auscultating lung sounds and taking a BP

[PCP]

I have been struggling with taking a pt. BP for some time now, as I know Practice makes perfect but it it does not seem to be helping me very much! I have read the books on how to take a BP, but for some reason I seem to be having a hard time figuring out the exact location I should be placing my stethascope on the brachial artery. I have been told I may not being pushing hard enough to hear the BP or I am pushing too hard, as well as I am told different spots as to where I should be placing the diaphragm on the arm. Any tips would be great as I am tired of telling my partner that I need to retake the BP as I did not get anything and I am not about to LIE!!

Another problem I find is alot of time I am unable to hear the pt. breath sounds. I palpate the ribs and find the intercostal space so that I am not placing my diaphragm over the rib so I am not sure where I am going wrong? My guess is I am not placing the diaphragm in the correct area on the pt. or I should maybe be using the "Bell" end of the stethascope insted? I feel silly asking these questions, as I was kind of shown in class, but not much time was spent on teaching us the proper way of using a stethascope.

Any suggestions would be great as I dont want to be making any vital mistakes!

[HinsdaleAmb21]

I just became an Emt this year but before that I was a first responder for my fire department for many months having great practice at getting vital signs. My advice to you is I position my stethoscope right where the humerus and radius connect (at the bend in the arm) pump up the bp cuff to around 200 depending on the patient i have and place my stethoscope where I said to put it and slowly release the bp and watch the needle as well as listening once u hear the faintest beat that's your first number then listen till u can't hear anymore and before u can't hear it anymore well that's your bottom number simple yes. Another strategy for you is maybe you need a better stethoscope, some are quite hard to hear from, you kinda want to test different ones to find the better one. The better you have the better you can hear what u need to hear. One more piece of advice is when you have the rig in a parked position once you load the patient in, keep it parked until u get you vital signs it much easier that way.

[PCP]

Thanks for the advice I will try that on my next patient. Another piece of advice I was told today was to use the bell end when auscultating the lungs. Has anybody had any success with using the bell end of the stethascope while auscultating lung sounds?

[Happiness]

When your placing the steth in your ears make the rubber part bend forward in your ears and not directly in the canal. Hope this makes sense. And make sure the steth is turned on.....

Edited November 23, 2010 by Happiness

[HERBIE1]

First step- palpate the brachial artery. I know this sounds silly, but many people simply guess as to where that pulse is actually located. Once you FEEL the pulse there, place the scope directly on it. Also good suggestions from others about having a good stethescope with a proper fit in your ears. Most scopes come with several sizes of ear pieces- choose the ones that fit you best.

You also need to understand the difference between the bell and the diaphragm portions of the device. The bell side is used for low pitched sounds, the diaphragm portion for the high pitched ones. Make sure you are using the correct side- it's easy to have them flipped and never realize it. As soon as I put the ears on, without even looking at it, I tap the bell and diaphragm on to ensure I have the correct side in place- a habit I developed 30 years ago and still do to this day. Sometimes the head may be slightly turned- ie not locked into place, and you won't be able to hear a thing.

Some places use electronic varieties, which can be useful in noisy settings like in an aeromed situation- or someone with bad ears.

LOL

As for lung sounds, it takes a lot of practice to become proficient. Listen to yourself and anyone else who will let you. Use both sides of the scope and see the differences in what you can hear and the quality of the sound. Remember to go back and forth on both sides of the chest and back- at the same levels- to compare and contrast what you hear. Different patient sizes/body types and medical conditions will also affect how well you can hear things.

Good question. As the old saying goes- the only silly question is the one you did not ask. If you don't know, then how will you ever learn?

[DwayneEMTP]

Good advice from all, with the exception, and I apologize that I'm going to bag on you a bitAmb21, of pumping the cuff up to 200 before beginning to listen.Try it, it hurts! Then imagine the frail muscles and tendons of the children or older folks that you will often be running on. That's the easy way, but it's also the lazy way. As is watching the needle jump. Every fiber of my body says that there should be a dependable relationship between the jumping of the needle and the auscultated sounds, and though I continue to try and give some validity to my intuition, I remain unable to do so.

Also, if you're using the stethoscope provided by your company I want you to stop what you're doing, take that $12 dual lumen piece of shit that seems to be in every ambulance and run in a smack your supervisor across the head with it. (Though in the short term this may not seem like sound advice, I think that you will find that EMS runs on stories, and the value of this story will pay WAY higher dividends over your career that the value of keeping this particular job. Trust me on this.) In my sometimes no so humble opinion dual lumen 'ears' have almost no place in an ambulance. I've used some that were really good, but when you're moving they just give way too much random noise for you to learn with. You need to back things up now, make them easier, and then you can throw foolish obstacles into your path. Now is not the time for a dual lumen stethoscope.

