Part 1: Vitals and Venipuncture
A 45 year old man walks into the ER dizzy, with chest tightness and a tingling arm. He is your patient. Today you and your partner take real vital signs, read them like a clinician, and make your first call as a team. Everything you find goes in your Casebook, the packet in front of you, and Marco's case comes back all four days. First stop: meet Marco.
You work in pairs today. Run each skill on your partner, then switch so both of you measure. Write every reading in your Casebook, because clinicians write everything down. A few habits keep everyone safe and comfortable:
- Treat your partner like a patient. Quiet voice, gentle hands, and tell them what you are about to do before you do it.
- Go easy with the penlight. A quick 1 to 2 seconds is all you need.
- The reflex hammer taps the tendon just below the kneecap, not the kneecap itself.
- Blood stays in the training arm. The venipuncture station uses a simulated arm, and your facilitator works it right alongside you.
You are Marco's medical team. Before you touch a single instrument, you need to know his story.
- What concerns you most about Marco, and why?
- If you were the ER team, what would you check first?
- What does his family history tell you?
Vital signs are the first language of a clinician. A handful of numbers tell you in sixty seconds whether a patient is stable or crashing. Run each skill on your partner, then read the results like a doctor.
High blood pressure could explain Marco's dizziness and chest tightness, and it is the number one risk factor for a heart attack. There are two ways to measure it. Learn both, then pick the one you trust.
- Resting BP. Wrap the cuff snug on your partner's bare upper arm, just above the elbow. Sit still and quiet. Take a reading with each tool and record both. Within 5 mmHg is excellent. More than 10 apart, recheck your technique.
- Stress BP. Do 2 minutes of jumping jacks, then measure again right away.
- Recovery BP. Wait 3 minutes, measure once more. Coming back near resting quickly is a sign of a fit heart. Switch roles and repeat.
Elevated: 120 to 129 and under 80
Stage 1 High: 130 to 139, or 80 to 89
Stage 2 High: 140 or higher, or 90 or higher
Crisis, call 911: 180 or higher, and or 120 or higher
Low oxygen can cause dizziness. This checks whether Marco's blood is carrying enough oxygen to his brain.
Clip the sensor on your index finger. Wait about 10 seconds for a stable number. Record SpO2 and pulse. Try a different finger, does it change?
Keep the sensor on and record your resting numbers. Now take 5 to 10 slow, deep breaths and read again. Your oxygen probably barely moves, but watch your heart rate as you slow down and relax. Record before and after, then switch with your partner.
Marco's chest tightness could be his heart or his lungs. The stethoscope lets you listen to both.
- Heart. Clean the earpieces with a wipe. Point the tips forward, toward your nose. Place the flat side on the upper left chest. Listen for the LUB DUB.
- Lungs. Listen at the front, both sides, then the back, both sides. You should hear quiet, even breathing. Note what you hear at each spot. Switch and repeat.
Tingling and dizziness can mean the brain and nerves are not communicating well. PERRLA means Pupils Equal, Round, Reactive to Light, and Accommodation.
- Size. In normal room light, are both pupils the same size? Use the pupil gauge printed on your penlight. Normal is 2 to 4 mm. Record both eyes.
- Light. Dim the lights. Shine the penlight into one eye from the side and watch both pupils shrink together. Repeat on the other eye.
- Accommodation. Hold a finger 30 cm from your partner's face. Have them look at your finger, then a distant object. Both pupils should change together.
- Patellar reflex. Partner sits with legs hanging free. Tap gently just below the kneecap. Test both knees. Grade each one: 0 absent, 1 weak, 2 normal, 3 brisk, 4 hyperactive.
Your knee jerk fires in about 50 milliseconds, faster than a blink. The signal never reaches your brain. It loops through the spinal cord and back. That is why reflex testing is one of the fastest ways to check spinal cord health.
A thermometer reads core body temperature. Normal is about 98.6 F, and anywhere from 97 to 99 F is fine. A reading above 100.4 F is a fever, a common sign the body is fighting an infection. Take your partner's temperature and record it on your Casebook.
Marco's doctor flagged high blood sugar. A glucose meter reads blood sugar from a tiny finger prick. This station is optional and always supervised. If your program is not doing finger pricks, your facilitator demonstrates it and you record the sample value shown.
When bloodwork is ordered, a phlebotomist draws from a vein. There are two training arms, and pairs rotate through them with your facilitator. Each arm has artificial veins filled with simulated blood and a practice syringe for the draw. No needle ever touches a person.
Feel for the vein, a soft bouncy tube in the inner elbow. Tourniquet above the site. Wipe with alcohol. Insert at a 15 to 30 degree angle, bevel up. Your facilitator guides each step.
Raw numbers do not help a patient. You have to figure out what they mean by comparing them to normal. Your Casebook has a comparison table, one row per vital sign, with a column for your reading, the normal range, and whether it lands inside or outside.
Complete the comparison table on your Casebook. As you go, mark where normal ends and danger begins. That boundary is where clinical judgment lives.
- Which of your readings landed outside the normal range?
- What could cause an abnormal reading like that?
- Look at your BP before and after the jumping jacks. What happened, and what does a fast recovery tell you about the heart?
You practiced on each other. Here are the actual numbers from Marco's ER visit. See if your instincts were right.
Heart rate 92 BPM (normal 60 to 100)
SpO2 96 percent (normal 95 to 100)
Fasting glucose 118 mg/dL (normal 70 to 99, prediabetic 100 to 125)
Pupils equal and reactive
Reflexes normal, both sides
- Compare Marco's BP to the chart in Station A. What category is he in?
- Which of his vitals worry you most, and why?
- Pull it all together: his symptoms, his history, his smoking, and these numbers. What do you think is going on, and what should happen next?
Two more patients arrive at once. Classify each one against the chart from Station A, then decide who you would see first.
Patient C: BP 88/54, HR 124, SpO2 90 percent, temperature 102.5 F, confused and sweaty.
Which patient is more critical right now, and which exact readings told you? Write your call on your Casebook.
- What surprised you most today?
- Which skill was hardest, and what made it difficult?
- If you were Marco, what would you want your medical team to do next?
Every skill you used today is somebody's job, and most of these start right here in the Central Valley. Watch a paramedic's shift, then talk careers with your partner.
Valley first step: Fresno City College EMT, one summer or one semester, then the Fresno County Paramedic Program.
Pay, roughly: EMT around $46K to start, paramedics and fire based roles past $70K.
Valley first step: a short phlebotomy certificate around Fresno, often just a few weeks. Many use it as a step into nursing.
Pay, roughly: around $45K.
Valley first step: Fresno City College Respiratory Care, a two year degree that works ICUs and ERs.
Pay, roughly: around $100K and up in California.
Valley first step: Fresno City College nursing, then a BSN at Fresno State if you want to specialize.
Pay, roughly: around $120K and up in California.
Valley first step: a short certificate, then hospitals across Fresno like Community Regional Medical Center.
Pay, roughly: around $40K to $50K.
Valley first step: a bachelor's, then medical or PA school. Central Valley doctors train at UCSF Fresno, and there is a California Medicine Scholars path that starts at community college.
Pay, roughly: PA around $130K and up, physician $200K and up.
Pick the two careers that surprise you or that you would want to learn more about. Which one could you start the fastest? Write one step you could take while you are still in high school, then share one with the class.
You walked in this morning having never taken a blood pressure. You leave having run a full patient assessment with your partner and made a real clinical call. Tomorrow you go inside the heart.