Episode Transcript
[00:00:02] Speaker A: Welcome to the AT Pit Crew Podcast. This high energy show dives deep into the world of sports emergency care. Join us as we explore cutting edge strategies, real world experiences and expert insights to help you step up your game in emergency care. We've got the tools, tips and stories you need to be ready when seconds matter. It's time for the @pit crew podcast. We have the green light in three, two, one.
[00:00:32] Speaker B: Welcome to the @pit crew podcast. I am Ryan Hart, your host for today's episode. If we haven't met, I am the sports medicine event manager with Action Medicine Consultants. And I'm excited to be here in the host seat for today's episode for the very first time with me. Today's guest is Dr. Ray Castle, a leader in sports emergency care and athletic training. Today we're diving into a skill every sideline clinician should master, and that's taking blood pressure by palpation and more importantly, why recognizing systolic blood pressure in emergency situations can make a major difference. So here we go. Let's get started.
[00:01:13] Speaker C: Good deal. Good to be here. And Ryan, thanks again for having you on as a. Being the host now. So it's kind of nice to be in the. In the end of not being the driver's seat every now and then. It's time. It's fun just to be on the ride, so to speak. So as we take 10 laps today on really, I think a really interesting topic that's kind of overlooked in emergency medicine.
[00:01:35] Speaker B: Absolutely, Ray. So like you mentioned, we're going to be going through 10 laps with you today. So let's dive in with a few questions on those 10 laps. So here we go. So setting the stage.
So setting stage. Let's talk about blood pressure being a key vital sign. But often, you know, athletic trainers, I find, rely on other methods.
[00:01:59] Speaker C: The.
[00:01:59] Speaker B: Ray, can you talk to our listeners just a little bit about setting the stage for taking blood pressure by palpation?
[00:02:04] Speaker C: Yeah, so it's one of the things that it's, it's that I've seen a lot in our, in our pit crew course and other courses we do over the last year or two is just thinking about how we need to collect vital signs. Often, you know, we're in a very loud environment and it is, you know, I like to use this approach, you know, using a data point. It's really critical. One's better than none, two is better than one, you know, kind of so on and so forth when we're collecting data, especially when we have to get that handoff to EMS and this is a, it's a valuable data set. It's not incomplete. It is incomplete. In fact, you want to have a systolic and diastolic but if you don't have it, you can still get that especially in a loud environment. So that's kind of really where the focus gets into is just providing it helps to paint the picture, so to speak, when we are look at the patient status and then where we are just giving that patient on based on the situation.
[00:03:05] Speaker B: Absolutely. Ray, you know, and you talked about being in a loud environment. You know, emergencies rarely give us perfect conditions for an assessment of vital signs like blood pressure. You know, can you talk to our listeners maybe about some of the most common scenarios where palpation would be the best option for obtaining a valid blood pressure?
[00:03:27] Speaker C: Well, I think any, you know, you think about the sports settings like for example a football game or a. In a gym where the band is going, you know, where there it's loud, you've got music playing. You don't. It's hard. It's hard enough to. You can hear that all get a, get a good sound. So when you're thinking about that if it's difficult to hear, period, you know, like even some of the events we cover, like the endurance events like marathons have marathons, they've got music playing and they're not going. The band's not going to stop. If you're on the sideline trying to do a blood pressure or other things as well or in a court, it still keeps going. So you have to be able to find just to get the data points you can achieve. It just still gives you. Even though it's not complete, it does and you're not able to go into a quiet environment, then at least you have something to look for. You have an idea to look, look at at least some type of valuable and accurate measurement that you can bring along or package in with your initial core vital sign set to determine get a baseline vitals and then you can work at trending especially if the, the patient is, is deteriorating.
[00:04:37] Speaker B: Yeah, that's some great information and hopefully is getting our listeners kind of thinking a little bit about their own practices, games, scenarios, things that they're covering. So let's break down the skills a little bit better for practitioners who, you know, either haven't practiced this skill in a while or maybe they've never even heard of this. Can you walk our listeners through kind of a step by step process of taking blood pressure by palpation in a sports emergency situation?
