Beginning of an education

“Omigosh, you don’t have a pulse!!!” Sounds like something only a first year medical student would say to another living, breathing human being. At least I didn’t say it out loud. But that’s what was going through my mind when the blood pressure meter needle dropped down below 100mm of Hg without me having heard any sound. “That or I somehow just missed it… But that’s impossible because when I measured his blood pressure just 5 minutes ago, it was 170/100.” I continued deflating the cuff, but now my mind was occupied by feelings of insecurity. Measuring blood pressures was supposed to be the easiest skill we learn in medical school. If I couldn’t master the easiest skill, then the rest of my medical career was doomed. My thoughts were interrupted by the pulsations of Korotkoff sounds. There they were! As the cuff stopped squeezing the artery to open it just enough, the sound of blood rushing in. The needle was now sitting at 85 mm of Hg. They were loud, I knew I had missed the first, systolic measurement while I was wrapped up in my own thoughts. The patient was getting tired of standing up and I didn’t want re-inflate and subject him to my incompetence with the blood pressure meter again. Did I do something wrong? There was a drop of at least 70 mm of Hg between two measurements. What changed? The only difference was the patient was sitting before and now he was standing up.

At most US institutions, first year medical students are not involved in the direct patient care. We spend most of our time sitting in lectures, learning about the workings of a healthy body. However, a majority of the medical schools now also introduce the basic clinical skills of doing a history and physical in the first year. At my institution, we learn these skills in small groups, try them out on each other, and then practice these skills in the hospital on real patients, while being supervised by a fourth year medical student. This was the first of those sessions in the hospital. My fourth year medical student caught on to my puzzled look and helpfully explained the mystery. Upon standing up, the blood tended to pool to the legs and less blood goes to the heart, decreasing the blood pressure. The body normally has mechanisms to counter this, but in some people with heart disease or diabetes, that process gets interrupted, producing orthostatic hypotension, a large drop in blood pressure when changing posture from sitting to standing. Ha! So there is a reason to measure blood pressure in different positions of lying down, sitting, and standing up.

The knowledge I gained about a particular condition that day was important. But the lesson learned was much greater. I had expected the blood pressure to be in a certain range based on a previous measurement. When it wasn’t, I stopped listening and got wrapped up in my own insecurities instead of paying attention to what was going on. I had let a preconception guide me instead of the data. Today the patient’s care didn’t depend on my analysis and diagnosis, but someday it will.

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  • Legalese

    The purpose of this blog is to share interesting bits from around the web and beyond. All opinions expressed on this site are my own, unless credited to someone else. The images and artwork have also been created by me, unless credited to the sources. Oh! And please don't hold me liable for your actions resulting from any information on this site. As with everything else on the internet, read with the requisite amount of skepticism.
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