Vital Signs: Field Medicine in the Valley

1. Station A — Vital Signs. A community clinic day. Patients line up.
2. Station B — Suturing. A dairy hand kicked by a cow. Close the wound.
3. Station D — Neurological Assessment. A Hwy 33 collision victim arrives confused.
4. Triage Capstone. Six farmworkers down in 108° heat.
5. Station E — Careers. Where do you go from here?

• Sharps stay parked. Suture needles live in the foam block when not in your hand. Never pass needle hand-to-hand.
• Penlight in eyes: 1–2 seconds max. Never longer.
• Reflex hammer is a tool, not a toy. Tap the tendon, not the kneecap.
• Your partner is a patient. Treat them like one. Quiet voice, slow movements, explain what you're about to do.

You measure three vital signs on each patient: blood pressure, pulse oximetry, and heart rate. You interpret the results. You decide who needs follow-up care.

Three of these patients are stable. One is not. Your job is to figure out which.

Step 1: Blood Pressure. Watch the video, then pair up and try it. Sit quietly for 1 minute. Wrap the cuff snugly above the elbow. Press START. Record both numbers. Normal for a young adult is around 110–120 / 70–80.

Step 2: Pulse Oximetry. Clip the pulse ox onto your index finger. Wait 10 seconds for it to stabilize. Record the SpO₂ (should be 96–100%) and pulse rate (60–100 BPM resting).

Step 3: Stethoscope. Clean the earpieces with an alcohol wipe. Insert them angled forward (not straight in). Listen to the upper-left chest for LUB-DUB — that's your heart valves closing in sequence. Listen to the back for breath sounds: quiet, even.

Step 4: Run it on the four patients. Your facilitator will play the role of each patient one at a time. You collect all three vital signs on each one and record them in your Patient Notes.

Three of your patients had completely normal readings. One did not.

Manuel Silveira's vitals:

• BP: 132 / 84 — borderline high, not alarming on its own
• SpO₂: 94% — low (should be 96+)
• HR: 105 BPM — elevated at rest
• Temp: 100.4°F — low-grade fever

Three abnormalities on one patient. Combined with the two-month cough and the fact that he works outdoors with cattle in dusty dry conditions, this is a classic presentation of one thing.

Discuss in your pair:

1. Which of Manuel's three vital signs would have been the EASIEST to miss? Why?
2. If you only checked his BP and called him "borderline hypertensive," what would you have missed?
3. Why is "BP, pulse ox, HR" the standard first check on every patient in every ER, even when the patient says they feel fine?

Paramedics are the first medical professionals on the scene in emergencies. They assess vital signs, provide life-saving treatment, and transport patients to hospitals. Every skill you practiced here — BP, pulse ox, stethoscope — is what paramedics do on every shift. EMT certification takes ~150 hours of training (about 6 weeks full-time) and costs $1,000–2,000. Paramedic certification is 1,200–1,800 hours after that. EMT salary in California: $35–55K. Paramedic: $55–90K. Riggs Ambulance Service in Merced and American Ambulance in Modesto both hire local. Many ER doctors started as EMTs in high school.

The window to close this wound without infection: 6 hours. After that, the risk of bacteria settling in rises sharply. Learn the instruments. Master the technique. Close the wound.

Step 1: Learn the instruments. Hold the needle driver like a pen — your thumb and ring finger in the rings, index finger steadying the shaft. Grip the needle two-thirds from the tip. Hold the forceps like tweezers. Scissors with the blunt tips. These grips aren't about style — they're about control.

Step 2: Watch the technique.

Step 3: Banana practice. The skin of a banana feels surprisingly like human tissue and is forgiving. Make a small cut. Place 3 simple interrupted sutures. Needle enters at 90°. Pass through both edges. Pull until edges meet without bunching. Get the motion right before you move on.

Step 4: Suture pad. Move to the silicone pad — it feels more like real tissue resistance. Place 3 simple interrupted sutures on the pre-cut wound. Goal: edges meet, spacing even (about 5 mm apart), tension even (no blanching or bunching).

