Discussion in 'Medical Students - MD' started by jellygreen2001, Sep 8, 2006.

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  1. jellygreen2001

    jellygreen2001 Junior Member 7+ Year Member

    Sep 24, 2005
    :scared: :scared: :scared:

    Hey everyone, we have been doing blood pressures for a couple of days and I totally stink at it. It seems like everyone is getting it except me:( I don't know what the problem is, I just can't hear the systolic part-the first two beats. It all just sound muffled and then I hear a few beats near the disystolic part and I don't even hear a distinct end. All I hear is a muffled sound. What could I be doing wrong? Any tips? Am I the only one who is having trouble measuring blood pressure? I have seriously practiced on like 15 people now, and still now luck:( Please give me your advice. I seriously don't want to be the one doctor who never learned how to take blood pressures.
    Thank in advance:)
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  3. crazy_cavalier

    crazy_cavalier T3-Weighted 7+ Year Member

    Relax. By the time you actually practice, it'll all be digital.

    No but seriously, maybe the cuffs you are using just suck? Try new cuffs and see if you still can't distinguish it.
  4. tiredmom

    tiredmom Senior Member 5+ Year Member

    Sep 18, 2005
    You may be dropping the pressure too quickly. Go slow, it's normal for the first sounds to be a bit muffled, but if you're dropping the cuff slow enough, you can still discern what # you were at when you first heard the sounds. Be sure you are using your dominant hand on the pressure dial - otherwise you tend to turn it with a jerk and it drops quickly. You should end up hearing about 8-10 sounds on a patient with a normal heart rate. Keep practicing, it will eventually get easier.
  5. UCLAstudent

    UCLAstudent I'm a luck dragon! 10+ Year Member

    Sep 6, 2002
    I feel your pain. At my school, we had to do a physical exam on a standardized patient as part of the final exam. We were required to use the bell to do this, not the diaphragm. Well, tons of us were having trouble hearing ANYTHING with the bell. Most of us have the Littman Cardio III, which has a combined bell/diaphragm apparatus. Anyway, the night before the exam, someone figured out the problem: you have to physically twist the bell/diaphragm apparatus 180 degrees to switch between listening through the bell and the diaphragm. We all felt really stupid after that, haha. Maybe that's your problem?
  6. cfdavid

    cfdavid Banned Banned 7+ Year Member

    Oct 24, 2004
    If it's any consolation, I went to a clinical skills session the other night (a student run clinic....etc.) and we were doing blood pressures. I had a seriously hard time hearing the blood. I tried a bunch of times, and finally got pretty embarrased. So, I started just watching the needle and guestimating where systoli started.

    Then, Mr. Vasovagal Syncope (me) decides to come VERY close to passing out about 1 minute after my partner pulled the needle out of my cephalic vein. This was followed by an uncontrolled, and very pronounced, sympathetic response to my sweat glands........

    Then, due to my little "incident" (and the subsequent sympathetic response), I was all shaky while trying to suture up some skin on a pig's foot. All this after feeling like a jack as.s because I ripped my gloves (sweaty hands and non-powdered latex gloves just don't mix) and had to get up (all sweaty and stuff) to get more from the other room......

    Let's just say it wasn't one of my better
  7. felipe5

    felipe5 Fingerpickin' Good 10+ Year Member

    Sep 30, 2002
    definitely do not'll get the hang of it with practice. No one becomes an expert after doing something only for a few days. take your time and don't forget to repeat a bp if necessary....if you still can't do it in a clinical setting where a value needs to be recorded, just ask someone to come help you out. It sucks to sometimes admit defeat but it happens to all of us at some point in one way or another: might as well get used to it here and there :horns:
  8. 45408

    45408 aw buddy 7+ Year Member

    Jun 13, 2004
    hahaha, that's just as bad as the girl who couldn't hear anything until I told her that she had the earpieces in backwards.
  9. TX515

