auscultating lung sounds and taking a BP

[uglyEMT]

OMG Dwayne that long post was great. I needed a great laugh today.

Umm I have nothing else to add. I am still learning myself and use my POS dual lumen on scene and the rig provided Cardio II while on the road. Hate to admit it but it takes me a few tries on certain patients to get clear sounds. But hey Im still learning. I will get great at it one day.

[HERBIE1]

I though you were so full of crap here. That perhaps you saw someone playing with one of those nasal intubation scopes, but lo' and behold, Google turns up pages of them.. $2 stethoscopes. Amazing. On the flip side though is the issue of people deconing their equipment, including their 'ears' which I have to admit, though I likely do it more than many, I don't in fact do it after each patient when I get busy. No excuse for that and now that I've admitted it to the world will try and make sure that I never have to do so again...

Yeah, you beat my brains out with your figurative mental walker daily. I'm better for it and say thank you...

Dwayne

I first saw those disposable scopes years ago in a first aid station at a special event I was working. I could not believe my eyes. Later, when I saw some supposed "professionals" using them in the field, I was just appalled.

Have a little pride in your work, folks. You can only be as good as the tools you use, and if you have some lousy disposable set of ears, how on earth can you hear anything? How can you accurately assess lung sounds? To me, it would be like a police officer using a Saturday night special 22 caliber gun as their primary weapon. Convenient, cheap, and small, but would you really want to trust it?

I've had 2 personal stethoscopes in all my years of doing this. The first one I bought while in paramedic school. Probably ran me around $100 back then, and it was far more elaborate then I needed. It lasted me around 15 years, until one of the tubes got a cut in it. I replaced it with another similar model, and I still have it today.

Hey on walker jokes .. that's just hurtful !

PCP you may find in high abmiant noise environments the "bell" may isolate extra noise.

cheers

LOL

No offense intended, triugs...

[BoCat9]

One way I learned in my basic class was to start out like you are going to palpate the BP. With your fingers on the radial pulse, pump the cuff up until you no longer feel a radial pulse, then pump about 10-15 mmHg higher, so you don't miss the first beat. Then put the bell of the stethoscope on the crook of the arm and release slowly. If you feel like you missed one of the beats, make sure you let the air out of the cuff before you pump it back up.

Also, make sure it is quiet in the back of the unit when you are taking a blood pressure. Some types of patients have a BP that is very difficult to obtain, i.e. dialysis patients. Palpating a BP is acceptable, but should be used as a last resort.

When auscultating lung sounds, I usually place the stethoscope right below the clavicle for the top lobes and right below the 5th or 6th ribs on the mid-axillary line for the bottom lobes, pretty much where I would listen to verify placement of an ET tube.

[HERBIE1]

One way I learned in my basic class was to start out like you are going to palpate the BP. With your fingers on the radial pulse, pump the cuff up until you no longer feel a radial pulse, then pump about 10-15 mmHg higher, so you don't miss the first beat. Then put the bell of the stethoscope on the crook of the arm and release slowly. If you feel like you missed one of the beats, make sure you let the air out of the cuff before you pump it back up.

Also, make sure it is quiet in the back of the unit when you are taking a blood pressure. Some types of patients have a BP that is very difficult to obtain, i.e. dialysis patients. Palpating a BP is acceptable, but should be used as a last resort.

When auscultating lung sounds, I usually place the stethoscope right below the clavicle for the top lobes and right below the 5th or 6th ribs on the mid-axillary line for the bottom lobes, pretty much where I would listen to verify placement of an ET tube.

Sounds like a solid technique to me. I will palpate a BP as a back up- in case I'm not sure I heard the systolic number correctly. I know-not entirely accurate, but sometimes folks have really faint BP's, and confirming that top number is important to get a baseline.

The only thing I will say is that often times, enroute to the ER, I will only palpate a BP, because it may simply be impossible to hear anything accurately- especially if the person has a weak pulse to begin with. If you are not moving, and it's just you, your partner, and the patient, you can control the noise level. If you are on scene, or with a bunch of folks, sometimes quiet is a relative term. LOL

[BoCat9]

Sounds like a solid technique to me. I will palpate a BP as a back up- in case I'm not sure I heard the systolic number correctly. I know-not entirely accurate, but sometimes folks have really faint BP's, and confirming that top number is important to get a baseline.

