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.