Robert Vroman, M.Ed., BS NREMT-P

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EMS1 Daily News

Teens ‘get buzzed’ from lip balm on eyelids

The latest trend of “beezin” involves spreading Burt’s Bees lip balm on eyelids for a tingling sensation

Will community paramedicine help or hurt EMS?

See what EMS1 readers think, and add your own response to the comments.

Will EMS insurance fraud ruin it for the rest of us?

It's alarmingly simple for someone with criminal intent to get into the medical transportation business, which could lead more regulations and less reimbursement

$5 billion Medicare bill for ambulance services points to fraud

Officials say it explains why a newly released report shows Medicaid paid more to ambulance companies than cancer doctors or orthopedic surgeons

Conn. town mum on replacing 3 deteriorating ambulances

Crews have been down to just one functioning ambulance, but say the town hasn't responded to a plan to fund new ones

Ambulance plows into Ga. house when brakes fail

An EMT dropped off a patient at a home, and crashed into a house across the street

Woman crashes into ambulance with lights and sirens activated

She said she didn’t see it; the ambulance crashed through a fence on the way to a call for an injured pedestrian

Medic pronounces still-breathing woman dead

She eventually died from a closed head wound; her husband questions if her life could have been saved had the EMT not determined she was DOA

Man throws traffic cones at Calif. ER staff

The patient got angry because they wouldn't give him painkillers, and returned at midnight with the traffic cones, injuring two workers

Man charged in hoax 911 call that caused Yale lockdown

Jeffrey Jones was charged with falsely reporting an incident, second-degree threatening, second-degree reckless endangerment, misuse of the emergency 911 system and breach of peace
Top

EMS1 Topic Articles

Teens ‘get buzzed’ from lip balm on eyelids

The latest trend of “beezin” involves spreading Burt’s Bees lip balm on eyelids for a tingling sensation

Will community paramedicine help or hurt EMS?

See what EMS1 readers think, and add your own response to the comments.

Will EMS insurance fraud ruin it for the rest of us?

It's alarmingly simple for someone with criminal intent to get into the medical transportation business, which could lead more regulations and less reimbursement

$5 billion Medicare bill for ambulance services points to fraud

Officials say it explains why a newly released report shows Medicaid paid more to ambulance companies than cancer doctors or orthopedic surgeons

Conn. town mum on replacing 3 deteriorating ambulances

Crews have been down to just one functioning ambulance, but say the town hasn't responded to a plan to fund new ones

Ambulance plows into Ga. house when brakes fail

An EMT dropped off a patient at a home, and crashed into a house across the street

Woman crashes into ambulance with lights and sirens activated

She said she didn’t see it; the ambulance crashed through a fence on the way to a call for an injured pedestrian

Medic pronounces still-breathing woman dead

She eventually died from a closed head wound; her husband questions if her life could have been saved had the EMT not determined she was DOA

Man throws traffic cones at Calif. ER staff

The patient got angry because they wouldn't give him painkillers, and returned at midnight with the traffic cones, injuring two workers

Man charged in hoax 911 call that caused Yale lockdown

Jeffrey Jones was charged with falsely reporting an incident, second-degree threatening, second-degree reckless endangerment, misuse of the emergency 911 system and breach of peace
Top

EMS1 Columnist Articles

Will community paramedicine help or hurt EMS?

Community paramedicine and mobile health care initiatives are growing across EMS. Many agencies are have implemented programs, and many others are considering how to best make a program work in their community.

While models vary depending on need and other factors, there’s no doubt that the concept itself changes the role and expectations of EMS workers. We asked our readers if they thought these programs would help or hurt the EMS profession, and why.

“I think it will help. The elderly come home from hospitals and have a bag of meds that they have no idea how or when to take. Public health is an integral part of our job.” — Carylyn Healey McEntee

“Hurt, we are overworked by abuse as it is.” — Brian Duvall

“It is supposed to help, as it targets those who may need help, but not emergent care. The programs I've read about that have been implemented have had success so far. I like the patient education part as well. An ounce of prevention is better than a pound of cure.” — Robert Michael Lassiter Jr.

