How important are those vital signs?

[MrBrown]

One thing that annoys me, and also puzzles me, as of late is abnormal vital signs and the lack of appreciation we seem to have of them. We've all been there, somebody with a bit of a tachycardia and we write it off as them being a bit upset and think nothing of it.

Then they ring back an hour later in cardiac arrest.

Or somebody who is feeling a bit unwell and has a temperature of 36 degrees C and we say oh its OK its just a bit of an infection and you sometimes feel a bit hot and cold.

Then they die the next day.

Every job we gather up the numbers, write them down and give them a cursory glance and I think really that is all we do. How often do we sit down and look at them in a complete clinical picture and go ah huh ..... well I think this means that .... no we look at them and go uh huh ok thats great you can stay at home bye now because we are tired, or seen it a hundred times before, or because we get so caught up in the complex stuff we forget the basics.

Lets take some basic fundamentals of physiology you do not need to be a HEMS Registrar in an orange jumpsuit or a sword carrying Ninja House Officer to figure out ....

- A fast heart rate means increased sympathetic response due to increased demand for blood to vital organs whereas a low heart rate means poor cardiac output

- Hypothermia is often a sign of low cardiac output

- Hyperthermia is often a sign of infection

- Low blood pressure is due to low cardiac output or something like loss of vascular tone, an altered level of consciousness or something of the like

Etc, they are grossly oversimplified in some cases and not all encompssing

Why would we never leave somebody with a GCS of 13 at home but we leave people who are tachycardiac and have a fast respiratory rate at home because they are just a bit agitated and need to have a herbal tea ?

Lets look at some cases where people have missed things (these are on-published cases and not ones I have selected based off PRFs or anything like that)

- Guy had a temp of 36 degrees C, a borderline bradycardia and didnt feel well, he was left a home, he died of a massive PE

- A non English speaking elderly gent who fell 3x in the past two days (who did not normally fall) was left a home - his cause of death was unclear but it was thought to be massive haemodynamic collapse due to burst varacose veins

- A young girl who was hyperthermic, somewhat normotensive, tachypneic and tachycardic was left a home coz she had "the flu" and died of massive sepsis

- A lady who was hypoglycaemic was given some glucose and told she was OK to stay at home, I don't know what she died of but she had multiple hypo's in the past few days.

I think too often Ambulance Officers just explain away abnormal vital signs as something that is not uncommon for context and do not consider the larger clinical picture. Does that mean we should transport EVERYBODY that has a bit of a tachycardia? No not at all, but should we be leaving people at home? Maybe not it seems.

So my question is just how important are these abnormal vitals and are they truly abnormal ... eg somebody who is tachycardic and tachypneic, do they have a massive aortic ruputre or do they just have a bit of the jitters?

Why do we just gloss off the numbers and more often than not explain them away without really appreciating them? Do we appreciate the basic tennants of physiology enough or are we too quick to just come up with a reason for those numbers as being acceptable to us as Ambulance Officers?

I am particulary interested in what we think about tachycardia, because that seems to be the buzz at the moment and have seen several Ambulance clinical publications pointing out that a tachycardia should not be explained away as it were.

Apologies for my jumbled rambling, I have to be up at 4.45am tommorow which means I can't watch Greys Anatomy tonight and I don't have a DVR or TiVO

*Brown gets into his orange PJ onsie with "McBROWN" written on the back. climbs into bed and turns on the answering machine connected to the phone from Ambulance Control.

 

[DrParasite]

- A fast heart rate means increased sympathetic response due to increased demand for blood to vital organs whereas a low heart rate means poor cardiac output

very true. so either the heart is making up for an increased demand in oxygen to the body, or something is preventing the heart from getting all the oxygen. either way the HR attempts to compensate. As for a low rate, what is that? is the patient's heart rate normally low, because they only weight 80 lbs? or because they have a problem that needs an ER for fixing?

- Hypothermia is often a sign of low cardiac output

yep. also a sign of exposure, and poor circulation when limited to the extremities.

- Hyperthermia is often a sign of infection

again, it might be exposure, or an infection. now, whether or not the infection is life threatening or not is a the important question.

- Low blood pressure is due to low cardiac output or something like loss of vascular tone, an altered level of consciousness or something of the like

dehydration, hypovolemic shock, weighing 90 lbs etc. got to compare to what the patient's baseline is.

Why would we never leave somebody with a GCS of 13 at home but we leave people who are tachycardiac and have a fast respiratory rate at home because they are just a bit agitated and need to have a herbal tea?

depends, what is their baseline? are they having an anxiety attack, are they normally confused, what is their history and what are they being treated for?

