Oh the Signs, they are Vital!

We have all endured sitting in our doctor's office and watching the nurse take our vital signs.  Staring at a watch while holding our wrist, they wrap that cuff around our arm and pump it up tight with the stethescope tucked in at the crook of our elbow and (sneakily, if they are any good) watch our respiratory rate.

It's the first thing an EMT does when responding to an emergency call.  It's the first bit of information a doctor wants when the floor nurse calls about a patient who is having an issue.  It's basically a universal health measurement and yet, from what I understand, most lay people regard it as a bit of a mystery and wouldn't actually know how to perform these fundamental measurements. 

As I explained in my previous post about documentation, an ongoing log of a crew member's vital signs (or, 'vitals') when they are having a health issue can be extremely helpful when that crew member goes for follow up care, or, in an extreme situation, we have to call for help from shore.  Vitals give a great overview of what might be going on with someone, and when combined with the data points of any assessed symptoms as well as health history and details of the present condition, they can get us very close to knowing 'what's wrong'.

As always, I sincerely hope that you won't ever have the need to take someone's vitals (aside from the baseline ones we should all have in our file before we set out cruising), but, just in case, I will explain here what those measurements are and how to take them.  And, as always with any of the procedures I have talked about here in my blog, I will continue to stress that it's a REALLY great idea to practice a lot before you set out anywhere so that you feel comfortable performing them when you are out in weather and one of your crew is sick.

The classic set of vital signs include these readings: Temperature, Pulse, Respirations and Blood Pressure.

Temperature:  This reading will tell us a lot.  The body normally controls its core temperature tightly because any variation will affect chemical reactions going on in our metabolism, etc... something the body doesn't want.  If the temperature is elevated, there is very likely an infectious process going on, the person is dehydrated and/or there is some inflammation present.  Generally, a temp. above 99 degrees F for any longer than a day is cause for concern.  Another cause for concern is hypothermia, which is a real danger for cruisers.  If you see any of the usual signs of hypothermia (slow speech, confusion, shivering, blue lips, nose, extemities, etc.) and a temp below the normal 98.6 degrees F, you need to jump into action.  This is a subject for another blog post and is a very important subject to read up on before heading out.

Have more than one thermometer on board.  The electronic ones are great, but will of course fail at the most inopportune moment... so have a few of the old-style mercury ones around.  There is also a nice single-use disposable brand called Tempa DOT, which is cheap and very user and kid friendly.

Again, taking a baseline temperature of each crew member and having this information on file will help you to be sure that this is, in fact, a deviation you are observing.  Different people have different baselines and can vary by up to a degree or two at times.

Pulse:  A pulse tells us the heart rate of a person, and can give clues about hydration status, emotional status, any present infection etc.  The easiest way to get this reading is at the wrist, just above the bony joint, on the thumb side.  Gently press with your index and middle fingers until you feel the pulse.  You can also find this (sometimes more reliably) at the carotid artery, which is the large artery found on the neck, slightly to one side of the trachea.  Another option is to simply use a stethoscope and listen to the heart itself over the left pectoral muscle.

The measurement for a pulse is how many beats per minute.  Nurses will often count for 15 seconds and multiply that number by 4, and you can choose to do this as well.  Normal readings for infants are about 130 to 150 beats per minute, for toddlers 100 to 120 bpm, older children 90 to 110 bpm, adolescents 80 to 100 bpm and adults anywhere from 50 to 80 bpm.

Respirations:  Respiratory rate can tell us of any distress a crew member is in, physical or emotional, and can give more data about lung or cardiac issues as well as level of consciousness.  My comment above about the nurse being sneaky about assessing a patient's respirations was valid: if a person knows his breathing is being watched, he or she will almost certainly alter the rate without knowing it.

Respirations are also measured in breaths per minute, and again, you can also count this for 15 seconds and multiply by four.

Normals are: Infants (from birth to 2 years): 25 to 50 breaths per minute, older kids: 17 to 27 breaths per minute, and adults:15 to 20 breaths per minute.

A good trick to measure the respiratory rate without the person knowing it is to hold the wrist as if you are still taking their pulse, watch the second hand on the clock and also watch their chest rise and fall.  You can also simply listen to their chest with a stethescope.  This gives an opportunity to also listen to breath sounds and their character (wheezy, gurgly, etc.) which is another good observation to include in your assessment.