[00:05:03] Speaker C: Well, I think just go back and look at, you know, you look at a blood pressure assessment in general. So you only have a cuff, you have the right size, you know, the right size cuff for the arm or let's say the patient.
You know, you have your stethoscope on and you put your measurement start, you start pumping it up. So again, when you, you're looking, you're looking for the disappearance or the reoccur appearance or occurrence and reoccurrence of the sounds which are the cord cough sounds for blood pressure, the, you know, when you hear them moving through so, or it disappears. So all you're doing, you pump the cuff up. You know, you may go to one, you know, 180, et cetera, and you start backing it down. So when you first start hearing that pulse, you know that sound. That's the. Not looking at the gauge, but you're listening to that sound and you recognize when that sound occurs. That's the first sounds for systolic, it's court cough sounds. And then when it dissipates, you move it down to like 80 or 70. That's when it disappears. That's the diastolic sound. The only difference is, is that now you're, you're just combining two skills into one. You're going to find a radial pulse. You can also do this on a brachial pulse. You know, the look, if the, if the cuff is high enough, you could do on the brachial side. Maybe very seldom you may do that. But again, you're getting a radial pulse, you identify the pulse and then, you know, you're simply, you do this with one hand and other hand you're pumping, you're, you know, pumping the cuff up and controlling the cuff. So you pump them up and then when you move it back down and then when you first feel it, you, you, it's going to occlude the arterial flow. So when it restarts back again, you feel, you note it on the cuff and you record that measurement and that's all it is to it. It's really easy. You're just recording systolic and you say It's I've got 160 by over pulse. I mean pressure over pout for BiPAP. And it's understandable what that is.
[00:07:00] Speaker B: Excellent. Well said. You know, you talked about in the beginning explanation, you talked about the right size cuff and you equipment can make all the difference. You know, why don't you talk to our listeners a little bit about what equipment they should have in their kits to successfully perform blood pressure by palpation. And maybe what are some of any of the gear related pitfalls to kind of watch out for or be cognizant of?
[00:07:26] Speaker C: Well, I think, you know, when we, our kits, we have them set up and I think just a vital signs kit, that's not, you know, you could, you can do that if you have a, you know, electrical, like an electronic cuff, you know, you could do by wrist. That's the offshoot of that. You would, you wouldn't need to do that if you have electronic cuff. And now they have that, you know, put it on the wrist cuff or on the arm, those will read those, you'll get the vitals from that. But again, if a battery doesn't break, you know, it's just more mechanical. So in our, our kits we have, we have a pen light and it's one like a BP cuff set is contained. We put pulse oximeter, which you can do pulse rate and oximetry or you get some better ones. You know, bigger cuffs, you can get mean arterial pressure. But we're really looking, you know, for this really rapid in the pen light and a glucometer. So those are all in one. So if I pull one out, if I pull that bag out, just do blood pressure. I know I need to get those other vital signs. It's just more of an easy reminder and you don't have to go scrounging around trying to find something as well. So that's really the main thing is having a cuff, whether it's a, whether it's digital or it's a manual, you're able to perform that, get that measurement?
[00:08:37] Speaker B: Yeah, absolutely. You know, I like what you said about having you all of your vital sign equipment in one bag. You know, I had the same thing back in Atlanta. We kind of referred to it as the vital sign go bag. And because mistakes can happen when you're under stress, you know, let's maybe help our listeners kind of avoid some of these mistakes. You know, what are the most common errors you see when clinicians are trying to do palpation or blood pressure by palpation? And maybe what, what are some tips that you would give to, to help our listeners get this skill correct?