“I understand it as part of the job. We're supposed to advocate for our patients, and educate the communities we work in. However, knowing how the system works and how people run things, I can see this turning into ‘busy work;’ when you're not on a job, this is what you should be doing. That could lead to burn out and frustration real fast. But to be fair, I come from a busy area in N.J., and have worked for some companies that have some real issues with management and resource allocation.” — Chris Radzion

“Only if we get paid more.” — Nick Schoendorf

“I think it would help. It would cut back on the amount of non-emergency calls. It would also give an opportunity for more jobs to be created ...” — Bianca LaShay

“CP shows tremendous promise; good use of resources and good patient outcomes. I'm concerned for our industry on how we get paid for these awesome (and cost effective) services. I'm a reimbursement specialist, so worrying about how you get paid is my job. Minnesota is on a good path with their Medicaid-recognized CP that pays for the service. Facilities and third party payers need to pay attention to this movement. CP will save them money too, but the EMS community must get paid for what it's doing. This part of CP is still evolving.” — Maggie Adams

“Good for EMS ... it expands our capabilities. Great for ERs as it reduces the influx of unnecessary visits and can keep rooms open for patients who actually need emergent care.” Jason Berrie

Will EMS insurance fraud ruin it for the rest of us?

Back in 1989, a growing private ambulance company that provided 911 service to several communities in the metro Boston area suddenly went out of business, its owner convicted of Medicare fraud.

Decades later, the medical transportation industry struggles to escape its sordid past. Recent reports of Medicare fraud in cities like Chicago and Philadelphia are black marks in a profession that is inadequately reimbursed for its services.

As I pointed out in an earlier commentary, the issues surrounding EMS reimbursement are huge, and emblematic of a health care system that is structurally deficient and rewards bad behavior.

This article about ambulance services being held responsible for $5 billion in Medicare abuse points out some of the issues: low barrier to entry, little oversight, and an emphasis of transportation versus care. In another words, it's alarmingly easy for someone with criminal intent to buy some ambulances, pay minimum wage to their employees, meet bare minimums of equipment, and get into the medical transportation business.

It's tragic, since the public really doesn't know the difference between a sneaky ambulance operator and a service that struggles to survive on what little they receive from insurance reimbursement. To them, we are these rolling boxes with flashing lights and a star of life emblazoned on the side.

That perception will be shared by the politicians and lawmakers, who I fear will end up painting all of the profession with the same "we don't trust you" paintbrush. Whether this will translate into even more regulations and less reimbursement rates remains to be seen.

8 great EMS motivational tips

One of the most essential jobs of EMS leader is to motivate those around them.

The first step is accepting one inevitable truth: your team is counting on you to be a role model and mentor. The keys are to help people feel terrific about themselves, make staff feel like they are part of a winning team, and try to ensure that everyone feels competent, successful, and respected by others.

Emotional intelligence (EI) is defined by the ability to understand and manage not only our own emotions, but also the emotions of those around us. It’s broken down into five components: self awareness, self regulation, motivation, empathy and social skills. In our third installment of examining the elements of EI, we take a look at motivation.

8 ways to motivate yourself

There are two key approaches for motivating yourself:

  • Whatever the task, make it intrinsically interesting and satisfying to you.
  • Then provide your own extrinsic rewards.

This combination is one of the most effective ways to motivate yourself, and it can be applied to many undesirable tasks at work.

1. Set go­­als

By setting goals for both personal and professional development, you will know exactly what you need to do to achieve what you want in life. Having your eye on the big picture puts unfavorable tasks into perspective, and helps you see how they can actually help you reach your goals.

Think about the goals that can be achieved in EMS. Develop a list of short-term goals, six-month goals, and long-term goals to move your career forward.

2. Share goals

Sharing goals with your manager and peers helps build in accountability. Knowing that someone else is expecting you to complete a certain task can help keep you motivated. In our daily duties as EMS professionals, it is paramount we not only hold ourselves accountable, but the folks we deal with every day. Set the standards for others to follow.