    TX515 Senior Member 10+ Year Member

    Nov 27, 2005
    the great state of Texas
    When you don't hear any more beats, then you have reached the end. Like above posters have said, make sure you are not deflating the cuff too quickly. You might try this little trick...with your free hand, feel for the radial pulse in the wrist. Once you have found it, keep your fingers on it and inflate the cuff. When systolic pressure has been reached, you will no longer be able to feel the radial pulse. Go ahead and inflate the cuff about 30 more units so you can listen for the systolic. While listening through your stethoscope, deflate the cuff so that the guage needle is moving about as quickly as the second hand on a watch, or maybe just a little quicker than that. When you hear the beats, you just reached your systolic. When they stop, you just reached your diastolic. Also, make sure you place the stethoscope diaphragm on the proximal side of your elbow crease. Hope that helps.
  10. FenderHM

    FenderHM Where there's a will... 7+ Year Member

    Feb 19, 2006
    keep trying, you can do it! dont get into the mindset that you'll never be able to get it...if you can handle med school you'll get the hang of the little procedural stuff too, just give it practice and check your equipment! make sure you can hear it if you tap lightly on the outside of your scope, and make sure you're putting the diaphragm/bell close to the artery
  11. QuikClot

    QuikClot Senior Member 5+ Year Member

    Nov 20, 2005
    Good trick. Another one I use is to palpate the brachial pulse first -- where you feel the pulse with your fingers is where you will hear it best with your stethoscope.

    BPs, pulses, IVs -- these are non-trival skills. They take practice, and more practice. In MD land, they often get short shrift as "what the nurses do," but believe me, there is a big difference between lack of respect and lack of difficulty.

    Keep trying. It took me weeks to get comfortable taking pressures. Like you, I thought I would never get it and thought a lot about how to fake it plausibly. Eventually it all clicked, and now I have taken thousands. You will get it.

    Couple other tips -- there will often be a muffled sound higher than the systolic BP, but if so, the tone and volume will change dramatically when you "cross the line." Deflate slowly, and if you feel unsure or just for practice, try re-inflating the cuff as soon as you hear the pulse -- just a little, then bring it down again, knowing where you expect the sound to start.
  12. Miami_med

    Miami_med Moving Far Away Moderator Emeritus 7+ Year Member

    Just practice a lot. Get your equally confused (but better at hiding it) friends together, sit in a room for a few hours, and just take pressures over and over. After a while, you'll just recognize it.

    As an MSII, I am pretty comfortable with this skill, though I am repeatedly shown up by attendings who do it with a grace and speed that I could only hope to have. However, 20 years from now, both you and I will be intimidating the next crop of students. That's just the way of things. Don't worry about it.
  13. Mr. Freeze

    Mr. Freeze Not right. (in the head) 10+ Year Member

    Good ears make a BIG difference, too.

    You might try palping a few in combination with trying to auscultate some, just to get a better idea where you should expect to hear your first beats.
  14. Pythagoras

    Pythagoras Senior Member 7+ Year Member

    May 13, 2003
    dude. Nurses do this ? It isnt rocket science.
  15. Rugby MD

    Rugby MD Junior Member 5+ Year Member

    Feb 11, 2006
    I had a crappy stethoscope and was having lots of problems. got a cardio III and a new world opened to me. maybe your ear pieces don't fit properly.
  16. lattimer13

