eMedinewS Editorial

Health Care 13 Comments

Measuring blood pressure (Part 1)

Measuring BP is an expert’s job. It’s not the job of quacks, paramedics or the patients to learn it as they invariably will default. Most often doctors default on this very essential part of examination. Accurate measurement of blood pressure (BP) is important not only to diagnose but treat high BP as well.

Even 2-5 mm variation can make a difference in the treatment. A 5 mm reduction in BP can reduce chances of heart attack by 21%.

Today, I discuss the significant aspects of this very basic but crucial technique of measuring blood pressure, which may be a revision for most of us.

  1. Correct measurement and interpretation of BP is essential.
  2. Proper machine calibration, training of personnel, positioning of patient, and selection of cuff size are essential.
  3. Most doctors do not follow correct steps leading to potential errors in diagnosis and management.
  4. Time of measurement: To diagnose high BP, multiple readings should be taken at various times throughout the waking hours. To monitor treatment, BP should be measured before anti BP drugs are taken. If BP is measured soon after a drug has been taken, it may be normal or even below normal; it will gradually increase to potentially hypertensive levels until the next dose is taken.
  5. Factors that influence BP, such as food intake, strenuous exercise (can lower the BP), smoking and caffeine, should be avoided in the 60 minutes prior to evaluation.
  6. Smoking transiently raises the BP. One may underestimate BP in a heavy smoker who has not smoked for more than 30 minutes before the BP is measured.
  7. Caffeine intake can raise the BP acutely in non habitual coffee drinkers.
  8. Measuring BP in a cool room (12ºC or 54ºF) or while the patient is talking can raise the BP value by 8 to 15 mm Hg.
  9. Type of BP instrument: Mercury sphygmomanometers are the most accurate. Aneroid instruments should be checked against a mercury device since the air gauge may be in error.
  10. Automated oscillometric BP measuring devices are now available. The readings are typically lower than BP obtained with the auscultatory method. The oscillometric method has a somewhat greater inherent error and requires a proper AC atmosphere. Proper timing, patient positioning, cuff size and placement are still necessary, as is evaluation of machine accuracy at periodic intervals.
  11. Cuff size: Use of a proper-sized cuff is essential. If too small a cuff is used, the pressure generated by inflating the cuff may not be fully transmitted to the brachial artery; in this setting, the pressure in the cuff may be considerably higher than the intra arterial pressure, which can lead to overestimation of the upper systolic pressure by as much as 10 to 50 mm Hg in obese patients.
  12. The length of the BP cuff bladder should be 80 %, and the width at least 40 % (46%) of the circumference of the upper arm. This is often difficult to achieve in obese patients.
  13. Appropriate cuff size for a designated arm circumference
    • Arm circumference 22 to 26 cm: ’small adult’ cuff, 12 x 22 cm
    • Arm circumference 27 to 34 cm: ‘adult’ cuff, 16 x 30 cm
    • Arm circumference 35 to 44 cm: ‘large adult’ cuff, 16 x 36 cm
    • Arm circumference 45 to 52 cm: ‘adult thigh’ cuff, 16 x 42 cm
  14. A lack of manufacturing standards also results in designated cuffs differing by several cm in both width and length depending on the manufacturer.
  15. Pseudohypertension: This is a condition of falsely elevated BP and is found in patients with stiff vessels due to marked arterial calcification. Here, compression of the brachial artery requires a cuff pressure greater than systolic. Pseudohypertension is characterized by systolic upper and diastolic lower pressures estimated from the sphygmomanometer that are ≥10 mm Hg above the directly measured intra arterial or oscillometric pressure.
  16. Patient position: The BP should be taken in the sitting position with the back supported. Supine values are different, with the systolic pressure higher by 2 to 3 mmHg and the diastolic pressure lower by a similar degree.
  17. In the elderly, supine and standing measurements should always be taken to detect postural hypotension (fall of BP on standing).
  18. The arm should be supported at the level of the heart.
  19. Allowing the arm to hang down when the patient is sitting or standing will result in the brachial artery being 15 cm below the heart. As a result, the measured BP will be elevated by 10 to 12 mm Hg due to the added hydrostatic pressure induced by gravity. The opposite is true if the arm is above the level of the heart.
  20. The mercury manometer should be visible but does not have to be at the level of the heart.
  21. The patient should sit quietly for five minutes before the BP is measured.

Dr KK Aggarwal
Editor in Chief

eMedinewS Editorial

Health Care 474 Comments

Can a pediatrician expected to treat an adult?