Step 5: The instrument tie. This is the hardest part. First throw — wrap counterclockwise around the needle driver, grab the short end, pull through. Second throw — wrap clockwise, grab, pull. That's a square knot. Practice until your hands know the motion without thinking.

Score yourself 1–5 on four criteria:

• Spacing — even, ~5 mm apart
• Depth — consistent across stitches
• Tension — edges meet without blanching the skin white
• Knot quality — flat and secure, not loose

Be honest. This is for your own improvement.

For José's case (the dairy worker): the attending physician would use 3-0 non-absorbable nylon — the forearm isn't a high-tension area, and the sutures will be removed in 5–7 days. Rule of thumb for stitch count: one stitch per 5 mm of wound length. A 4 cm wound needs ~8 stitches.

Treatment plan for José — fill in on your Patient Notes:

1. Suture size: __________ (hint: 3-0 nylon)
2. Number of stitches needed: __________
3. Tetanus booster needed? Yes / No (cow-kick + dirty environment — what do you think?)
4. Return for suture removal in: __________ days
5. Post-care instructions: keep clean, keep dry for 24 hours, watch for redness/swelling/discharge

Surgical physician assistants close incisions, manage wound care, and often perform the actual suturing while the attending surgeon moves to the next case. PA programs take 2–3 years after a bachelor's degree. Surgical PA salary: $110K–140K. Trauma surgeons do this under pressure — gunshot wounds, car accidents, falls — and make life-or-death decisions in seconds. Training: 4 years undergrad + 4 years medical school + 5–7 years surgery residency. Salary: $350K–500K. UC Davis and UCSF Fresno both run surgery residency programs that take Central Valley applicants.

Two bedside tests — taking less than 60 seconds combined — can reveal life-threatening conditions. PERRLA (the pupil exam) and the patellar reflex. You're going to perform both on your partner.

PERRLA = Pupils Equal, Round, Reactive to Light, Accommodation. Five separate things to check. Each one matters.

Step 1: Estimate pupil size. Sit facing your partner in good lighting. Use the pupil gauge card. Normal pupils are 2–4 mm in standard room light. Record both eyes.

Step 2: Light reactivity. Shine the penlight into the right eye from the side (not straight ahead). Hold 1–2 seconds. Watch the pupil constrict (shrink). Repeat for the left. Both pupils should react equally and briskly.

Step 3: Accommodation. Hold your finger 6 inches from your partner's nose. Have them focus on it, then slowly move it toward their nose. Both pupils should constrict as they focus on the closer object.

Step 4: Patellar reflex. Have your partner sit with legs dangling freely (feet off the ground). Place your non-dominant hand flat under the patellar tendon (just below the kneecap). With a smooth, quick wrist motion, tap the tendon with the reflex hammer. Watch for the quadriceps contraction and foot kick.

Grade the response: 0 (absent), 1+ (weak), 2+ (normal), 3+ (brisk), 4+ (hyperactive — concerning). Test both knees and compare. They should match.

You just performed two of the simplest tests in medicine. They can also reveal conditions that kill within hours if missed.

Back to Ana, the Hwy 33 collision patient. The trauma team performs PERRLA and the reflex test. Findings:

• Right pupil: 4 mm, reactive. Left pupil: 4 mm, reactive.
• Accommodation: normal both eyes.
• Right patellar reflex: 2+. Left patellar reflex: 2+.

All findings normal. Combined with her vital signs (also normal), the trauma team concludes Ana likely has a concussion — confusion is common, brain swelling is not yet apparent. She'll get a CT scan to confirm, and she'll be observed for 24 hours.

Discuss in your pair:

1. If Ana's right pupil had been 8 mm and non-reactive while the left was 4 mm and reactive — what would the trauma team have done differently?
2. Why do hospitals still teach the 60-second bedside neuro exam when CT scanners exist?