Blood Pressure:  The blood pressure is actually two measurements called the systolic blood pressure and the diastolic blood pressure.  The higher number is the systolic BP and corresponds to the highest amount of pressure put on the walls of the arteries at the peak of the contraction of the heart.  The lower number is the diastolic BP and corresponds to the amount of pressure put on the artery walls during the resting phase of the heart beat.  These values can tell us many things including hydration status and cardiac status and is also an indicator of shock. 

Normals are: Infants: 70/55, children and athletes: 95/65, adults: 120/80.

Again, these are all approximate normals with much variation noted.  The best way to know your normal reading is to have a few baseline readings taken at different times of day on a few different days.  This will give you an idea of the general area where your numbers like to hover and when there is a big enough variation to cause concern.

Automatic blood pressure cuffs are really great, however, just like the automatic thermometers they will, as a matter of course, fail at the most critical moment and give you some crazy reading or just not even turn on.  For this reason I really recommend getting a stethescope and a sphygmomanometer (or manual blood pressure cuff - cheap and easily found online), learn how to use it and practice. 

Here is a quick explanation of how to take a manual blood pressure reading: wrap the cuff around the upper (non-dominant) arm so that it is snug when not inflated.  Check to see that the arrows on the cuff point to the inner part of the elbow where the large arteries are.  Turn the knob by the bulb so that the valve is closed and put the gauge some place you can see it where it won't be disturbed (some cuffs have a clip on the gauge and a loop for the clip on the cuff itself).  Put your stethescope in your ears and hold the diaphragm (the listening part) on the inside of the elbow.  Now, pump the bulb up until the gauge reads about 150 to 160 mmHg, then slowly loosen the knob until the needle on the gauge begins to fall.  Listen for the heartbeat and note what the gauge reads when you first begin to hear it and then when you no longer hear it.  Those two numbers are your blood pressure reading.  This can be a slightly tricky skill to learn but with some practice can start to feel like second nature and can become invaluable in certain situations.

I have watched about 20 You Tube videos demonstrating this technique and so far this is the best I've come across.

I hope that helps!

The Fifth Sign:  There are a few different candidates for 'The Fifth Vital Sign' and different medical camps have different opinions about whether or not each should be included.  These are: pain level (on a pain scale such as 1-10), blood glucose, oxygen saturation and pupil measurement (that is, if they are equal and reactive to light).  I don't have any opinion about whether these should be included in the official vital signs measurements, but I do think that the more information, the better.

For the pain scale, simply ask the crew member how they would rate their pain on a scale of 1 to 10 with 1 representing almost no pain and 10 being the worst imaginable pain and record this number.

There are blood glucometers sold in drugstores and online for as low as $64.  They are very easy to use and blood glucose levels can give good clues about reasons for some symptoms such as dizziness/grogginess, etc.  Normal ranges fall somewhere between 82 mg/dL and 110 mg/dL and will vary according to whether someone has recently had a meal or not, but usually nothing higher than about 180 mg/dL is recommended.  Higher than that or lower than about 80 mg/dL and you may have a problem.

Oxygen saturation levels (or SPO2) will tell us how well the blood is carrying oxygen to the various organs and limbs of the body... this is a critical process and without it we will have tissue death and organ failure if it goes on for any length of time. This level can be measured with a little machine called a pulse oximeter which can be purchased online for around $30.  A desirable saturation level is at least 92% and above... lower can be cause for concern.

And finally, there is pupillary function.  This is an observation of whether the two pupils are equal in size and shape, and whether they both react to a flashlight shined directly into them.  If you observe any anomalies here (such as unequal size and/or shape or slow constriction of the pupil with light), it could mean there is something going on neurologically.  If the person is exhibiting other symptoms such as an altered level of consciousness, change in behaviour and/or has suffered a head trauma or has any history of stroke or other neurological problems, get help ASAP.

Well, that about wraps up this subject for now.  I hope that this post gave you more insight into some of the skills you may want to learn before you set out on the high seas.  If it brought up any questions in your mind, please feel free to contact me.  I am also going to be conducting workshops in the near future to teach these and some other fundamental skills.  These workshops will include one of our Expedition Medical Chests and some great hands-on demonstrations, which should give you a great head start on your cruising preparations.  I hope to see you there.

Cheers and Fair Winds!

Kirsten