Question:
a 20 year old is found with a slightly elevated BP (130/90), a HR of 140, and a resp rate of 35. he is hot, and soaked in sweat. bystanders state he was running on the track in the park in 95 degree temps with 90% humidity, completed lap #5, and passed out. should he go to the hospital, and if so, what is going on with him?

a 30 year old volunteer FF (who is a state trooper in real life), a former HS and college football player comes out of a room and contents fire in 85 degree weather. his pulse is 100, his BP is 110/70, and his resp rate is 12. should he go to the hospital?

an 110 lb girl who is 21 year old just got out of the shower, and passed out. her bf called 911, and when you arrive he is holding her up on the toilet. she looks pale, cool/moist, ashen, and feels like she is about to pass out.her BP is 60/30, pulse of 130, and resp rate of 18. she said she went out drinking with her bf the night before, they did the college bf/gf thing the night before, and she says she skipped dinner and hasn't had breakfast yet. what is going on with her?

and lastly, I am 27 years old, and am hypertensive. 3 back to back days of fevers of 102+, no appetite, tachycardic, bp 100/60, pulse of 120, and no food or drink in the past three days. not that i couldn't eat anything, just wasn't hungry. what do you think I had? and to not break any rules, so I am not asking for help, I am no longer sick, but using it as an example.

To answer your question, yes, abnormal vitals are generally not a good thing. But just like it's the "practice of medicine" and doctors make mistakes, so do paramedics and EMTs. Should your examples have been left at home? probably not. if they had been transported to a hospital, would the end result have been any different? maybe, maybe not.

Also remember, just because a person is sick and dying, doesn't mean they HAVE to go to the hospital. They chose to go. Diabetics often refuse to go, after they are woken up from their hypoglycemic episode. kinda hard to FORCE them to go against their will.

Abnormal vitals are just that, abnormal, but you can't look just at vital signs. you need the entire picture, as well as all the history and everything else, as well as the patient's baselines.

oh yeah, and just because you think the vitals are abnormal, doesn't mean the patient will be discharged from the hospital with a clean bill of health, with the ER/MD/RN/lab tech finding absolutely nothing life threatening with the patient.

just sayin

 

[Enzo]

- Guy had a temp of 36 degrees C, a borderline bradycardia and didnt feel well, he was left a home, he died of a massive PE

A temperature of 36 degrees C is considered normal. 37+ is a fever. Everything below 37 and above 35 is normal.

 

[Melclin]

There are a couple of problems when it comes to vitals.

-I think people often blame the gear when you get a vital sign you don't expect. I don't actually think this is unreasonable. Esp in ambulance, our gear gets knocked around a bit. Even in hospitals the same thing happens. On obstetrics placements, I took a BP of a woman in labour of 165/100 after half hourly averages of ~110/60, I assumed it was wrong, as did the midwife observing me, it took a total of 4 attempts by her and myself on two different machine before we finally accepted it (in our defence, there were a couple of good reasons why we thought it might be wrong) and called the obstetricians.

-The textbook norm doesn't always apply to patients, and its easy to think, "oh well maybe that's normal for this bloke". Regarding temp and cardiac output, I regularly have a temperature of 35.5-36.8 and I'm not having a massive PE. Hindsight is 20/20. Plenty of doctors make woopsies and kill patients, especially in primary care, because they erred on the side of what was most probable. I think in a lot of cases that's also reasonable. Its sad but you cant send every pt with a sniffle to ID, (?) ebola virus. Even with our considerably reduced responsibility in EMS, we will make similar mistakes, but that's just health-care. They said in hour first ever lecture, "You will bury one of your mistakes - get used to it, learn from it".

-Vitals have to build a bigger clinical picture. You really need to have a great body of knowledge to guide clinical decision making. Its not enough to give a person a set of vital sign ranges to memorise, teach them how to use a BP cuff and expect them to be health-care professionals. As I said to Vene in a thread about education a while back. I think a provider needs enough education to be able to meaningfully interpret the information they collect. In EMS we have this culture of teaching just enough about the few problems that there are protocols for. Problem is conditions (and the vitals that indicate them) don't always present in black and white terms. Understanding all the shades of gray - knowing what its not as well as what it might be - helps a provider to pick up on the more realistic and subtle presentations as well as the textbook case. It seemed to easy when I sat in my first cardiology class and the lecture slides went up, "AMI, symptoms: diaphoresis, central chest pain....etc", then you get to a 95 year old bloke with dementia, sometimes he has pain, sometimes he doesn't, his vitals are confusing and don't fit the numbers you wrote learned for your exam, there is a medication list and hx as long as your arm all possibly affecting vitals, and he flexes his arm every time you take a pressure. It doesn't seem that clear cut anymore.... Education education education.