    lattimer13 good boy! 10+ Year Member

    Nov 11, 2002
    Pacific NW

  17. Fashionista

    Fashionista Member 2+ Year Member

    May 14, 2006
    I'm a post bac student now, but last semester during undergrad (as a health science major) I interned full time with cardiac rehab. Every morning I had o take about 30 BPs in the fitness center with the TVs on and treadmills whirring. I'm a fairly confident individual, but when it came to blood pressures, I was a mess. My boss was great and gave me some tips that really helped. Find the intercubital space and go slightly medially. Find a willing individual who will let you keep the cuff inflated (above their normal systolic) for a longer period of time. Sloooowly, turn the dial and really listen. Don't rush it. After you hear it, try it again at a normal release speed- maybe about 4-5 units per second and listen for that first noise again where you know it is. This will help give you some confidence as you will know what it sounds like and when it will be audible. If you are having problems with turning the dial (like I did) practice just turning the dial with one hand for a while until you get the hang of it. Also, make sure the tubing is not tangled at all. The slightest movement on your part or of the patient will make the tubing tap and sound like Korotkoff sounds. I know your frustration! It is a good skill to have, but remember, we won't have to take BPs day in and day out for the rest of our lives. Good luck!
  18. Wizard of Oz

    Wizard of Oz Guest

    Sep 8, 2006
    Somewhere at your school, you should have a teaching stethoscope, i.e. a scope with two sets of ears wired into one bell. I've only ever used it when I was being tested, but there are a couple of advantages to using it.

    The obvious plus is that somebody can help you recognize the sounds or tell you what you are doing wrong. The other thing is that the models that I have used have been quite cheap and sometimes hard to hear with. This means that if you can get the skill down with poor equipment, then it will be a breeze with a little bit better scope.

    Don't dismiss this skill--the digital cuffs have pros and cons, and they are by no means the gold standard. If you are working in a teaching setting, it is possible that you will be following student nurses, student nurse aides, student medical assistants, etc. who also may not have the technique down. If you have someone present with apparent hypertension but goofy values, you will need to verify the numbers yourself.
  19. ER_BluEyez

    ER_BluEyez Chicago's Finest!

    Sep 9, 2006
    Chicago, IL
    Im in the wrong section for I haven't even applied to Medical school. However, I've been a nursing tech in the ER for almost 6 months, and had an 8 week Nursing Assistant course. Before that class i had never ever even touched a stethoscope or cuff....but I learned some tricks :)

    When you're practicing, you can put the cuff up (usually about 170 on your friends is a good place to start ;) ) and only twist the dial so that the air barely relieves. Eventually, you'll be able to see the dial jump a teeny tiny bit with each beat. I used to sit and let the dial do it's own thing and just sit there until I could finally hear the first systolic beat. can loosen the dial to let the air out faster and wait for your diastolic. I also found not letting the bell rub against the cuff cuts down on any extra noise.

    I would encourage you to do this on both arms of the eprson..however not repeatedly. Having the cuff on the arm that tight for that long is kinda's a really great way to learn.

    Also, I'm small but it was really hard for anyone to hear my ebats..tihelped a lot when I laid down :) Maybe during practice have someone lay down!

    That teaching 'scope mentioned above is a great idea too. Usually the teachers ahve them so you can test off on BP.

    Just dont get too worried about it...after 2 weeks of doing it I barely had to think twice...

    Good luck!!!! :)
  20. mjl1717

    mjl1717 Senior Member 10+ Year Member

    May 24, 2003

    This is good advice! In addition consider buying a stethoscope with an amplifier, which is not that conspicuous. Also if you are right handed you should easily be able to palpate the brachial pulse with you left 2nd or 3rd fingers.
  21. NapeSpikes

    NapeSpikes Believe, hon. 10+ Year Member

    Mar 27, 2004
    If it's too loud around me and I can't hear the systolic, I just watch for the needle/column of liquid on the dial start to pulse.
  22. Delicate Genius

    Delicate Genius Member 2+ Year Member

    Aug 1, 2006
    If it hasn't been mentioned yet, avoid pressing down on the bell with your thumb. Your thumb has its own pulse and may throw off the pressure sounds. Also, I agree that you should first palpate the brachial artery before listening--it is a big help. Good Luck.

    edit: also, you could hear the diastolic pressure in some patients all the way down to rediculously low levels. The best thing to do is to listen to a distinct change in the sound to accurately get the diastolic pressure.
  23. DrHopeless