3. Master time management

In EMS it seems we live and die by the clock. An important key to staying motivated is learning to take control of your time. Response times, total task times and scene times are used in our daily responsibilities. The number one way to master time management in the ambulance is to have a strong understanding of how long it takes for your crew to complete necessary tasks. Develop a schedule of tasks and estimate how long it will take to complete them to help manage your time more efficiently.

4. Reward yourself

When motivation is low, it’s easy to put off until tomorrow what you can accomplish today. Procrastinating is a true recipe for disaster. Try offering yourself a reward after completing a task or reaching a goal as a reward for staying on track.

This is something we need to do more often. For instance, eating right always seems to be a challenge in EMS. Set that as a goal, and tell, yourself you are going to eat as healthy as possible on the truck, but on the weekend you will order that pizza. In my experience, one great, greasy burger does the trick.

5. Be your own cheerleader

Sometimes, just telling yourself that you can achieve something is all it takes to get started. Positive thinking and positive self-talk are very powerful allies, as is surrounding yourself with positive people who will support and encourage you to keep moving forward.

When we deal with life and death on a daily basis, it’s easy to get lost in our patients’ emergencies. Keep telling yourself you’re there to make a difference and deliver the best patient care possible. We are in control of our own happiness.

6. Get feedback

In EMS we do not use feedback to the best of our ability. It seems we get defensive when folks offer comments or criticism of our medicine.

Feedback, either objective or subjective, is essential for sustaining a high level of drive. Ask those in your chain of command, mentors and colleagues how they view your work, and request advice on how to polish or develop needed skills. This should be one of your best tools to develop in your delivery of emergency medicine.

7. Raise your expectations

One of my favorite quotes is, “It’s hard to be good when you dream of being the best.” EMS is one of those professions where we have to give 100 percent at all times. When you raise your level of expectation, you are likely to achieve more. By continually telling yourself you expect to succeed, you will find yourself succeeding. Do not be the reason you are settling for “good” when you have the ability to be the best.

8. Cultivate a strong work ethic

A strong work ethic is a set of values based on the ideals of hard work and discipline to do the best job possible. Once you believe there is true value in the work you do, there will be a joy in working hard, and you will find work more motivating. As an EMS provider, your partner and peers will look to you to set the standards for others to follow. A strong work ethic is contagious.

As an EMS leader you have the power of choice, which will lead to personal independence along the path to success. The strongest leaders start with the belief that every obstacle contains an opportunity. They do not see problems; just solutions that they are motivated to find.

It’s important we follow our dreams, reach our goals and never give up. Self-motivation is an important part of being a successful leader with strong emotional intelligence.

Live your life by using the three “P’s”: persistence, patience, and perseverance. As you visualize your success, that mental picture of what you are looking to accomplish enhances self-motivation.

Autism awareness: 5 steps to adapt your response

By Leischen Stelter, American Military University
InPublicSafety.com

The number of children diagnosed with autism spectrum disorder (ASD) is on the rise. In 2013, the Centers for Disease Control and Prevention (CDC) released a report that 1 in 50 U.S. schoolchildren are diagnosed with ASD. That is up significantly from previous estimates of 1 in 88 children. In more tangible terms, the CDC’s new statistics mean more than 1 million children are diagnosed with some form of the neurodevelopment disorder.

In recognition of April as Autism Awareness Month, here are some tips about what emergency responders should know about the disorder and how they should modify their response.

Step 1: Educate Yourself

Emergency responders must educate themselves about this disorder and learn how to adjust their response to situations that involve an autistic individual, said Dr. Kevin Kupietz, adjunct professor of Emergency and Disaster Management at American Military University and a volunteer firefighter with the Roanoke Rapids Fire Department in North Carolina.