Well that's my two cents, such as it is anyway.

 

[Veneficus]

You can always justify things to yourself.

Vital signs are simply a part of the clinical picture not the whole thing.

I had a clinical preceptor who challenged the students to find evidence on patients as to why our initial presumptive dx might be wrong.

Only when all else has failed should anyone consider "abnormal findings" on presumption.

True psych dx are actually rather difficult and time consuming because everything else must be ruled out first.

Should we transport every patient for every test? Certainly not.

Some people will always fall through the triage cracks. In my experience the more time you spend on a physical and history, the smaller the cracks become. The more shortcuts you take, the larger the cracks.

Just my thoughts

 

[sdadam]

A single vital sign means nearly nothing.

A vital sign is like a frame of a mystery movie.

If you randomly selected a single frame from a movie it would most likely tell you nothing, it takes many frames over a period of time in order to tell the whole story.

Vital signs work the same way.

Now on occasion you might get the one frame which shows you exactly what is going on, (i.e. a HR of 260 in SVT) but that is the exception not the rule.

Tachycardia alone means very little, as does any other vital sign alone, even if elevated or depressed.

Now that said, I don't ever write off an abnormal vital sign, but changes happen systemically. HR doesn't go up without requisite changes in pallor, respiratory rate, pupil size, mentation, etc.

</my two cents>

 

[firetender]

somebody with a bit of a tachycardia and we write it off as them being a bit upset and think nothing of it.

Then they ring back an hour later in cardiac arrest.

Or somebody who is feeling a bit unwell and has a temperature of 36 degrees C and we say oh its OK its just a bit of an infection and you sometimes feel a bit hot and cold.

Then they die the next day.

- Guy had a temp of 36 degrees C, a borderline bradycardia and didnt feel well, he was left a home, he died of a massive PE

- A non English speaking elderly gent who fell 3x in the past two days (who did not normally fall) was left a home - his cause of death was unclear but it was thought to be massive haemodynamic collapse due to burst varacose veins

- A young girl who was hyperthermic, somewhat normotensive, tachypneic and tachycardic was left a home coz she had "the flu" and died of massive sepsis

- A lady who was hypoglycaemic was given some glucose and told she was OK to stay at home, I don't know what she died of but she had multiple hypo's in the past few days.

So my question is just how important are these abnormal vitals and are they truly abnormal ...

You speak of patients evidencing altered vital signs not considered serious deviations by the medics and then, within days, they ended up dead. Your only notable exception was the guy who croaked an hour after the medics left. You didn't mention whether or not he actually wanted to go.

You speak of this as if it is our responsibility to predict the future. Our job is to make sure the patient has a now. If that now is being endangered, then we intervene.

The way many people die is they hover on the edge for a while and then start to "feel" lousy. That's when we usually show up. Often, it's just before the time they tip over the edge and take that certain slide into death. In the moment, they really are still okay. But we can neither predict nor prevent that sudden tumble from happening.

"Within days" tells a different story. We actually may be called to an emergency and then, upon arrival see there is nothing emergent (needing immediate intervention to preserve life) and go on to the next call. That is appropriate because we cannot, nor would we be allowed to, transport EVERYONE to the hospital.

"You really need to be checked out because your pulse is high and your temp is up, but I don't see where you are facing any immediate danger." is probably not only an appropriate response, but accurate as well.

Believe me, out of the hospital setting and if asked to do our jobs, most MDs would declare your examples non-emergent and have the patient brought in by other means than an ambulance.

I'm not advocating neglect of evidence, I'm just trying to distinguish that our role in the field is to intervene in situations that are life-threatening NOW. These are not so much mis-interpretations of vital signs and disease entities so much as they are attempts to appropriately use EMERGENCY resources at the time of the call.

 

[Melclin]

Believe me, out of the hospital setting and if asked to do our jobs, most MDs would declare your examples non-emergent and have the patient brought in by other means than an ambulance.

I'm not advocating neglect of evidence, I'm just trying to distinguish that our role in the field is to intervene in situations that are life-threatening NOW. These are not so much mis-interpretations of vital signs and disease entities so much as they are attempts to appropriately use EMERGENCY resources at the time of the call.

The vast majority of ambulance work does not involve an immediate threat to life, but it still requires our assessment, treatment and transport to an appropriate facility for medical assessment. Are you suggesting that the only people who you transport are people with immediate and obvious threats to life?

