Posted by: notdeaddinosaur | September 12, 2010

Orthostatic Vital Signs: Much Ado

Dr. Bob Centor has inadvertently started a cute little brouhaha over the measurement of orthostatic vital signs (pulse and blood pressures on the same patient taken while standing, sitting, and lying supine) that Happy the Hospitalist has eagerly jumped into. As usual, Dr. Bob is right, and Happy goes off like an idiot. (Dr. RW’s comments in support of Dr. Centor are spot on, also as usual.)

There are two different issues being discussed that are being incorrectly conflated:

  1. The value of orthostatic vital sign measuresments, and
  2. Who should be doing them, nurses or doctors.

Let me begin by saying that I have no dog in this fight, because the entire discussion is moot to my practice. Ever since my last medical assistant threw a hissy fit and walked out several years ago, I’ve been doing it all. Weighing and measuring patients, doing EKGs, drawing blood (plus spinning it, completing requisitions, and packaging specimens for lab pickup), as well as all vital signs. In my office, there is no such thing as “nurse’s work”. I do everything.

Measurement of vital signs is part of the evaluation of the patient. Delegating the task to non-physicians does not change this fact. I agree that in many settings, it is efficient and appropriate for nurses and others to perform many patient evaluation functions, including so-called routine vital signs. But a physician should never feel it is “beneath him” to do them. There is also a fine line between so-called “routine” patient evaluation maneuvers, as many consider vital signs to be, and, say, the more subtle procedures that constitute the physical exam. For example, nurses often assess for the presence or absence of bowel sounds, but few of them have the training or skill to detect shifting dullness or a fluid wave. I suspect Dr. Centor would be equally dismayed to see “abdominal exam” relegated to the status of an admission order.

I rarely do orthostatic vital signs, just as I don’t often check for shifting dullness. I reserve them and other specialized maneuvers for appropriate clinical scenarios. To do otherwise would not be an efficient use of my time. Specificity and sensitivity of orthostatic findings in syncope patients is an interesting discussion, just as whether or not the finding of a fluid wave can quantify ascites. The issue is that of tailoring our evaluation to the clinical presentation. (Perhaps this was Dr. Centor’s lament?) I’m sure many people, like Happy, no longer bother with abdominal exams (we already know he doesn’t do rectals or pelvics; I wonder if he bothers with the neuro exam before the brain MRI?), because everyone’s getting a CT anyway. I agree with Dr. RW that this attrition constitutes dumbing down of clinical medicine, and I strongly agree with Dr. Bob that the physical examination is not scut work, regardless of how many of his commenters feel otherwise.

If you as the physician feel that measurement of orthostatic vital signs will add to your assessment of the patient, you should be performing them yourself.

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Responses

  1. Thank you for your insightful commentary. I hope you are having a wonderful day. God Bless You.

  2. Happy doesn’t believe in bagging patients either. He’d rather walk calmly down the hall and inform the nurse that the patient in Room 403 isn’t breathing.

    Some things he says I totally agree with. Those things are usually outweighed by the other 95% of his positions that leave me scratching my head.

  3. Just so you’re aware, nurses are trained to detect fluid waves–especially critical care nurses and those in the ER.

  4. @Guitargirl:

    Just because nurses are trained to do certain things doesn’t mean doctors aren’t supposed to. Patient assessment is not an either/or MD/RN function.

    Respiratory therapists are also trained to listen to lung sounds. That doesn’t make it appropriate for residents to write orders for them to do it in lieu of learning it themselves.

  5. My paramedic students are trained to assess for fluid waves, and to a greater extent, heart and lung sounds.

    However, many paramedics are not, and I’ve had to explain myself on such things to more than one ER nurse.

    Education is still highly variable, which just drives home Dino’s and Dr. Centor’s point – doctors need to be willing to do it themselves, even if they trust the skills of the nurse or paramedic who assessed it first.