[00:09:10] Speaker C: Well, I think the one thing early on you see blood pressure and you'll see it on a gauge and it's starting to, you know, that jumping right when it gets closer, you start seeing that and confusing that for getting a measurement versus what you hear. You have to be able to hear it, it's not a visual. Only time it's going to be visual is if you're actually, you know, you're recording it, but it's not a visual. It's. This is not a visual technique. If you're recording digital, it is visual, but it is a physical assessment. And that's a really key difference is not to look at that measurement. You can, you can start to see if you're trying to control the measurement if you're moving too fast on releasing the pressure. But again, it just has to go into, you're able to see where they're going to start. You may start seeing to jump some where you're getting closer in pressure, but until you actually palpate it or in the case, if you have the stethoscope and you do auscultation, then you're actually recording the initial actual listening or the palpation technique. The other one is just, I think just understanding what it measures. You're going to the how the question gets into how accurate it is. Well, it's usually within 4 to 6 millimeters of mercury compared to auscultations. Again, you're not getting diastolic, so you're thinking, okay, typical is 120 over 80. You know, you get this pressure and it's below 90. You get into 80. This is a really.
They're going to be showing up as a rapidly deteriorating patient if they've not already be compensating or potentially. So again, that has to be thinking of where that may be in a normal pressure. You know, 90 over 60 is not necessarily uncommon in an elite person or someone who's typically generally at rest. I'm not going to say hypotensive, but they have a lower blood pressure values than, than you may see a 120 over 80 or et cetera. So just to make sure you're not underestimating that using that tool, but also understand that palpation by palpation may underestimate in some cases, such as shock and weak pulses, the measurement you get. So you just got to be aware of that in looking at the person as a whole in terms of that vital sign assessment.
[00:11:24] Speaker B: Yeah, I really like that, you know, and you, you actually kind of already started touching on some of the questions that I wanted to ask you next, you know, getting more into like the details of what this technique is actually giving you in terms of a vital sign and how that correlates to, you know, guidance within that emergency situation. Are there any additional details you maybe could give our listeners Regarding specifically what you're measuring the systolic blood pressure and how that correlates to providing care during that emergency.
[00:11:56] Speaker C: Yeah, I think the one what I did I mentioned is I'm glad you asked reasset or asked that question is when you think about kind of a rule of palpation, a pulse palpation or its rules. So if you're doing a this and this is in the field estimates, it's not going to be set number zero. But if you're doing a carotid pulse palpable, you know, if it's palpable to what level it is, you're thinking about 60 millimeters of mercury. If you go to femoral, you got to think systolics could be at least 70. If you're doing a femoral artery, if you're palpating, I'm sorry, the systolic BP and radial is going to be, if you're palpating radial, it's going to be about 80. So just think about the systolic pressure, what at normal values are and these are again, it may, it, it vary. That's going to vary. You can't say, oh, it's because it's 60, 70, 80. This is locked in. You have to be thinking about what the patient's presenting as. Also, you know, take into consideration you've got noisy environments. If that's a problem.
You have a person who has low profusion rates. If they are already having labored breathing or they have some type of, you know, internal, I mean breathing versus internal bleeding, like for example a femoral fracture, those perfusion rates are going to be really low or you have the stethoscope's not available or in the case it breaks or the, the end comes off by chance. So again it just, it gives a quick affirmation of one data set, gives a quick estimate to see where they are in that and it's used more as a pivot. You're, you know, you're going to try to do blood pressure by auscultation and if you can't get it like by two times and just go right to the palpation, get one measurement and then move on.
[00:13:33] Speaker B: Yeah. You know, I mean something is better than nothing. Right. And so now that we've, now that we've obtained our blood pressure, kind of talk to our listeners about how do we effectively communicate our readings to EMS or to physicians during a fast moving emergency situation.
[00:13:52] Speaker C: Well, I think you go back in and I don't, I'll, we'll, I Don't want to go a lot of detail on the, like on a missed report, which you would like. It's a handoff format. It's very concise. It's very to the point what you're doing. You want to be able to give visually what the vital signs are initially the set. In that case, you're going to say, oh, respirations are 20. Initial assessment, respirations 20.