The only thing I will say is that often times, enroute to the ER, I will only palpate a BP, because it may simply be impossible to hear anything accurately- especially if the person has a weak pulse to begin with. If you are not moving, and it's just you, your partner, and the patient, you can control the noise level. If you are on scene, or with a bunch of folks, sometimes quiet is a relative term. LOL

Oh yeah, I understand that. I guess I should have really worded that a little differently. I know people who don't even try to auscultate a BP. They either don't do one or they just use palpation.

[Lone Star]

Ok, I've just got to chime in here....

I was taught (by an amazing instructor) many years ago that you place the B/P cuff about an inch above the antecubital region (the 'front part' of the elbow), and the palpate the brachial artery, and place the diaphragm of the stethescope over it, and lightly press on the stethescope. Begin to inflate the cuff until you cannot hear any 'thumps', and then increase the pressure 30 mm/hg. S-L-O-W-L-Y start to release the pressure in the cuff.

As the pressure is being released, you will hear the pulse return, this will be your systolic pressure.

As you continute to release the pressure, you'll end up 'losing' the pulse sounds. This will be your diastolic pressure.

I will defend the use of the Sprague type stethescopes. I find them easier to hear with (especially in noisier situations). It is my personal choice.

If you ARE using the Sprague type, remember the head of the stethescope will turn. I use the large diaphragm for lung sounds and blood pressures. Remember that there is a 'flat side' of the head fixture. This indicates which diaphragm is 'turned on'. This 'flat side' will be toward your patient.

When using a stethescope that is 'single lumen', remember to keep your fat little thumb off the back of the head. I've noticed that those stethescopes are notorious for picking up YOUR pulse sounds from your thumb.

Also remember that if you take a blood pressure in the left arm and aren't sure of what you heard, if you inflate that cuff again, you'll get a different reading than you initially had.

I've seen people who inflate the B/P cuff to a minimum of 250 mm/hg or more rather than the correct way, and I want to auscultate a corotid B/P on them! It's not the proper way to do it, and causes the patient undue discomfort.

As has been stated before, the earpieces should be comfortable and fit the ear canal, and the 'arms' on the stethescope shoud be angled slightly forward. This directs the sound into the ear canal, and you don't try to rush though the process because the ear pieces make your ears hurt.

Practice is the key here. As you start practicing, do it in relatively quiet places, and then start to work with more noises (television, radio, other people talking; etc). This will help you hone the skill and be able to work in environments that are less than 'dead quiet'.

[PCP]

Thank you all for your comments and helpful hints Our service does provide a stethoscope in some cars, but for the most part we all supply our own stethoscope. The way I look at is, I really don't want to be putting something inside of my ears that another person has been using and just so happen to have not cleaned the inside of their ears in the past six months.

when I was taking my PCP program, everybody in our class decided we wanted to order our own stethescope and I after some carful consideration and what my wallet would allow me to spend, I decided on the "Littmann Classic 2 SE" I figured it was in the middle of the road and was not too expensive, but expensive enough that I should be able to use it for a while without any problems.

Again thanks for all of your suggestions and comments. As a new person to this forum and not sure how one will be taken when posting questions or adding their comments I find it great to see that people actually take the time to try and answer a question or even add a few suggestions. I can see that there are some really seasoned medics on this site with some real great advice, along with some funny comments (DwayneEMTP) which I find very entertaining to read.

Looking forward to some more great discussions with all of you

[Addb]

Don't take this the wrong way, but have you had your hearing checked lately? I say it because my old partner was almost deaf in one ear and really had to focus on some patients to hear. A good scope and practice can overcome the problem, but it's something to think about if you just don't seem to be having success, especially when learning.

[Eydawn]

Addb raises an excellent point! You may simply need your ears irrigated from a wax buildup, or you could be starting to have some baseline hearing loss. A hearing test is an excellent thing to get when you first get into the field, so that you can show progressive loss from work exposure...

Wendy

CO EMT-B