Read full story: Autism Awareness: 5 Steps to Adapt your Response

A medic’s haunted memory of a scared child

On one of the toughest streets in Providence, a little girl named “Shyla” begins to board a school bus when her face starts to twitch. Then her legs start shaking. She's afraid – petrified, really – and wants to cry out but finds she cannot. Her voice is gone.

It lasts long enough for the other kids to notice, and for the driver to stop the bus and call 911. We arrive and help her through the gauntlet of other students, and out the side door as they gawk.

The episode has passed, and we’re in the safety of the rescue now. She’s with her family who joined us when they saw the commotion at the bus stop, and Shyla appears normal again.

She tells me she likes math. She's in a charter school — one only the best students get into. She sits on the bench seat, next to her little sister and brother, with her mom in the Captain’s seat and the baby nestled in a car seat that I've secured to the stretcher. Her siblings are fascinated with the "amboolance."

Shyla had something similar happen a few weeks ago, at a birthday party. Her sister saw that episode and was afraid; she thought her big sister was dying. Their mom took her to the ER where they did a CT scan that was inconclusive, then follow-up testing, an EEG and some blood work, but no results yet. They’re waiting for their next doctor’s appointment to get some answers — hopefully.

So young to be so worried

Her mother holds up pretty well, but she works in the neurology department of a local hospital, and sees daily the effects of neurological disorders. Perhaps it's just a seizure, but why" There is no history of such, no fever, nothing to indicate that.

Shyla is lost in her thoughts, but the worry is evident on her pretty face that is the mirror image of her sisters, and a more youthful version of her mom’s. I keep an eye on her. The other kids enjoy the ride as we bounce toward the hospital. For them this is quite an adventure. But for mom and Shyla, there is no adventure; just the realization that something may be seriously wrong.

They're hopeful, and so am I, that this is nothing — just a weird thing that will go away. But I get a sense that isn't the case, and I think Shyla does, too. Her quiet, subdued demeanor stands out as her siblings carry on.

I thought of them all the way home, and into the night. Somebody else will take their place, probably by tomorrow. But for now, I'll close my eyes, and offer them the closest thing I know to a prayer.

Inside EMS Podcast: Airway management, how to cope with PTSD and depression

Download this week's episode

​In this week's Inside EMS podcast, hosts Chris Cebollero and Kelly Grayson discuss how emergency medical personnel need to shift their thinking in terms of tactical EMS in light of a recent high school stabbing in Pennsylvania.

They also talk about airway management in the clinical issue segment of the podcast and their thoughts on medics intubating patients in the field.

"We've gotten so far away from what this was really meant to do," Chris said. "We don't spend enough time training it, growing that skill and I think that we allow our ego to get in the way."

Chris and Kelly interview Kyle Norris, public information officer with the Code Green Campaign, in their guest table segment about how to assist responders that suffer from PTSD or depression.

If you have any topics or items you would like to hear discussed on Inside EMS, let us know in the comment section below.

Here are links to some of the articles and other items mentioned on the show:

3 dead, gunman arrested in shootings at Jewish centers

4 students seriously hurt in Pa. school stabbings

10 killed when truck, bus carrying students collide

Witnesses describe panic, fear at scene of fatal Calif. bus crash

2 medics injured in Tenn. ambulance rollover

Medic, parking officer get into fight at convenience store

Emergency dispatchers suffer from symptoms of PTSD, study reveals

The Code Green Campaign

Tactical EMS: An overview

New take on emergency care: Christian hospital using paramedics to reduce 911 calls

How to sell your story in grant applications

When tackling online grant application forms like the one used for American Fire Grants or most foundation grants, it’s easy to get the impression that funding decisions are based on “just the facts, ma'am, just the facts.”

Seemingly endless “fill in the blank” fields can lull you into a false sense of security. You’ve done your job as a grant writer when you’ve checked every box, right"

No matter how tedious the fact gathering and reporting may feel, it goes without saying that it is a crucial step in the process. Your agency’s application may already be scrutinized for eligibility and completeness before it even reaches an official funding decider.

However, getting your application to the top of a committee’s “maybe pile” is determined by your story. How you sell your story will be the deciding factor as to whether your facts are considered at all.

