Automated Vital Signs – Who's the automaton?
Being, myself, a patient from time to time, I have noticed a disturbing and developing trend. The convenience, automation, and data-recording abilities of monitors, have changed the nature of vital signs measuring and of interactions with the patient.
How the presence of a EMR computer in the room often means a computer-driven interrogation of the patient with visual focus on the screen rather than the patient. As a nurse-patient, whom I know, said to her caregiver, "Hey, I'm the patient; I'm over here!"
When there is difficulty detecting the blood pressure, as in the "definition of insanity is doing the same thing repeatedly, expecting a different result," staff perseverate upon running it again, instead of substituting a manual blood pressure cuff.
Patients more often complain "the cuff is hurting me" especially when the machine struggles for a result (arrhythmia, positioning, movement, obesity) and over hours of rechecks develop bruising. There is a vast difference in comfort between older soft cloth cuffs, and newer cuffs of harder material that are disposable or are resistant-to-disinfecting-chemicals.
Pulses are no longer counted by palpation for quality of strength, regularity, equality. nor to assess skin. Instead, the pulse oximetry sensor is held out until the patient complies by inserting a finger (often without an offered explanation). This, of course, allows more time for mandated 'screening' questions that aren't yet pertinent.
How often now is an auscultatory gap in the Korotkoff's Sounds noted and reported, which may be important in accurately determining true systolic and diastolic pressures (gaps of 20-50 mm/Hg are not uncommonly found). Some staff do not even have their stethoscope ready to hand.
Some patients have a disparity in BP between arms (which can be a vital clue if there is dissection of the aortic arch). I recall a patient brought in by EMS on a Dopamine drip, who appeared "pink, warm, and dry" and appeared (as she was found to be) normotensive in her other arm ---which had not been checked before beginning a vasopressor. It was a known piece of her history which was forgotten in the excitement.
We take a lot on trust, nowadays. With the exclusion of Mercury from the clinical environment, there is no reference sphygmomanometer which can be trusted to respond only to the laws of physics, nor, likewise, a thermometer that is not subject to electrical faults. Think of the thermometers that you've used that needed their swinging coiled cord to be held "just so" in order to complete the reading. Even aneroid gauges can be out of whack, forcing a guessing game until it is recalibrated.
Don't get me wrong. I LOVE good equipment that is accurate, discerning and makes work easier, records things, and does the math on a lot of extra data and parameters. But the machine is to be my servant, not I to be its servant. The machine is to be a servant of the patient, and helper to me; it is to be a comforting and abiding guardian protector that does delegated tasks while I unite its data with my findings, diagnostic process, and tasks.
We must remember to build a relationship with our patient, and engage ourselves in the clinical observations and interactions that inform our decisions. Not one of these machines is human enough to glance at a person and decide "Something's wrong here! This person is 'BIG Sick!'" Nor, are they able to give a comforting and reassuring smile.
Tom Trimble, RN
All opinions are solely those of the author.
Readers must verify validity to their own practice.
BLOG – 2018-1