and what the course would entail. Designating a first aider for the course (a course for first aiders who are all at least trusted to use an AED, if not medical gases, and with a doctor also attending) caused a brief session of everyone volunteering everyone else. A quick reminder that if we came across anything while cycling around on the bright yellow, Organisation branded bikes, we would need to stop and help. Then, on to the course.
Our instructor first had to take us out to a car park and get us to show that we could actually ride our bikes. We had to demonstrate that we could ride without wobbling, signal and look over our shoulders without problems, and perform an emergency stop from a sprint without falling off (or shooting over the handlebars).
Next up was the low-speed manoeuvring. As a Cycle Responder on duty, it is expected that we will spend most of our time on our bikes. Unless we’re treating or stopping, we should aim to cycle everywhere. This includes through crowds and behind people meandering down the pavement. Constantly mounting and dismounting looks silly, and on a bike that’s a little on the tall side, is rather awkward.
To make sure we can do this safely, we have to demonstrate that we can handle the bikes at the speed of a slow walk. This is a pain in the arse. It involves gearing down as low as possible, and then peddling with the rear brake partially on to give a little resistance to work against. Doing this, while remaining balanced, is hard.
The first unofficial test is what our instructor called the slow race. A set of cones, spread out in a triangle shape, with everyone at the wide end. The aim was to be the last person to reach the point, without stopping. Chaos ensued as we all moved off to fast, slowed, wobbled, collided with each other, and generally tried to move slowly. Needless to say, none of us did well.
Next, after much more practice moving slowly, came the 10 foot box. More cones, this time arranged in a square with sides 10 feet long. We had to enter the box, circle inside of it three times, and then cycle out, turn around, and do the reverse.
Picture, for a minute this box. Now add in a bike. A bike about 5 feet long. With two heavy panniers on. This is not an easy manoeuvre.
We spent several hours on this, by which time we were all thoroughly bored, irritated and frustrated, but everyone pulled it off, to our unified relief. Though, when we found out that this was a practice run, and we would be assessed on it tomorrow, we were far from impressed.
Then, after a bit of a talk on bike maintenance (mainly how to take a wheel off and repair a puncture), we were done for the day. Tired, sunburnt, a still a little dizzy from the box, we headed home.
Related articles
- Cycling First Aid (walkingplasterdispenser.wordpress.com)
Cycling First Aid
I have wanted to do cycle response with the Organisation for a long time now. So much so that I would consider delaying my ambulance training to do this.
To my joy, a course is coming up. It’s super short notice, and I don’t know if I’ll be able to get the time off of work (working weekends sucks…), but that is the least of my worries…
The requirements are simple. For me, I need to be fit (I think I can meet the standard required), be able to cycle a bike with heavy panniers (done that before) and I need a basic First Aid qualification, with O2 and AED as a bonus (my patient transport qualification covers that and more). This is all fine. The catch is the last requirement: ‘Unit to agree to pay for uniform’.
The uniform costs something of the order of £140 per person. That’s for one set of uniform. There are three of us who want to do the training at the unit. That’s more than £400! This is a sizeable chunk of a youth unit’s budget, not least because we are technically a non-operational unit. Our main source of income is the cadet subscriptions (despite being told otherwise by everyone else who doesn’t look at our statements…), and I don’t think I can justify the unit spending that much on three members in one go. I definitely can’t ask them to do it (I certainly can’t afford that much on a single set of uniform).
So this presents me a problem. I really really want to do this training. But I just can’t see how I can make it work. I’ll have to talk to my boss tomorrow.
I can feel this opportunity slowly slipping away from me as I watch.
I Passed
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I forgot to mention a few months back. I passed my Patient Transport assessments. It was a very weird feeling being on the other side of the deal, treating instead of being treated. I can certainly sympathise with all the people who make the silly mistakes. Nothing is half as obvious when it’s you who is being scrutinised…
My treatments were all fine, as was my dealing with the patient. We had to have two goes at the resus because my partner froze. The second time around I was told to step back, to allow her to demonstrate the competence we all knew she had. I ended up being held outside the assessment room an annoying amount of time ’getting equipment’, and then spending ages calling for an ambulance.