  6. I am sorry to hear about your assistant. However hissy fits are pitched not thrown. Perhaps he/she had a tantrum instead? Although, as some years have passed and you seem to have a vivid recollection it probably was indeed a hissy fit as they do tend to be memorable.

  7. Why are you being mean to Happy?

  8. Anon 1216…Happy is, sadly, well known for being a self reported prick and a not-very-good doctor.

    He manages to alienate just about everyone in health care~fellow physicians, allied health folks (lab, radiology) and nurses~with a subtle blend of hubris, cluelessness, and total self absorption.

    He is totally convinced that his fecal material is without odor.

    And he goes on and on about his dogs ad nauseum. Yet I continue to read for the amusement and the comments!

  9. Hi Pattie, RN. God Bless you and the kindness in your heart for helping others.

  10. Patti,

    From what I can tell Happy loves you and the Dino and works hard to take care of his patients in an evidence-based, systems-based (ie. each person in the system has their role to fill in order for the whole system to function) and you and the Dino are just being bullies.

  11. HH: “God Bless you and the kindness in your heart for helping others.”

    Anon: “From what I can tell Happy loves you and the Dino…”

    Yeah, Anon; sarcasm doesn’t come always come across too well on the web.

  12. […] back-and-forth, on Sept. 13 the some­what anony­mous author of Mus­ings of a Dinosaur sum­ma­rized the matter: There are two dif­fer­ent issues being dis­cussed that are being incor­rectly […]

  13. Did someone miss the part where I am still reading Happy? His numerous sponsers should be thrilled about that part, at least!

    And yea, Dino and I are just great big bullies picking on the poor young doctor….mostly by quoting him! The things a couple of chubby middle aged health care professionals can due with a few keystrokes is overwhelming, isn’t it? As we say in the south, if you can’t run with the big dogs stay on the porch. You don’t want your life examined and commented upon? Don’t have a blog highlighting everything you do, say, and think.

    And Happy/ Anon (one in the same, methinks?)…we are helping you. Your interpersonal skills need some serious work. You have mastered the technical aspects of being a doc…now let’s get some of those “soft skills” polished up.

    It is insightful to see what happens when brilliance and skill is mixed with a total inablility to relate to patients and coworkers. Is there a cut-off age for Aspergers? Really, man….you are so SMART in many ways…but are you smart enough to recognise that you have to live and work with other human beings??

  14. (that was “do”, not “due” above. Mea culpa)

    Dino-sorry to perpetuate the hijacking of this excellent thread…

  15. “Brilliance and skill?” Happy has the bedside manner of a rattlesnake with shingles. That precludes brilliance and skill.

    If you can’t figure out that your personality turns people of faster than Oprah ina peek-a-boo thing, you’re not brilliant.

    If you can’t effectively relate to your patients on any level whatsoever (prissy purse dogs aside), you lack skill.

    Happy’s skillset seems to be primarily mixing vinegar and water for His Majesty’s daily douche cocktail.

  16. OK, ya’ll, trying to be nice. Happy is NOT stupid, except in the Idiot Savant definition. Pretty good at numbers and all that Vulcan stuff…

    But gosh darn-it, we all have these pesky humans around us to deal with every day.

    If only mere mortals could discern the superiority of Dr. Happy in all things seen and unseen. Be reasonable…do it HID way.

    And HAPPY? PLEASE save us the” blessings”…..we really can discern a veiled “F-off and Die” comment, no matter how sugar coated.

    Try, just TRY to understand all of us inferior beings….maybe that way you can accept your child as a flawed but special human…..like everyone except you.

  17. Geez, Patti! You seem to put a lot of thought and energy into hating Happy. Maybe you should take your own advice and:

    “Try, just TRY to understand all of us inferior beings….maybe that way you can accept your child as a flawed but special human…..like everyone except you.”

    God bless you.

    PS. I am not Happy.

  18. I was doing a little bit of reading on orthostatic vitals, part of case study homework, and I stumbled on this. I just wanted to say, the commentary here is very eye-opening. 🙂


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