So the probably urinary tract infection in a supported cared pt with a IDC who just meets the definition of SIRS; no threat to life right now, but four days from now, they'll be dead...they don't get transported? The 9 year old kid with a broken arm at the skate park...no life threat, but was he supposed to walk 19kms to the ED with his arm flopping about? What about strokes - a given stroke might only affect motor function in a persons right hand...you're not interested? Of course you are. True, obvious and direct threats to life right now are pretty rare and you've been in EMS probably for longer than I've been alive, so I'm assuming you know that - so whats with this is "every call is savin' lives" talk? I know we're talking about the relevance of vitals and all, but you seem to be suggesting that if it doesn't involve immediate life threat, then EMS has zero role other than to turn them down for transport and bugger off to the next job? Did I misunderstand (I have been up all night)?

Sticking with that theme, should we be ignoring patients who are not particularly sick but who, for some reason of health, lifestyle or environment, are likely to become sick in the future? The old bloke Brown talked about who fell a few times, a BS call, right? No immediate life threat, not your problem, next job please. How about we start taking a minute to consider the reasons behind why the fell and considering idea like falls being high on the list of causes of death and disability in the elderly. Move the rug they tripped on? Call the council/their kids/other relevant health authorities, organize a walker? Consult with the Referral and Discharge team/hospital risk assessment team/what ever its called in your area if you have one. Fix the problem before you get called back to the same person 3 weeks later decaying on their living room floor after another 'minor fall'. I know I'm a baby in this field, but I reckon there's a bit more to it than tubes and choppers.

 

[MrBrown]

I think its more that people are looking at, often multiple, "abnormal" vital signs and fail to put two and two together and just explain them away so they can go to the next job

This is not specific to NZ and I think everybody does it to a degree; I know I have once or twice out there and I am sure we all have.

Does everybody with a bit of a tachycardia need to go to the hospital? No ... but I wonder if we are taught enough to appreciate the significance of, again sometimes multiple, abnormal vital signs?

So often we want to rush in and start treating or have a pre-determined mindset of oh yep its an old bloke with a bit of the sniffles etc and we fall into that trap.

And they call back an hour later in cardiac arrest, or dead.

 

[firetender]

And they call back an hour later in cardiac arrest, or dead.

If that's what they do in New Zealand, I'll stay in the Zombie-free States! I don't want my mistakes callin' me up and giving me hell!

But seriously consider things ARE a bit different here in the States.

Medics in the US are not trained to think and anticipate at your level (or Melclin's for that). High-volume areas makes it very, very easy to skip over someone who'll be dead within 48 hrs. The variable of refusal of transport is often determined by economic fears; as is even going to the hospital at all (thus the call for the ambulance in the first place!).

Often times availability is considered more important than delivering service. How that translates is in anything determined non-emergency, there's not the time to dawdle -- you're out of there and in the rig, in-service. Not having to rush out the door allows time to reconsider.

...and I'm not too sure that many Medics here look at themselves as responsible for a bigger, more long-term picture for their patients. The training is highly specialized; the bag of tricks, limited.

Perhaps my observation is your system may have different concepts of time management and responsibilities than ours do.

 

[MrBrown]

Medics in the US are not trained to think and anticipate at your level (or Melclin's for that). High-volume areas makes it very, very easy to skip over someone who'll be dead within 48 hrs. The variable of refusal of transport is often determined by economic fears; as is even going to the hospital at all (thus the call for the ambulance in the first place!).

...and I'm not too sure that many Medics here look at themselves as responsible for a bigger, more long-term picture for their patients. The training is highly specialized; the bag of tricks, limited.

Perhaps my observation is your system may have different concepts of time management and responsibilities than ours do.

I think to a degree you are right; I know I am not totally responsible for the long term outcome of my patient eg if they are having thier sixth heart attack (which I have seen) is it up to me to talk to them about diet and exercise and lifestyle? No.

But, I know that many things I do may have an impact on long term outcomes such as appropriately identifying which patients warrant further observation and diagnostics, early locate-to-treat time in strokes and MIs and things like that, or not hyperventilating my intubated traumatically brain injured patient as it has shown to have worse outcome.

To use your logic we should be even better at patient assessment and our knowledge of physiology/patho because we can determine whether or not to leave people at home. But it seems maybe we aren't ... and this is not something I am highlighting to sat hey look at NZ we leave people at home and they die!

Rather I am saying hmmm I wonder if we get caught up in the as you put it, highly specalised bag of tricks and the high level complex knowledge we sort of forget the basics.

Maybe, maybe not, who knows but it puzzles me

 

[firetender]

Rather I am saying hmmm I wonder if we get caught up in the as you put it, highly specalised bag of tricks and the high level complex knowledge we sort of forget the basics.

the basics are even more basic than you're imagining, Brown. Since statistically the percentage of patients presenting to ERs or EMS who have nowhere else to go for reassurance (the most potent placebo in God's Universe!) is huge. Where we're really needed is to tend to the humans on our beat because no one else does.