A private doctor was fined ‘3 lakhs for not attending to Mr. K.L. Guliyani, a Kargil fighter. The details of the cases were covered in national newspapers in front page or in the local city page. I remember, the case which happened when I was the President Elect of Delhi Medical Association and also I was a part of the DMC team which investigated the matter of Orchid Hospital.

As per the reports, Mr. Guliyani who was traveling in a DTC bus was robbed and stabbed by some pickpockets in Janakpuri just opposite the clinic of Dr. Manocha. He was bleeding profusely. Dr. Manocha is a consultant pediatrician. As per the newspaper reports, the bleeding patient was brought to his clinic by passerby. About 50 meters away from Dr. Manocha’s clinic is Orchid Hospital which has got indoor facilities. Dr. Manocha did not have any of these indoor facilities in his clinic and asked them to take the patient to the nearest Orchid hospital. When they (patient) reached the Orchid hospital, he was declared ‘brought in dead”.

We all understand the Supreme Court guidelines that every serious patient must be rendered medical help to save his life, but there are many points which this case raises:

  1. Consumer Rights starts once the patient pays for his or her services. In this case, no fee was paid to the doctor but still the case went to the Consumer Court.
  2. Is a private pediatrician consultant is expected and / qualified  to attend to adult cases in emergency? Are they required to remember how to treat adult patients?
  3. What is wrong if Dr. Manocha had asked to take the patient to the nearest nursing home/hospital which is only 50 meters away from his clinic as there was no way Dr. Manocha could have given any service to an adult patient in his clinic. If he would have attended the patient in his clinic, it would have been a waste of time. In that case, if the patient would have died, allegations would have been that why he was not shifted to the nearest hospital when the Doctor was not qualified to look after the adults.
  4. A patient who died within minutes could have died in his clinic also. There is nothing doctor can do without indoor facilities and emergency equipment facilities.
  5. The only thing a doctor can offer is CPR which is usually not effective in road accident cases or in case of stab injuries. CPR is only effective if a patient dies of heart attack.
  6. The patient who was profusely bleeding required immediate IV fluid and blood transfusion the facility of which can only be provided in a hospital setting.

At the most, it can be a case of ‘error of judgment’ as the pediatrician thought at that moment that it was safer to send him to Orchid Hospital and did not attempt to treat him in his own clinic. I think, this is one matter IMA should look into and fight for doctor’s case and appeal to the High Court.

(With inputs from Dr. R.S. Bajaj, the Consultant Pediatrician, Rohini)

Dr KK Aggarwal
Editor in Chief

eMedinewS Editorial

Health Care 40 Comments

Sawan Ka Mahina Pawan Kare Sor

This was a famous song in the movie Milan which has a lot of health implications. During Sawan, air both in the body as well as in the atmosphere gets vitiated leading to storm of rains, high tides in the ocean and movement related disorders in the body. Ayurveda describes them as VATA disorders and homeopathy describes them as Psora disorders. In allopathy, in terms of physical health, it represents dyspepsia, gases, dystensia, constipation, tachycardia, accelerated hypertension etc. and in terms of mind, it represents instability of mind, irritableness, anger and unsteady mind. This is one reason why in Sawan, auspicious functions are not held, including marriage as a marriage requires lot of cooperation, mental understanding and a steady mind.

The mind is more unstable during Sawan is also depicted by the festival Guru Purnima which also falls in Sawan month. It indicates that during Sawan, one requires supervision to tame the mind.

The Nag panchami also falls around this season. Nag is a symbolic representation of ego and Nag puja indicates again taming the mind and controlling the ego.

Leafy vegetables are not allowed to be eaten during this month as they precipitate Airy disorders. It is also during this month that leafy vegetables contain more worms and their eggs and are unhygienic to ea especially in a community food serving.

Another filmy song Mere Naina Sawan Bhadon Phir Bhi Mera Man Pyasa depicts the unstable state of mind during Sawan.

Sawan is also the month where on every Monday Lord Shiva is worshipped. Lord Shiva represents ability to wind up jobs. The unstable mind in Sawan month does not allow one to take decisive actions. Shiv ki pooja represents that it takes efforts to wind up jobs in Sawan month.

During Sawan month, Lord Vishnu is also seen lying under a Sheshnag in an ocean in an open eye meditative pose. The ocean represents the disturbed state of mind, Sheshnag indicates the need to control the ego and meditative pose of Vishnu represents the need to do pranayama and meditation in this season and also it indicates that it is very easy to get dissociated from your consciousness in this month as the ego gets easily activated during this period.

Dr KK Aggarwal
Editor in Chief

« Previous Entries Next Entries »