And as Herbie mentioned, regardless of your scope, make sure you know how to use it. Also, palping the artery is great advice. When he started they didn't have stethoscopes, they just had to put their ear at the crook of the elbow, so knowing the exact location of the artery was vital. Soon though, thank goodness, one of his partners saw an old movie (not so old then of course, but I've only see them on reruns) where someone spied on the people in the next hotel room by putting a glass against the wall and listening through it, and his practice was changed forever! (Don't tell anyone, but I'm convinced it's the reason for freakish 'roundness' of his ears to this day.)

And lastly. This is not a skill that you should be learning in the back of an ambulance. You do not, not, not, not, practice new, sensitive skills under pressure if you can help it. You should be practicing this at home. Unless you are a complete asshole, of which I've seen no signs so far, you should have ample family and friends that will help. Quiet room, no tv, no radio, not during one of your Friday night parties, it should be very quiiiiiiiiiet. Palp the pulse as Herbie instructed, put your stethoscope on that spot and begin to inflate your cuff. As the cuff begins to put pressure on the artery it will get a little bit noisier for a few seconds before it gets quiet due to be occluded. Once it gets silent increase the pressure a few mmHg and then begin to release the pressure. Very Slowly at first!

Ok..now this is the good part...As you slowly release the pressure you will begin to hear the heartbeat in your ears, right? Awesome! Now you've found a spot to auscultate...as you continue to release the pressure I want you to move your stethoscope around, in small movement, to use it like you might use a metal detector, seeing where the sounds get stronger, or weaker. Once you've found the loudest spot you've gone from A spot to THE spot. Even if you started out on THE spot, I still want you to move it around so you can see what it sounds like in different places, different distances from THE spot. What this should do is give you a feel for the underlying vascular anatomy, see?

If you're like me when I was new I'd be trying to get a BP thinking "Oh God, please, please, please let me hear it!!" Hoping that the EMS Gods would send me the sounds I needed to do my job. Fuck that, I'm not asking, I'm going to take the information I need! It's been my experience that any time I truly needed the EMS Gods to send me the information that I needed to keep from looking like a complete shithead in front of a gazillion people (with seemingly nothing better to do than stare at me) that they simply laughed while making fart sounds with their hands in their arm pits. So I don't really trust them so much any more.

Anyway. Babs is shopping, Dylan and I are done raking leaves and I had way too much time to write a bunch of crap that probably could have been said in three sentences, but reading it is the price you pay for asking questions on a forum with no real standards for who can reply. :-)

Going to forgo the lung sounds for now as I have used up all of my spare time rambling, but others will give good advice I know, and if not then I'll throw in my two cents when I can.

Good questions. Very brave to ask them here man...I have a lot of respect for that.

Dwayne

[chbare]

Know your equipment:

The bell is typically for low pitched sounds such as murmurs and bowel sounds.

The diaphragm is for higher pitched sounds such as lung sounds.

Make sure the ear pieces are properly positioned in a generally foreword direction.

Make sure your equipment even works.

Clothing makes it hard to hear sounds.

Excessive pressure when auscultation may make things worse, especially when using the bell.

Are you good with what lung sounds mean what?

Take care,

chbare.

Edit: Phucking iPhone...

Edited November 24, 2010 by chbare

[HERBIE1]

PCP- Dwayne did a great job of walking you through the intricacies of actually getting the BP. I will echo his suggestion of making sure you have a GOOD stethescope. I actually saw a crew on a rig for a local private using those disposable type scopes made from plastic- probably company provided. I could not believe it. Do yourself a favor-shop around and get a good quality, stethescope, made by a reputable company. Ask Santa for it, or splurge and buy it for yourself. It will be one of the best investments you can make for yourself. Obviously you do not need a $500 scope designed for a cardiologist, but don't go cheap on this item either.

And yes, like Dwayne said, I HAVE been doing this awhile, and just as soon as I finish my Ensure shake, I'm going to beat the crap out of him with my walker...

[tniuqs]

And yes, like Dwayne said, I HAVE been doing this awhile, and just as soon as I finish my Ensure shake, I'm going to beat the crap out of him with my walker...

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

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

cheers

[DwayneEMTP]

...I actually saw a crew on a rig for a local private using those disposable type scopes made from plastic- probably company provided. I could not believe it.

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...

And yes, like Dwayne said, I HAVE been doing this awhile, and just as soon as I finish my Ensure shake, I'm going to beat the crap out of him with my walker...

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

Dwayne