    DrHopeless The Monkey is In 5+ Year Member

    Oct 15, 2004
    Well my problem is a bit worst than your, I tend to be really gentle so I can't even find the freaking pulse, but I figured that out now. But yeah....... I know your frustration I am not very good at doing this thing either. I feel strange asking other people if I can test out my "skill" on them, but so far I think I got it on my roomate, but yeah a quite enviroment is def needed. Also all the tips that I heard so far are pretty good. However, I don't know why but on my cardiology 3, the ped side works a lot better than the adult one.
  24. Aurora013

    Aurora013 Member 2+ Year Member

    Jun 27, 2006
    Another tip- find a willing friend, and inflate the cuff on their arm to ~100. For most patients, you should be able to hear the pulse nice and clear, so if it's not, keep shifting the stethoscope medially little by little until it becomes so. When you find out where the best spot to listen is, pump the cuff up the rest of the way, and nice an slowly take their pressure (it's usually a good idea to be nice and deflate for a few seconds before reinflating it). This way you know the stethoscope is placed where it's supposed to be, so when you hear the sounds they should be nice and clear.

    A few other points, most of which have been mentioned above:
    1) make sure you don't hold the bell with your thumb
    2) hold with two fingers, so it's more stable
    3) make sure the cuff is at least two finger widths above the crease of the elbow, to prevent rubbing against the stethoscope when it inflates
    4) make sure the person keeps their arm nice an still, because if they move it you'll get some rubbing/muffling
  25. TexasRose

    TexasRose Gotta run Moderator Emeritus 7+ Year Member

    Jul 24, 2002
    where else?
    Are you practicing on a young, athletic person? I highly recommend finding a friend who doesn't make you nervous, who is thin and fairly athletic. His or her pulse will be much easier to hear than on someone who is heavy set. Older kids who are cooperative are also great to practice on.

    I know this because I asked my husband and kids to let me practice on them. ;) Once you get the hang of it on someone easy, it'll get easier with the less ideal patients.

    good luck!
  26. greytmedic

    greytmedic Faster than you 10+ Year Member

    Dec 17, 2005
    I kind of wandered in here from pre-allo just looking around, but I can offer some advice. Palpate the brachial artery first in the antecubital space, follow it up slighty so your fingers are actually about 1" above the crease of the elbow(your fingers will be close to being in between the bicep and the tricep). Put your stethoscope here but make sure the cuff is another inch or so above the stethoscope. This will be a louder and more distinct sound.

    I wouldn't go with the watching the needle/mercury bounce. That puts a lot more variation into the reading, which can be off quite a bit. I would rather just palpate than make a decision based on watching the needle bounce.

    PS: I may not be in medical school yet, but I do have experience with blood pressures.
  27. tupac_don

    tupac_don Senior Member 5+ Year Member

    May 16, 2004

    Maybe you are not putting the stethoscope in properly, try putting it in so the ear pieces are pointing in not out. You should hear just fine, especially from a healthy young med student. Listen for a distinct sound and then listen till you can't hear it no more, presto.
  28. Wackie

    Wackie Inappropriate, always 5+ Year Member

    Mar 20, 2006
    Home with the Armadillo

    Are you saying everything is muffled? If so, have you tried pulling out on the ear pieces just a tad to make sure they're not stuck too hard in your ears?

    I know it sounds funny. I was toying with mine to see if I could replicate a muffled sound. It was about the only way I could get it to.

    I'm not sure what you're history is with your ears as well. I had tubes put in mine multiple times. The scar tissue on the ear drums has contributed to some hearing loss. Knowing that, I bought a decent scope, but I still couldn't hear much. Then I bought a Littman Master II and can hear in the back of an ambulance with it. :D
  29. BlondeCookie

    BlondeCookie Senior Member 7+ Year Member

    Jul 4, 2005
    I'm sorry to ask this question, but it is related to the original poster's topic.