Pulse ox was 93. BP over pal was, you know, seven or 80 or get something, whatever number, you know, just making something up and so on and so forth, full clammy skin, et cetera. This is, and this is what we did, this is the intervention you did. Whether it could be putting a mylar sheet to keep them warm. It means if you administered medicine, you know, rescue medicine, for example, you know, if you're giving a, let's say for example, an anaphylaxis get due to EpiPen administration, oh, a couple minutes, you need, you need to know what the initial value is. But then five minutes later, just know that you're going to have a change in with epinephrine. You're going to, you're going to see a rise in or an elevation in vitals. So just gotta be aware of that. And then they may, they may roll back down again after several minutes. So just knowing what that looks like, that's the biggest thing to communicate. Practice it, be with confidence. It takes some time if you don't do that and then be able to give that back very simply if you're passing it on to ems so they know what that looks like. So again, you're just handing them off and they're having to move forward. But the information needs to be very simple, concise, to the point, hey, is there any other information you need? And that's simply just good. We're not top. When, you know, either the provider coming on the unit, whether it's, you know, EMT or medic, they're coming in, they're going to probably. They may ask that question, they may not. But it's always good to, hey, what other information do you need? And then they can help in case. And just in case you miss something, it helps them fill in the gaps.
[00:15:50] Speaker B: Yeah, that's some really great nuggets for our listeners, you know, to kind of hopefully think on a little bit and, you know, eventually practice and implement into their clinical skills. And speaking of practice, you know, let's, let's kind of shift gears a little bit and start talking kind of in that direction of how do. How do we start preparing for this? How do we implement this into our protocols? Talk to our listeners a little bit about maybe how athletic trainers should include blood pressure by palpation in their emergency action plans in their practice drills and incorporate that into their.
[00:16:25] Speaker C: Well I think the easy thing is you have it part of your skill set of your training. I mean if you've done it it's not something that you know I get to ask how often should you practice these skills? Well skills can erode pretty fast and number you know either from compressions, cpr, it's well documented. Some other skills as well. I think if you do it and you're doing enough you it's just pretty easy to get you know to do that. I think in terms of just general skills that would be practice. The question gets into more so is what skills are you applying into emergency emergency situation based on its per protocol. So you're just having to push practice that in the real time. I think something easy to do is you can do these in three minute scenarios you present in a staff training. It doesn't take a lot to do that where you're just trying to get them initially here three to four minutes you run through a scenario. You know you're going to have to do the first things first. Do the initial assessment, find the problem, start treating the problem. If it's spine, you know you have to think of issues related to that or you circulation, airway, breathing. You're just identifying that you're not doing about this on the front side. You're not taking by you need to do what's the. Is the airway clear? Is cool clammy skin. You're recognizing there's a problem. Try puts interventions and then you know as part of some of your secondary assessment, you know or immediately after doing an intervention you've got to get those vitals and then work on trending set every five minutes unless they're stable. Then you can do every 10 minutes. That's the maximum news but this is right it's easy. It's easiest to practice this. I mean it's a one off but you have to practice. You need to know that hey just put a loud sounds and just practice it once or twice. You can kind of see the difference of. Well this is really easy to do and but use it not as it's not the measurement, it's the pivot. If you're not able to get by auscultation that's the. That's the main thing to think about Is it's not the go to measurement. It's just in. It's the, it's the, you know, have a plan A, which is by auscultation using digital or by manual blood pressure. And if it doesn't work, then go to plan B, which is I can try it by the.
By palpation. And then plan C is you don't have that available or the device or your equipment's broken, which is not good.
[00:18:50] Speaker B: Yeah. You know, you talked about, you talked about. You just have to practice it. Let's talk with our listeners a little bit about diving deeper into what that means. You know, what's your advice for athletic trainers out there looking to practice and maintain specifically confidence in blood pressure by palpation, that skill throughout the year and maybe how often should they be practicing this skill?