I understand the reasons, but having to stand outside while I can hear my partner struggling to get going had me climbing up the walls with the AED I had been sent to get. Oh, and doing that in the same room, watching my partner struggle with nerves, and spotting all the little mistakes that I could have solved without a problem, grated. I have never been so keen to do CPR in my life… Fortunately, second time was lucky.
My partner and I, two very slight people, were nearly referred on our lifting, but we got it right on the second go and it was put down to lack of confidence and over-caution.
Needless to say, I’m rather pleased. The second part of the course, the Emergency Transport section, is hopefully going to be mid next year, and I can’t wait.
Now all I have to do is work on my lifting, revise my First Aid Manual, learn my Ambulance Manual. Oh, and pass my Uni exams, get through this years group project work (which I already think is going to be a nightmare), and survive my new job. Could be an interesting year…
Cycling Decision
I mentioned a while back that I was very interested in getting involved in the Cycle Response section of the Organisation. To me, the CRU seems much more interesting than the working on an ambulance, however prestigious having an ambulance qualification might be in this Organisation (don’t get me started on this…)
It’s not going to be long before I have to make an important decision. I am told by our County Ambulance Officer, BigPara, that it won’t be too long until the first Ambulance course is held. I intend to go to it. However, in this area, the first course, which centres around Patient Transport, is mainly considered to be a stepping stone to the next one, the Emergency Care bit that fully qualifies us to crew one of the Organisation’s emergency ambulances.
BigPara has always seemed keen to get me on to this course. The first thing he said to me after I got out of my Medical Gases assessment last year was “so when are we getting you on a Patient Transport course?” I like to think of this as a vote of confidence. I would hope that he wouldn’t recommend someone for a course if he didn’t think they could pass it. I even signed up for the course based on this (up until then I’d been doubting that I was ready to do it).
However, now I’ve come across a few more opportunities, and I find myself wanting to do them all. Which means I need to decide. I’ll do the first course, if only because it makes life easier when I need to do my yearly revalidation. The choice is whether or not I continue to the full level. If I do, I get to crew ambulances, a whole new range of opportunities open up, but I might not get to do my cycling. If I don’t, I’ll be left with a qualification that doesn’t really mean much, and the possibility that the cycling will never happen.
I hate decisions like this.
Thoughts on Disappointment
Those of you paying attention will have noticed that I had hoped to be on a course this weekend just gone. I wanted to be at least some of the way in to cycle response training by now.
At the last-minute, the course was cancelled. Needless to say, I’m very disappointed. I realise it could have been worse, I haven’t been turned down, and the course didn’t go on without me. But I still would have loved to have been on that course. I really don’t want to have to wait the weeks or months until they try to run the course again.
The wait also leaves me with a decision to make. I have been told (admittedly indirectly) that it is possible that if I complete my ambulance training, I might not get on to the cycle response course. In a way it makes some sense, the ambulance crews end up on ambulances. I probably wouldn’t end up on a bike unless they were in desperate need of bikes, or have enough ambulance crews (this is rare).
I particularly want to become a cycle responder. As I can’t drive, if I go on an ambulance I’m always going to have to be put with someone who can drive. While this means I’m almost always likely to be in the back with the patient, it also seems like a bit of a limit to me. Cycling, is much more my thing. I’m much more confident on two wheels than four. Yes it means I could be responded alone (a slightly scary thought), but with backup a matter of minutes away if really necessary, I think I can deal with it.
So now I have to decide. Do I continue with my original plans, finish my ambulance training, and risk not being able to do something I’ve wanted to do for ages? Or do I delay the ambulance stuff, on the chance that I might get on to a very small course, but possibly delaying my ambulance training even more without gaining anything.
I think one thing doesn’t need any thought. If both courses are on at the same time, I know which will win…
