Trail-side Pulse Check: The Fingers as Medical Tools

It's no surprise that the saying of having one's "finger on the pulse," is used to describe someone that knows what's going on. A person's pulse can provide a wealth of information. 

Taking a pulse (including your own), is pretty simple, but a little practice will make you more confident if you ever come across someone who may not have one. 

I just learned that people have been assessing pulses for thousands of years: 

It is undisputed that the ancient Egyptians were the first to describe the relationship between heartbeat and peripheral pulse. They counted the pulse during palpation. It was counted with the aid of an earthenware vessel that acted as a clock. This vessel had a tiny hole at the bottom, allowing the water to drip, drop by drop. The pulse rate was determined by correlating it with the drops of water escaping from the vessel. The markings on the side of the bowl divide the day into 24 increments, each increment representing 1 h.

With various methods also described in Chinese, Greek, and Indian historical texts. 

Now, thousands of years later, we have a multitude of ways of assessing a person, but a pulse is still very informative. 

In a hospital setting, we obviously have monitors and other digital tools that can give real time information on the rate, rhythm and quality of a person's pulse, but a physical hand over an artery is still quite telling. 

I think most people know what a pulse is, but let's review just to cover some basics. When the heart beats, it does so in a rhythmic fashion and in a manner that forces blood first from the upper chambers (atria) into the lower chambers (ventricles). Then, valves close, and blood is pumped from the ventricles out to the body, blood from the right ventricle goes to the lungs so that blood is oxygenated, and blood from the left ventricle pushes oxygen rich blood out through the aorta to the tissue that needs it, from the top of your head to your big toe. 

The sound that we listen to with a stethoscope is the sounds of the valves closing.

Anyway, I mentioned that the heart should be beating rhythmically, and it can have a regular or irregular rhythm.

• beat....beat....beat....beat....beat....beat....beat....beat.... (regular)
• beat..beat......beat..beat......beat..beat....beat..beat...... (irregular)
• beat.beat.beat.............beat.beat.beat.beat.beat......... (irregularly irregular)

Think of the three version as one being totally like a metronome, one having a distinct pattern, and one being chaotic.

Distinguishing these solely on the basis of a pulse can be a bit of a challenge, and it's not ever going to be expected that you'd be making a call on a heart rhythm solely on the way a pulse feels, I bring these up only a things to think about if you're practicing on your or someone else's pulse. 

Another characteristic of a pulse is whether or not it feels strong or weak and that can help with the other big piece of information that a pulse gives you: how is the blood pressure?

There are two ways to look at blood pressure, one is from the perspective of a person's health over his or her life, and the other is from the perspective an emergency situation. 

Knowing that heart disease is still the number one cause of death in the US, and that high blood pressure is a leading cause of heart disease, it makes perfect sense that most people are very keen to worry about elevated blood pressure. But, for many emergency situations, a moderately high blood pressure will not even get a second glance. In the emergency department, we routinely see blood pressures with the "top number" (systolic) of 160, 170, 180, 190, 200 and do nothing about it. An elevated blood pressure--at a moment in time--can simply be a body's response to pain or stress or any number of other factors, and really just needs to be watched over time, We usually worry about blood pressures that are too low, and most emergency medicine providers will be more concerned about 90/60 than 190/60...

This brings me to what a pulse really is, and that's the effect of the heart pushing blood out of the left ventricle and that blood exerting pressure against the walls of the arteries. 

If a pulse feels weak, that suggests that someone's blood pressure is low and could be on the verge of passing out. 

I'll talk about the reasons that a person might pass out another time, but for now let's just focus on taking  pulse. 

There are many places on the body where a pulse can be checked, from the feet (dorsalis pedis) to the neck (carotid), but I think the easiest way is in the wrist (radial). 

Place two fingers (index and middle finger) along the wrist on the side of the thumb. You'll feel a bit of a notch between the bone and some tendons. Don't use your thumb as there's a faint pulse of its own that will confuse the feelings (although this may just be a myth). Once you feel the beating, you can use a watch to time 15 seconds while you count the beats. Multiply times four, and boom, you have beats per minute! 

If you have a smart watch or other heart rate monitor (on you, while practicing), check your number with the number your device gets. 

It's great if the person that you're checking the pulse on is wearing a smart watch, but you may or may not be able to quickly navigate to that feature, and for me, it would be easier just to grab the wrist. 

If you don't have a way to check the time while you're taking a pulse (I personally can't look at a watch and count beats at the same time), you can just make a judgement of "this feels too fast," or "this feels weak." That's good information to start with. 

We (healthcare providers) had been taught that the presence of a radial pulse meant that the blood pressure was likely at least 80mmHg, but this has been scrutinized and felt to be largely untrue.

While the radial pulse is, in my opinion, the easiest to find, CPR guidelines recommend checking the carotid (neck) pulse, but studies have shown that it's not easy, and may be more difficult in a stressful situation. The difficulty in checking a carotid pulse has been recognized: Time spent attempting to confirm the presence or absence of a carotid pulse by lay rescuers may significantly delay the initiation of cardiac compressions. Therefore, lay rescuers should start CPR once the victim is not responding and not breathing normally.

Still, checking a carotid pulse is something that you can easily practice on yourself by placing your fingers between the trachea and the vertically oriented muscle in the front/side of your neck (sternocleidomastoid muscle).

As you can see from this image, the artery is relatively easy to find if the person has no skin, but let's face it, if the person has no skin, there are probably going to be some major problems going on. 

I left my skin on for this photo, and this video covers the basics pretty well. 

This was a bit longer than I expected when I decided to do a quick review on checking a pulse and I don't even like that many beans. 

 I'll leave you with this:

My doctor said there’s something very strange about my pulse

I asked him what, but he couldn’t put his finger on it.

 

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