Here’s a general look at how it works:

Step One: The reviewer asks: Why do they want the funding"

Step Two: The reviewer reads your application narratives.

Step Three: The reviewer says: Now that I am persuaded, inspired and/or motivated, let’s see if the agency’s facts support the stated need.

Step Four: The reviewers check your facts and figures to determine whether or not the facts support your persuasive declaration of need.

Step Five: If there’s more than one reviewer, they discuss your agency’s predicament and urgency of your need, and come to a consensus.

Persuasive writing doesn’t tell a grant reviewer how to think about your situation. It paints a picture that helps the reviewer come to his or her own conclusion about your agency’s worthiness to receiving the funding you requested.

How to sell your story

Sell your story the same way a film documentarian presents a concept or idea. Use compelling anecdotes within your grant application narratives. Illustrate the gravity of your need by describing a past EMS call where the funding you’re asking for would have saved time, alleviated patients’ discomfort or prevented an employee’s on-the-job injury.

Help reviewers feel the weather and experience the road conditions of your EMS service area. Then present facts that justify receiving the money by using quotes from letters of support from community leaders.

Include photos and video clips to show your EMS employees in action, along with pictures of the outdated equipment that needs replacing. It boils down to putting a face on the people who will benefit from the new equipment or gear, and distinguish your agency by using third party awards or accreditations to bolster the authenticity of your facts.

Mentioning accreditation from the Commission on the Accreditation of Ambulance Services, state, and regional EMS awards, and community service awards, can favorably position your agency’s contributions and demonstrate your agency’s importance to your community’s health care delivery system.

Don’t think for one moment that grant application reviewers will somehow just look at all your statistics and intuit that your EMS agency is the one most deserving of the precious dollars over which they have control.

While the facts are crucial, you really must sell your story. While the ultimate funding decision rests in your agency presenting valid facts, grant application reviewers will use those facts and figures to justify their personal and subjective opinions about your need.

Reviewers are human, so appeal to their emotions.

How not to incriminate yourself at breaking news scenes

In what can only be described as a horrific confluence of unfortunate timing and rotten luck, two fire engines collided enroute to an emergency call, sending a multi-ton fire truck through a window and into a restaurant full of diners.

Fifteen patients were transported to the local trauma center and other area hospitals; among the injured were six firefighters.

Dozens more EMS personnel from neighboring agencies responded to the chaotic scene and made fast work of rescuing victims and sorting out what had happened. The specific cause of this terrible accident remains under investigation.

When the dust settles, I am sure there will be lessons learned followed by steps taken to prevent similar incidences. We must learn from tragedy to become better.

However, there are vital teachings we can take away immediately.

Later down the road the excitement and drama will fade and lawsuits by those in desperate need to find fault — and recompense — will likely just be coming to life. An army of investigators will leave no stone unturned for any trace of evidence, so make sure you’re not in the spotlight.

Here are three things that every EMS provider should remember and follow in the wake of such critical events:

1. Stay off your phone

Who called whom and what did they say" You have incriminated yourself or someone else. The person you called easily just became a witness too. The same holds true for text messaging.

2. Don’t take pictures

Don’t take out your phone to snap photos, either. It may be a spectacular shot, but taking pictures potentially violates confidentiality laws, and taking or sharing images from the scene and possibly compromises the investigation.

3. Remain silent

Do not speak about any aspect of the incident with reporters, civilians, or anyone else who is not directly part of the crew on the scene. After the fact, do not speak to anyone who is not a superior officer of your agency assigned to manage one or more aspects of the incident. Everything you say can be used against you or misconstrued against the truth.

The closer you are to the epicenter of the incident, the more vital — and precious — your right to remain silent and your right to counsel.

With a full understanding of the critical nature of the investigation, and an absolute willingness to cooperate with it, do not speak with law enforcement investigators until after you have consulted with an attorney who can quickly assess your criminal liability exposure and advise you accordingly. It’s a good idea to have such an attorney on standby who can respond to the scene for just such incidents.