    I am having some minor problems doing blood pressures also, but my problem is a little different. I start out by pumping air into the cuff and let off on the air very slowly. I can see the mercury falling. However, I usually see the mercury "beating" a little bit before I can hear the person's pulse. Aren't I supposed to hear the person's pulse at the instant the mercury starts to "beat"? I hope that makes sense.
  30. Dunce

    Dunce Senior Member 10+ Year Member

    May 15, 2006
    That small side is not actually a bell . . . at least the way most people have their Littman IIIs set up. The small chest piece is exactly that, a small chest piece -- like something you would use for peds.

    Someone correct me if I'm wrong but you just use light pressure with the chest piece and it functions like a traditional bell. If you press down more you hear higher pitch sounds.

    Edit: you can make the small side a standard bell if you take off the diaphragm and switch it with that spare rubber part that should have come with the stethoscope.
  31. bjackrian

    bjackrian Senior Member 10+ Year Member

    Apr 16, 2004
    Denver, CO
    Exactly right. By varying the pressure you're supposed to be able to hear bell sounds and diaphragm sounds without lifting the bell/diaphragm off of the patient's chest.

    Incidentally, I've found the small chest piece works better for BPs since there's less surface area to brush against things like sleeves, etc. You might try that.
  32. @rpy2848

    @rpy2848 2+ Year Member

    Sep 12, 2006
  33. fiznat

    fiznat Senior Member 10+ Year Member

    Mar 18, 2004

    For you, and for everyone else here who is doing this-- stop. The needle will just about always bounce before you get to the correct systolic pressure. You are listening for the sound, not watching for the bounce. This is a rookie mistake that will always give you higher than actual readings.

    As others mentioned, palpation of the pulses (both brachial where you want to put your scope, and a finger on the radial) is the key to learning how to do this right. Listen and feel together, you'll soon learn what it is that you should be listening for.

    Dont be discouraged. This skill does have a little bit of a learning curve. I am a paramedic (pre-med) who has been working in EMS for over 6 years, and even still there are occasionally people who's blood pressures I cant hear. Take it in stride, and most importantly: DONT make the pressure up!
  34. BlondeCookie

    BlondeCookie Senior Member 7+ Year Member

    Jul 4, 2005

    Thank you. I'm such a rookie, it's embarassing. So now I know to take the systolic reading when I first hear the pulse and not prior to that when the mercury/needle bounces. I just need some more practice.
  35. Rendar5

    Rendar5 10+ Year Member

    Nov 12, 2003
    Same w/ the diastolic read. The needle continues bouncing after u've hit the diastolic pressure. When you hear a sudden drop-off in sound, that's what you record (even if u can barely make out some slightlsounds afterwards).
  36. BlondeCookie

    BlondeCookie Senior Member 7+ Year Member

    Jul 4, 2005

    Thanks. The diastolic part is a bit tricky. I thought that you record the diastolic when you stop hearing the pulse, but I might be wrong on that also. So, you are saying that you make the diastolic recording when there is a sharp dropoff in sound. Correct? Uh oh. So are my recordings for the diastolic a little bit low due to me incorrectly recording the faint pulse sounds of which I shouldn't be recording? :confused:
  37. fiznat

    fiznat Senior Member 10+ Year Member

    Mar 18, 2004
    Possibly. They say in the literature that there is actually a "woosh" sound when the pressure in the cuff is finally low enough to let blood in the artery flow by with very little obstruction. I hardly ever hear a woosh, but I usually can hear the sound sharply drop off at a certain point. Thats where I record my dias.