Neurologists diagnose and treat diseases of the brain, spinal cord, and nerves — stroke, epilepsy, Parkinson's, MS, Alzheimer's. Training: 4 years undergrad + 4 years medical school + 4 years neurology residency. Salary: $275–450K. Emergency medicine physicians rely on neurological exams every shift — they're the ones who decide who needs the CT scan, the surgery, the airlift. Training: same first 8 years, then 3–4 years EM residency. Salary: $300–450K. The exams you just performed are used dozens of times per shift in every ER in the world.

You'll use the START triage system with four colors:

• RED — Immediate. Life-threatening. Treat first.
• YELLOW — Delayed. Serious but stable. Treat second.
• GREEN — Minor. Walking wounded. Treat last.
• BLACK — Expectant. Beyond saving. Comfort care only.

Your six patients (presented one at a time at the front):

1. Carlos Mendoza, 22 — semi-conscious, mumbling. T 105°F. Skin hot and DRY (not sweating). HR 140, BP 90/60. Was working without a hat.
2. Lupe García, 38 — alert and oriented. T 102°F. Drenched in sweat. Severe muscle cramps in legs. HR 110, BP 110/70.
3. Beto Vargas, 45 — alert. T 103°F. Dizzy, nauseated. Sweating heavily. HR 105, BP 105/72.
4. María Rodríguez, 19 — alert, chatty. T 99.8°F. Mild headache. Has been drinking water all day. HR 88, BP 118/78.
5. Joaquín Díaz, 52 — unresponsive. No pulse. CPR started in the truck on the way in. T 106°F. Known cardiac history.
6. Antonio Reyes, 31 — alert. T 99°F. Tired and thirsty. HR 92, BP 120/80. Worked next to Carlos but stayed hydrated.

For each patient: vote on the tag color (RED, YELLOW, GREEN, or BLACK). One vote per pair. Your facilitator runs the simulator to reveal the answer + reasoning.

The two hardest calls in this scenario:

• Carlos vs. Joaquín — which gets the trauma bay first? Joaquín is in cardiac arrest and the team is doing CPR. Carlos has heat stroke (the dry skin is the giveaway — his body has stopped sweating, his core is cooking) and will die without immediate cooling. In mass casualty, you don't spend 20 minutes on CPR for one patient when 3 others can be saved. Joaquín gets a BLACK tag — comfort care. Carlos gets RED.
• Lupe vs. Beto — who's more urgent? Both are heat-exhausted YELLOW. Lupe's cramping suggests worse electrolyte loss; Beto's dizziness suggests near-fainting. They get the next two beds in whatever order they fit. The hardest tags in real triage are these "almost the same" calls.

ER triage nurses are the first clinician every patient sees. They combine vital signs, chief complaint, and instinct to assign priority — hundreds of decisions per shift. Training: 4 years of nursing school + 6–12 months of ER experience. Salary in California: $90–130K with experience. Modesto Junior College and Merced College both run nursing programs that feed directly into local hospitals. Memorial Hospital Los Banos and Mercy Medical Center Merced hire local. The job combines everything you did today: vitals, hands-on assessment, neuro exam, and triage decisions under pressure.

Read the four categories. Pick the ONE that sounds most like you:

On your 📋 Patient Notes packet — Station E page:

1. List your top 3 careers. They don't all have to be from the same category — a trauma surgeon is High-Stakes and needs Robotics/Tech precision. Pick three that pull at you.
2. For your #1 pick, write: salary range, years of education, one specific thing that appeals to you.
3. Plan one concrete next step you can take this semester. Be specific.

Five hours ago, none of you had taken a real blood pressure. None of you had thrown a suture. None of you had triaged a mass casualty. Now all of you have.

On your 📋 Patient Notes packet, finish these three:

1. The skill that surprised me most today was…
2. One thing I'm going to do this semester because of today:
3. One word that describes today:

Then share your one word with the room. Every student. Just one word.