Of course, more often than not, the facts will bear out that there is no actual or probable criminal liability for you.

However, you do not want to be the one who forfeited the right to silence and lost everything because your description of events was "misinterpreted."

What Billy Joel taught me about EMS career satisfaction

During high school and college, I worked at several radio stations and was lucky enough to interview several famous musicians. One was the Piano Man himself, Billy Joel.

He shared some advice that some 20-plus years later still resonates with me: “Figure out what you’re good at, and do that. Otherwise, you’re just wasting your time.”

That memory was recently triggered by a phone call from a peer that I highly respect seeking some advice.

About a year ago he quit his job at a TV news station after feeling burned-out. He launched a new business, which is doing well. But he admitted he was considering returning to his former career because he missed the passion he used to have for his work.

Good vs. passionate

It got me thinking. Being good at something isn’t the same as being passionate about it.

In EMS, there are many ways we can incorporate our passion into our day job.

If you care about animals, find a way to fund pet oxygen masks for the ambulances in your department.

If drunk driving, a medical condition like a stroke, or a disease a family member suffers from are important to you, sell media on stories that connect your profession with your passion – your pitch will be that much more compelling.

EMS touches on many different issues, and our role as public relations professionals is to recognize the passion within ourselves, our organization and our peers.

Then, we need to tell those human interest stories to create memorable images and positive public awareness for our companies.

A lesson from finance

Here’s an example. A financial advisor I know had a passion to ensure that his personal investments were not “terror-infested.”

No mutual fund existed that screened out U.S. companies operating in terror nations like Iran, Syria and North Korea — so he created his own. He combined his talent with his passion. It’s not easy, but it’s fulfilling and personally rewarding.

So to update Billy Joel’s quote, “Figure out what you’re good at and passionate about, and do that. Otherwise, you’re just wasting your time.”

5 errors that are giving you incorrect blood pressure readings

Controversy erupted this year when revised guidelines increased thresholds for diagnosing and treating hypertension[1].

Nurses and physicians often argue over differences between arterial line and non-invasive blood pressure (NIBP) cuff readings. To make the best use of blood pressure monitoring equipment, it is helpful to have an insight into how the equipment works and the likely sources of error that can affect readings.

Here’s what many of us do wrong when taking BP, and how to get it right:

1. You’re using the wrong-sized cuff

The most common error when using indirect blood pressure measuring equipment is using an incorrectly sized cuff. A BP cuff that is too large will give falsely low readings, while an overly small cuff will provide readings that are falsely high. The American Heart Association (AHA) publishes guidelines for blood pressure measurement,[2] recommending that the bladder length and width (the inflatable portion of the cuff) should be 80 percent and 40 percent respectively, of arm circumference. Most practitioners find measuring bladder and arm circumference to be overly time consuming, so they don’t do it.

The most practical way to quickly and properly size a BP cuff is to pick a cuff that covers two-thirds of the distance between your patient’s elbow and shoulder. Carrying at least three cuff sizes (large adult, regular adult, and pediatric) will fit the majority of the adult population. Multiple smaller sizes are needed if you frequently treat pediatric patients.

Korotkoff sounds are the noises heard through a stethoscope during cuff deflation. They occur in 5 phases:

  • I – first detectable sounds, corresponding to appearance of a palpable pulse
  • II – sounds become softer, longer and may occasionally transiently disappear
  • III – change in sounds to a thumping quality (loudest)
  • IV – pitch intensity changes and sounds become muffled
  • V – sounds disappear

In their 1967 guidelines, the AHA recommended that clinicians record the systolic BP at the start of phase I and the diastolic BP at start of phase IV Korotkoff sounds. In their 1981 guidelines, the diastolic BP recommendation changed to the start of phase V, a standard that remains in the most recent (2005) recommendations2.

2. You’ve incorrectly positioned your patient’s body

The second most common error in BP measurement is incorrect limb position. To accurately assess blood flow in an extremity, influences of gravity must be eliminated.

