Tuesday morning arrived with a blustery cold wind that whipped one's hair and seemed to bore through one's coat. Gloves were a definite necessity. It was a typical late January brutal morning.

Those who drove had to find parking which was scarce and rather expensive. Plus, there was the need to start your car or truck about twenty minutes before, in order to warm up both the motor and the inside. I was so glad that I had decided to use the 45 minutes travel time on the subway and the buses. Sure, it meant three changes, but I was not exposed to the cold. I decided to go in early with the plan to drop my things off and go up the street to the store for some supplies. The school had large coffee and hot water urns, so I stocked up on coffee, tea, hot chocolate, sugar, sweetner, powder creamer, cups, stir sticks and napkins. No one would suffer the cold during class, at least not my students.

And I needed time to make some photocopies. I had organized my plan last night. Learning would be both beneficial and fun. I was determined.

By the time people started to drift in I instructed them to get a hot drink of their choice and at 0830 everyone was seated, ready to begin.

"Good morning, it's cold out there so I thought something warm was called for. Please feel free to quietly get refills at any time. Oh and for bathroom breaks, take them as needed, you do not need permission. It is all about respect, you get what you give."

A hand shot up followed by, "What about roll call?"

"Well, after yesterday, I know who you are and where you should be, so unless you mess with me I don't have to do roll call."

Smiles radiated across the room. Another hand. "I didn't notice a collection jar for the hot drinks? How are we to pay for our coffee?"

"It's free, just help yourself and enjoy. I believe that a warm body and a warm mind works better than being chilled. Now let's start reviewing again."

Way at the back, Ralph, my previous problem person raised his hand and when I acknowledged him, he stood. "I don't know if you saw all of us out there yesterday in the parking lot. But William and I shared what you said to us. And for everyone here today, we would like to say thank you. Especially for remembering that we are adults not children and for giving us a chance." He sat as the others clapped in agreement.

"Thank you, Ralph, thank you everyone. I promise I will push you, I will annoy you, most likely irritate you a lot but I will never let you give up on yourselves. Now on to reviewing."

Several hands were raised with questions. And in order to be fair I pointed to a person and assigned a number to indicate the sequence of questions. The first was from a pudgy-faced young man- in all fairness, all of them were young or at least under thirty. It was an interesting mix of male and female and cultures. An interesting thought crossed my mind and I scribbled a note for another day much later in the year long course.

"Mrs. Trenton had taught us about the heart and blood flow and how to take a pulse and blood pressure, can we review the pulse and blood pressure again? She said we would work on breathing and temperature this week."

"Great, who would like to discuss how to take a pulse, who other than Ralph?" I laughed.

Sallie volunteered and came up to the desk to use me as her patient / client. The class listened to her as she explained each step and then followed through with a partner next to them. It was a great review and relearning experience. I felt confident that pulse taking would not be a problem.

Michelle eagerly waved when I asked for a volunteer regarding taking a blood pressure reading. I had taken my stethoscope and sphygmomanometer or to the lay people a blood pressure cuff out of my drawer, along with alcohol swabs to clean the ear pieces.

She like Sallie explained each step using me as her patient. She discussed finding the brachial artery, the sounds that she was listening to- the lub dub, the difference between systolic and diastolic and how to record the reading. She was about to talk about the normal ranges when I asked her to hold that thought while the others practiced.

The BP cuffs, etc were retrieved from the storage cupboard and partners again set up to practice.

I instructed each pair to take each other's pressure, then switch partners and take the person in front of them. When asked there was a wide variety of numbers for readings. With the equipment cleaned and stored, it was time for our stretch break.

"Okay, let's talk about blood pressure for a wee while." This comment caused a few chuckles. "What you haven't heard about a wee while? It means a little more than a few minutes but not as much as an hour." More chuckles.

"Blood pressure is created by the blood pushing against the walls of the arteries when the heart pumps blood. High blood pressure or hypertension, occurs when this force is too high. Checking blood pressure readings is the same for children, teens, and adults. Using a gauge, stethoscope or electronic sensor, and a blood pressure cuff. The lub sound you hear is the systolic reading when the heart is pushing blood with a heart beat, the dub sound is the diastolic reading as the heart rests. Now what would you do if someone had big fat arms? Or you could not find the brachial pulse? Where is the brachial pulse?"

Puzzled looks were the response to the first two questions. I was making them think and problem solve. Slowly a hand was raised for the third question. I pointed and nodded.

"It is an artery on the inside of the arm in the elbow area, where they usually draw blood from for lab work."

"Great answer but what if you can't feel it? And again what happens if the person has a fat arm? Think about it, I know you are all able to come up with answers or at least questions about possibilities." I paused to give them time.

I saw the hints of light bulbs coming on, but I waited. I wanted them to develop what is referred to as critical thinking, which is really a new title for problem solving.
Two hands went up, "What about a bigger cuff?" asked one. "Do we have to do it on the upper arm?" asked the second.

"Yes, we could get a bigger cuff, if we had one but what happens if the patient refuses to have their fat arm squeezed? No, we don't have to do it on the upper arm. It is considered to be more accurate the way you are taught, but I like to cover the 'what ifs' just in case. Michelle can you come back up here?"

I instructed her to check my radial pulse and then to wrap the cuff around my arm just below the elbow. The stethoscope was placed over the radial pulse and she was able to distinguish the sounds. The cuff was inflated and slowly released. Breaths were held as she listened. Her smile grew broader as she obtained a reading. Cheers went up around the room.
It was time for lunch.