Your Captain Speaking: Before You Take That Blood Pressure

“Samantha, it’s hard but there are EMS calls where I have to remind myself not to start where obviously, really obviously I should have investigated first. Multiple calls as a matter of fact knowing where to start made me a better Medic. Some are small things, others big and fundamental.”

How about an easy one that we use just about every call? We take blood pressure on patients all the time but a simple, reasonable question asked at the wrong time makes a big difference. Before I ever put the sphygmomanometer on the patient (original and still current name of the blood pressure cuff), sorry, I digress. Before you start to take a BP you can ask “What does your blood pressure normally run?” Listen carefully to what is next said, or not said!  If they say “I have no idea” that tells you a lot. Perhaps they are reluctant to be forthcoming with their medical history or they just have no idea. If, however, they can detail what the past readings were and might elicit some medications they forgot to mention earlier. In any event, you have not increased their anxiety. You just asked a question. If you asked the same question but voiced it after you’ve taken the reading, it's totally different.

When you ask “What does your blood pressure normally run?” after the measurement, a likely response could be “Why? Is it bad? What is it? Is it OK?”  Even though you said it with the same tone and inflection, the patient's response could be with a higher level of anxiety. Providers never want a higher level of anxiety in their patients. Asking beforehand could lead to expectation bias but we always have to be aware of that pitfall. Ask first, pause, and listen to the patient for a moment, then take the BP reading.

“Where does it hurt?”  A great question. A huge number of our calls are because something hurting. Do Not Start There.  Here’s a trap that I had fallen into, subtly, over time. I’d go right to where they said it hurt and examine it. I wanted to see the signs, hear the symptoms, and figure out the rest of the puzzle. It’s what we do! While listening to their answer to “Where does it hurt?” the patient will usually point to it and fully expect you to examine the injury. Be observant: do they point with a finger, use a flat hand over the location, or use a fist to locate it?  All are different but subtle indicators. Maybe instead of going right for that location, a follow-up question of “Do you hurt anywhere else?” would be better.  A simple example, the patient is 28 y/o female  who puts a flat hand on her right upper abdominal quadrant when asked ‘where does it hurt?’  It’s a powerful urge to poke or prod the abdomen and fail to ask if she hurts anywhere else. “Well, yes,” the patient replies, “ Odd, but my belly button hurts and so does my right shoulder.”  Zonk! This might be referred pain and when taken with the rest of the patient history, could be an indication of an ectopic pregnancy!  My thoughts for the rest of the call just changed as well as what other follow-up questions I’d like to ask.

The point is don’t get tunnel vision or target fixation. When these things occur within EMS or otherwise, it is just about impossible for the person involved to recognize they have tunnel vision!  As a routine, get used to taking a step back for a moment clear the assumptions, and reassess the patient, the situation, and your next actions.

Dramatic injuries.  There are times when you need to move quickly to a dramatic injury such as a forearm arterial bleed spurting into the air but if no delay, perhaps direct another responder to stop the bleeding. Everyone is looking there and perhaps there is something more insidious and deadly elsewhere. A real call out. Two family members get into an argument but are vague as to the injury to 911. The patient is flat on his back with about a 3-inch pocket knife embedded in the medial corner of the eye. A family member is trying to remove it, but it is stuck.  I ask “Can I take care of that?”  While I wanted to jump in and stabilize that knife I fell back on my prime directive- start at the beginning, don’t skip any steps. Personal protection equipment for myself and my partner, scene safety, initial triage, and continued down the procedure.  By not skipping to the knife protruding from his face, I quickly found the major life threat was the knife wounds to the thorax. A puncture left side next to the sternum and another left lateral chest laceration making lots of bubbles. We avoided tunnel vision by taking a moment to think, communicate, and act with each other.  If you want a nice explanation of the flow pattern referenced above, check out the article in EMSWorld: Your Captain Speaking: An Acronym for Every Call.1

The point is following an orderly procedure for the well-being and safety of all involved. Hard calls, easy calls, same flow of thought and treatment order. Something as simple as a blood pressure check can cause patient anxiety or perhaps not! I always ask about the BP before I take the reading.   A patient answering your question “Where does it hurt?” can subtly cause you to not look elsewhere. Finally, a dramatic injury demands attention but the real life threat might be camouflaged and treatment delayed.  

1.  Your Captain Speaking: An Acronym for Every Call, Dick Blanchet and Samantha Greene EMSWORLD, March 23, 2021, https://www.hmpgloballearningnetwork.com/site/emsworld/article/1225859/your-captain-speaking-ems-acronym-every-call 

Dick Blanchet, (Retired) BS, MBA, worked as a Paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. He was also a Captain with Atlas Air for 22 years on the Boeing 747 with more than 21,000 flight hours. As a USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University.  

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (Ill.) EMS, and full-time at the St Louis South City Hospital Emergency Department as a Paramedic.   She was recently recognized as a GMR Star of Life.