[00:19:13] Speaker C: Well, I think it's a simple skill. I mean it's not we know how to take by palpation or radial pulse. You know, just check those. You can do it on yourself. You're doing a blood pressure. Not me on the outpatient. You know, for a pulse you can or anyone else. Or if you're getting a fetal pulse, a dorsal fetal pulse. Just looking at where you practice that, I think once you've done that, you've done it. You just got to go back and really where problems exist, not necessarily with palpation per se, but if you run through a short scenario, the problem you have to look if you're doing your evaluation, your drills, a problem is going to show up when it's in real time. Did you forget to do something? Did you do something out of order? Did you do some other things? And this is where skill breakdown. You know, again, you have to know the skill. Once you've done it, then you may some skills are just. You have to practice. They're more complex. But practicing know you have those skills a level of mastery because if you don't even practice it, you're not going to get confidence in doing it, period. But doing that and then you move into skill for a protocol and then you work into scenario and then the big, big interdisciplinary. That's the, that's the highest one from a, you know, interprofessional integration where you're moving through. Through this in a scenario going very deliberate. Well, they have this and do this and you just got to move them. You got to move through that, that progression to make sure that that's going to work at different levels. And then as you do each one, then it starts to speed up. And as you get more confident, it becomes more automatic. And then you can do those things in a very systematic way.
[00:20:51] Speaker B: Absolutely. You know, and at the end of the day, there's no better teacher than just personal experience, hands on experience with, you know, anything that you're doing in a clinical setting. Maybe share with our listeners an example where blood pressure palpation is directly impacted, you know, a sideline outcome or a change in your clinical decision making from your personal experience.
[00:21:12] Speaker C: Yeah, I mean, one of the most recent ones, we actually had a. There was an event earlier in the year where we had a athlete had a seizure right near the medical tent. And so, you know, EMS is there. We're not able to get a good pressure. So we're going, you know, we're having to move really fast to moving rapid interventions.
You know, having airway collapse. You know, the more of a respiratory. I say collapses and they're going into respiratory. Personal respiratory failure. And we had to get vital signs really quick and trying to get that. And it's loud. We couldn't. We're not just music inside a medical tank. Really can't hear the sounds very well. So we had to do that really quick. And then also getting other vital signs. By the time they got the LifePak unit, you know, they got it hooked up, they're able to start doing some rapid measurement digitally. But again, you're just trying to move in a very systematic way to determine whatever vitals we can until that other advanced support was able to arrive and other interventions are on site.
[00:22:12] Speaker B: Yeah, that's some excellent information for our listeners, Ray. You know, thank you so much for taking us through our 10 laps. You know, we're going to take a short break and when we return, Ray's going to tackle our final lap, the rapid fire questions, and then head into that victory lane for one last key takeaway. So don't go anywhere. Listeners, I am Ryan Hart and you are listening to the 80 Pit Crew podcast.
[00:22:37] Speaker C: Yeah. So when we go back and do this again, Ryan, we would probably go into. We probably put it between number five, like after number five.
[00:22:46] Speaker B: Yeah, not, not thinking. That's what I was just sitting here realizing. Yeah, I was like sitting here looking.
[00:22:51] Speaker C: I was like, on this one, we'll take it off. We'll just, we'll probably just take it off this time. So we'll do that as well. Or we can go back into.
Yeah. So what we could do is let's, let's record it. Let's see what it sounds like. Hey, we've, we've finished number five. We've got, we've, we've, we're five laps in and we're now going to get into, when we come back, we're going to talk about the, you know, talk. What are we measuring? Communicate. Just couple of things. Just do that and then do that one. Okay.
[00:23:23] Speaker B: Yeah, yeah, yeah. So we're, we'll do a rerecord of the break real quick.
[00:23:27] Speaker C: Here we go.
[00:23:27] Speaker B: Awesome, Ray. So we are five laps into our 10 laps and we're going to take a real quick break. But when we come back, you know, we're going to continue with lap number six and really start talking about measuring and getting into some applications of this skill and then how we should be practicing it, incorporating it into our policies.