The standard reference level for measurement of blood pressure by any technique (direct or indirect) is at the level of the heart. When using a cuff, the arm (or leg) where the cuff is applied must be at mid-heart level. Measuring BP in an extremity positioned above heart level will provide a falsely low BP whereas falsely high readings will be obtained whenever a limb is positioned below heart level. Errors can be significant — typically 2 mmHg for each inch the extremity is above or below heart level.

A seated upright position provides the most accurate blood pressure, as long as the arm in which the pressure is taken remains at the patient’s side. Patients lying on their side, or in other positions, can pose problems for accurate pressure measurement. To correctly assess BP in a side lying patient, hold the BP cuff extremity at mid heart level while taking the pressure. In seated patients, be certain to leave the arm at the patient’s side.

Arterial pressure transducers are subject to similar inaccuracies when the transducer is not positioned at mid-heart level. This location, referred to as the phlebostatic axis, is located at the intersection of the fourth intercostal space and mid-chest level (halfway between the anterior and posterior chest surfaces.

Note that the mid-axillary line is often not at mid-chest level in patients with kyphosis or COPD, and therefore should not be used as a landmark. Incorrect leveling is the primary source of error in direct pressure measurement with each inch the transducer is misleveled causing a 1.86 mmHg measurement error. When above the phlebostatic axis, reported values will be lower than actual; when below the phlebostatic axis, reported values will be higher than actual.

3. You’ve placed the cuff incorrectly

The standard for blood pressure cuff placement is the upper arm using a cuff on bare skin with a stethoscope placed at the elbow fold over the brachial artery.

The patient should be sitting, with the arm supported at mid heart level, legs uncrossed, and not talking. Measurements can be made at other locations such as the wrist, fingers, feet, and calves but will produce varied readings depending on distance from the heart.

The mean pressure, interestingly, varies little between the aorta and peripheral arteries, while the systolic pressure increases and the diastolic decreases in the more distal vessels.

Crossing the legs increases systolic blood pressure by 2 to 8 mmHg. About 20 percent of the population has differences of more than 10 mmHg pressure between the right and left arms. In cases where significant differences are observed, treatment decisions should be based on the higher of the two pressures.

4. Your readings exhibit ‘prejudice’

Prejudice for normal readings significantly contributes to inaccuracies in blood pressure measurement. No doubt, you’d be suspicious if a fellow EMT reported blood pressures of 120/80 on three patients in a row. As creatures of habit, human beings expect to hear sounds at certain times and when extraneous interference makes a blood pressure difficult to obtain, there is considerable tendency to “hear” a normal blood pressure.

Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mmHg or more, or diastolic blood pressure decrease of 10 mmHg or more measured after three minutes of standing quietly.

There are circumstances when BP measurement is simply not possible. For many years, trauma resuscitation guidelines taught that rough estimates of systolic BP (SBP) could be made by assessing pulses. Presence of a radial pulse was thought to correlate with an SBP of at least 80 mmHg, a femoral pulse with an SBP of at least 70, and a palpable carotid pulse with an SBP over 60. In recent years, vascular surgery and trauma studies have shown this method to be poorly predictive of actual blood pressure[3].

Noise is a factor that can also interfere with BP measurement. Many ALS units carry doppler units that measure blood flow with ultrasound waves. Doppler units amplify sound and are useful in high noise environments.

BP by palpation or obtaining the systolic value by palpating a distal pulse while deflating the blood pressure cuff generally comes within 10 – 20 mmHg of an auscultated reading. A pulse oximeter waveform can also be used to measure return of blood flow while deflating a BP cuff, and is as accurate as pressures obtained by palpation.

In patients with circulatory assist devices that produce non-pulsatile flow such as left ventricular assist devices (LVADs), the only indirect means of measuring flow requires use of a doppler.

The return of flow signals over the brachial artery during deflation of a blood pressure cuff in an LVAD patient signifies the mean arterial pressure (MAP). While a normal MAP in adults ranges from 70 to 105 mmHg, LVADs do not function optimally against higher afterload, so mean pressures of less than 90 are often desirable.