    I've argued about this in another forum before, but just a word of advice/personal opinion: dont worry so much about getting an absolutely EXACT blood pressure. Pressures obtained using a BP cuff and listening for sounds are notoriously innaccurate with very poor test-retest reliability. Real blood pressures are obtained using a-lines, swan catheters and wedge pressures, not indirect tamponade and qualitative sounds. What you are doing with the BP cuff is getting a good idea where the pressure is around, probably + or - 5-8 points. ...So dont freak if you hear the sound drop off at 78 but continue to hear small sounds down to 70 or so. No big deal, the diastolic is 74ish. lol just dont include the "ish" part when recording your measured BP. ;)

    Just my opinion.
  38. BlondeCookie

    BlondeCookie Senior Member 7+ Year Member

    Jul 4, 2005

    :) Haha. Very well. So, in that instance do you personally record 78 or 74? And anyone know of a good online resource for doing accurate BPs?
  39. UCLAstudent

    UCLAstudent I'm a luck dragon! 10+ Year Member

    Sep 6, 2002

    You are right, but I always use it as a standard bell, without the small circular plastic piece.
  40. ok ok going to sound SO STUPID but I am a med assistant student through one of those splashed too frequently across the tv commercials schools.

    Day one of class was in lab. I learned how to do a ppd, sub q, intra dermal and a z track (which was fun by the way.......)

    Not once was there any instruction on how to do a BP. I got the mechanics down, slap on the cuff, not too tight. Pump up slow release listen!

    Here is the freakin problem I CAN'T HEAR
    I bought a bp cuff and meter to use at home on my hubby who is a durn good sport. Diastolic no problem. I got that one. But the systolic? No clue. I failed my first month bp test btw... So I tell hubby and he's like let me take yours. I instuct him on the mechanics and what he is listening for. Same thing. Diastolic loud and clear. So then we start listening for heartbeat and breath sounds. Those should come through loud and clear. RIGHT? NO SOUND.
    Even grabbed the dog and couldn't hear a blessed thing. So my stethascope is broke, or cheap. Off to the store to buy a new one. A lumiscope sprague rappaport thing. Looks fancier, but still can't hear a blessed thing.
  41. AMSA


    Nov 6, 2006
    I know that you're trying a couple of steths, but are they clean? Tap the diaphraghm, is it loud (if not it could be blocked)? Also, make sure the eartips are pointing forward. The ear canal travels medially and anteriorly, if the earpiece is just resting at an angle perpendicular to the head, you will have reduced resonance.

    Secondly, make sure that the tube coming from the cuff (rightmost if there are two, or just the one otherwise) is lying directly over the brachial artery. You will feel it with gentle palpation just medially of the cubital fossa. You will not cause the patient harm unless you pump the cuff out to 300 mm/Hg, so don't worry. Although people say not to place the tube over the brachial artery, I recommend you do this, for 2 reasons. Firstly, you are applying better pressure with the cuff for less pumping, and secondly the cuff will give more accurate pressure readings to the sphygmomanometer.

    Finally, ensure that you place the chestpiece of your steth directly over the brachial artery (that is, in line with the tube). If the chestpiece is not over the artery you don't get sound! Also, think of your steth as a little bird: hold it too tightly and you will choke it, hold it too lightly and it will fly away. Apply this same principle to chestpiece pressure on the skin. Also, ensure that the chestpiece is held extremely stably against the skin, moving it or your joints even slightly will introduce artifacts (as will the two tubes rubbing against each other in a Sprague steth) which will preclude you from correctly auscultating.

    Other than that, your own kiddo!

    P.S. Had a hearing test lately?
  42. BlondeCookie

    BlondeCookie Senior Member 7+ Year Member

    Jul 4, 2005

    Hmmm. hearing test? Hypothetically, if you had a hearing test and it was advised that you get a hearing aid, how is the hearing aid going to help you hear a BP? I mean, the earpieces on the stethoscope aren't going to fit in the ear if a big hearing aid is in the way. Correct? Just curious.
  43. Hoberto

    Hoberto Squirrel Girl 10+ Year Member

    Apr 10, 2005
    Boy am I glad to see that someone noticed this and spoke up. Yes, both sides of the Cardio III can function as both a bell and a diaphragm. They are differently sized for pediatrics/adults. Although, it's nice to have that small piece for carotids sometimes.

    One can change out the attachments for bell-only use if desired.

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