So when we return, Ray is going to tackle our final laps like I mentioned, and then we'll get into maybe our victory lane laps and put a bow on it with a, maybe a rapid fire question or two for some last key takeaways. So don't go anywhere. Listeners, I am Ryan Hart and you are listening to the AT Pit Crew podcast. Welcome back to the AT Pit Crew podcast again. I am your host, Ryan, and with me today is our guest, Ray.
So we are moving into our final lap. I've got a few rapid fire questions for Ray, so let's see how he handles these. Ray, tell our listeners, what is your favorite sideline snack to carry with you in your kit? I'm just curious.
[00:24:29] Speaker C: Wow. First, it's a lot easier to ask these questions than to get these. I didn't know what you were going to ask, so, so I'm getting a dose of my own medicine, so to speak. Favorite, you know, I don't know. I mean, you know, honestly, having a Diet Coke, periodic, basically, if it's a longer event, you know, doing there and gosh, dog, I need something that's really easy to snack on. It could be either like a mixed nuts or even like just some type of, you know, energy bar. You know the one that I really like, this, those new packs, like a big bar, those are really, they come to, to a pack, it really packs a lot of energy, but it's relatively clean, you know, so that's probably my go to thing. If I'm, if I'm traveling, that's a whole nother thing. I'd probably go with. I haven't had this a while and now you mention it, probably I'd have to go with having an old, not, not the regular Coke. I mean, you don't want to Use regular Coke because that's. But having a bottle of Coke, say Diet Coke that you find in an actual glass bottle, like I grew up and you pour peanuts in it. So it's kind of one of those things that hadn't. I knew you would appreciate that.
I know you probably had that in Yazoo City. Growing up in Monroe.
It's a, you know, I do it every once in a blue moon, just, you know, don't do it all the time. But something like that. Yeah, yeah, that's, that's for driving. That's, that's a driving long road trips, you know, so yeah, a good road.
[00:25:54] Speaker B: Worthy snack for those, those distant, you know, team trips where you're having to go. Now here's, here's the follow up question that though, what is a snack that you regret carrying in your kit? One that's maybe just absolutely made a mess, left, left you hanging, you know, temperature change, who knows? I don't know. I'm gonna throw that to you.
[00:26:12] Speaker C: Wow. Well, anything involving chocolate. So I don't want, you know, it's just, it's mushy. It's, you know, if it has chocolate involved, it's just kind of a, you know, you don't have that like the energy bars, they make them with chocolate and whatever else. I just don't carry those period. It's just kind of a, it's a train wreck. And then also you just have peppermint. So the hard peppermint, not that soft, big ball peppermint junk. Starlight myths.
[00:26:35] Speaker B: I agree with you. The hard peppermints.
[00:26:37] Speaker C: Yeah.
[00:26:39] Speaker B: Awesome, Ray. Well, thank you so much for sharing your insights today. You know, before we wrap up, what, what's one thing that you maybe want to let every athletic trainer listening to today's podcast remember about using systolic blood pressure by palpation in sports emergency care?
[00:26:56] Speaker C: I just think the simple thing is just understanding what the value of having just getting a data set. You know, it's information that you can pass along. It may or may not be, it may not change, but at least it is a data set. It helps to paint the picture and especially if you're having, if you had limited resources, just like if you don't have it, if you don't have a BP cuff period, you can still, you still take pulse, respiration, skin color, their mental status using AFPU or, or if you're using Glasgow Coma Scale, either one. Any of those things helps in just any data helps to pass that along to determine where they were, what intervention you did how they change from the intervention and then moving on and then you hand those off.
[00:27:40] Speaker B: Awesome. Thank you so much Ray for being here today. And thank you for our listeners for attending today's episode with the At Pit Crew Podcast. For our listeners. Make sure you follow us on your favorite podcast app so that you never miss a lap and and remember, it's totally free. I've been your host, Ryan Hart, on today's podcast episode. You've been listening to the At Pit Crew podcast and we are out of here.
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