Clothing, patient access, and cuff size are obstacles that frequently interfere with conventional BP measurement. Consider using alternate sites such as placing the BP cuff on your patient’s lower arm above the wrist while auscultating or palpating their radial artery. This is particularly useful in bariatric patients when an appropriately sized cuff is not available for the upper arm. The thigh or lower leg can be used in a similar fashion (in conjunction with a pulse point distal to the cuff).

All of these locations are routinely used to monitor BP in hospital settings and generally provide results only slightly different from traditional measurements in the upper arm.

5. You’re not factoring in electronic units correctly

Electronic blood pressure units also called Non Invasive Blood Pressure (NIBP) machines, sense air pressure changes in the cuff caused by blood flowing through the BP cuff extremity. Sensors estimate the Mean Arterial Pressure (MAP) and the patient’s pulse rate. Software in the machine uses these two values to calculate the systolic and diastolic BP.

To assure accuracy from electronic units, it is important to verify the displayed pulse with an actual patient pulse. Differences of more than 10 percent will seriously alter the unit’s calculations and produce incorrect systolic and diastolic values on the display screen.

Given that MAP is the only pressure actually measured by an NIBP, and since MAP varies little throughout the body, it makes sense to use this number for treatment decisions.

A normal adult MAP ranges from 70 to 105 mmHg. As the organ most sensitive to pressure, the kidneys typically require an MAP above 60 to stay alive, and sustain irreversible damage beyond 20 minutes below that in most adults. Because individual requirements vary, most clinicians consider a MAP of 70 as a reasonable lower limit for their adult patients.

Increased use of NIBP devices, coupled with recognition that their displayed systolic and diastolic values are calculated while only the mean is actually measured, have led clinicians to pay much more attention to MAPs than in the past. Many progressive hospitals order sets and prehospital BLS and ALS protocols have begun to treat MAPs rather than systolic blood pressures.

Finally, and especially in the critical care transport environment, providers will encounter patients with significant variations between NIBP (indirect) and arterial line (direct) measured blood pressure values.

In the past, depending on patient condition, providers have elected to use one measuring device over another, often without clear rationale besides a belief that the selected device was providing more accurate blood pressure information.

In 2013, a group of ICU researchers published an analysis of 27,022 simultaneous art line and NIBP measurements obtained in 852 patients[4]. When comparing the a-line and NIBP readings, the researchers were able to determine that, in hypotensive states, the NIBP significant overestimated the systolic blood pressure when compared to the arterial line, and this difference increased as patients became more hypotensive.

At the same time, the mean arterial pressures (MAPs) consistently correlated between the a-line and NIBP devices, regardless of pressure. The authors suggested that MAP is the most accurate value to trend and treat, regardless of whether BP is being measured with an arterial line or an NIBP. Additionally, supporting previously believed parameters for acute kidney injury (AKI) and mortality, the authors noted that a MAP below 60 mmHg was consistently associated with both AKI and increased mortality.

Since 1930, blood pressure measurement has been a widely accepted tool for cardiovascular assessment. Even under the often adverse conditions encountered in the prehospital or transport environment, providers can accurately measure blood pressure if they understand the principles of blood flow and common sources that introduce error into the measurement process.

References:

1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. (Available at: http://jama.jamanetwork.com/article.aspx"articleid=1791497)

2. Pickering TG, Hall JE, Appel LJ, et al. AHA Scientific Statement: Recommendations for blood pressure measurement in humans and experimental animals, part 1: blood pressure measurement in humans. Hypertension. 2005; 45: 142-161. (Available at: https://hyper.ahajournals.org/content/45/1/142.full)

3. Deakin CD, Low JL. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ. 2000; 321(7262): 673–674. (Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27481/)

4. Lehman LH, Saeed M, Talmor D, Mark R, Malhotra A. Methods of blood pressure measurement in the ICU. Crit Care Med. 2013;41:34-40.

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