We Never Looked

Over at 9-ECHO-1 is a post from which I stole the title of this post. We Never Looked.

I do not think that it is important for the vital signs to be a part of the radio report, unless they are unusual in some way, or relevant to the presentation. I am not encouraging the use of Within Normal Limits to describe assessment findings. A much more appropriate term would be Unremarkable. Something that can be expressed by just not remarking on them.

How can we legitimately suggest that we have an understanding of what the limits of normal are for a particular patient? What is a normal heart rate, or blood pressure, for one patient may be an unstable heart rate, or blood pressure, for another patient, even though it falls into the WNL range of numbers.

Vital signs are just a part of a thorough patient assessment. Not even the most important part. If I assess the pulse of a patient as zero/unobtainable, do I progress to the blood pressure? Or is it more important to assess responsiveness?

Think. Think. Think.

The only reason to assess the blood pressure is if there is some sign of life. Some sign of responsiveness is one of the primary indications that an unobtainable pulse is not an accurate sign of vitality (life).

If vital signs are not even reliable in determining if the patient is alive, how important are they? I have had about a half dozen patients with no palpable pulse, even though these patients were awake and alert.

The reason we focus on vital signs appears to be that there are boxes to be filled out on the chart. If the boxes are not filled out, then the QA/QI/CYA people becomes apoplectic. Not because documented vital signs are important, but because QA/QI/CYA people seem to be afflicted with the curse of Kelvin.^[1]

Just because the information can be presented in numbers, as vital signs are, does not mean that the information is important, relevant, or even truly objective. Among other things, the documented pulse depends on the fingers palpating it. Among other things, the documented blood pressure depends on the ears auscultating it. Among other things, the documented respiratory rate depends on the eyes watching it. Is machine measurement of these vital signs any more accurate by decreasing human involvement?

Assigning something a number does not make that thing objective. We assess pain by asking the patient to assign a number to his/her level of pain, but that does not make it objective. There is no way to make the pain score objective, yet it is often referred to as The Fifth Vital Sign.^[2] The other vital signs depend on the person assessing them. The vital signs are no more objective than any other assessment.

Vital signs are secondary to the rest of a thorough physical exam. Vital signs are only a part of a thorough physical exam.

We assign too much importance to the vital signs. If we minimize the importance of the rest of the physical assessment, is it any wonder that medical directors demand that we assess the damage to a vehicle, rather than that we assess the actual patient?

Rather than We Never Looked, I think that WNL indicates that We Never Learned.


Footnotes:


^ ¹ William Thomson, 1st Baron Kelvin, Lord Kelvin
Wikiquote page

I often say that when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.

Lecture on "Electrical Units of Measurement" (3 May 1883), published in Popular Lectures Vol. I, p. 73; quoted in Encyclopaedia of Occupational Health and Safety (1998) by Jeanne Mager Stellman, p. 1973

^ ² Vital Signs - Fifth Sign
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