METHODS

A Simple Teaching Device for Examination of theArterial and Venous Pulse

ARTHUR KREITENBERG, MD, JOEL S . KARLINER, MD, ROBERT L. ENGLER, MD, and

E. ROGER MARCHAND, PhD

A simple teaching device is described for exami-nation of the cervical arterial and venous pulses . Itis a mechanical device that simultaneously gener-ates a visible jugular venous pulsation and a pal-pable carotid arterial pulsation to train medicalstudents, physicians, and paramedical personnel .Changing of cams allows the observer to appreciatethese pulsations in the normal or in a variety of ab-

As part of the physical examination, study of the vesselsof the neck may yield a great deal of information . Thepulsations of these vessels are the most proximal su-perficial indicators of the state of the heart and vascularsystem .' 6 Assessment of these pulsations is a usual partof a thorough cardiovascular physical examination . Theimportance and value of properly identifying and in-terpreting pulsations of the neck veins and arteries hasbeen recognized since at least the year 200 AD . 3 Inpresent-day intensive care units pressures and waveforms are often measured directly by insertion ofcatheters attached to the transducers . In these days ofmedical cost containment, it is increasingly importantthat the physician be able to assess, screen, and diagnoseas accurately as possible the condition of the heart at thebedside using only his or her own eyes, ears, andhands .

The variations of normal and the spectrum of ab-normal pulsations are subtle and best perceived only bythe experienced clinician . Traditionally, this experiencehas been derived exclusively from patient contact andexamination requiring many years of training . The de-vice is intended as an adjunct to this training . The de-

From the Division of Cardiology, Department of Medicine and the Officeof Learning Resources, Veterans Administration Hospital : and from theSchool of Medicine. University of California at San Diego, La Jolla,California . Manuscript received May 10, 1982, accepted June 10,1982 .

Address for reprints : Office of Learning Resources, School of Med-icine, University of Califonia at San Diego, La Jolla, California92093,

normal states. Graphic tracings of wave formsdemonstrate the accuracy of reproduction ofphysiologic tracings . In a test of the device, cardi-ologists performed significantly better than medicalstudents in the identification of unknown pulsations .The instrument is readily accepted, simple to op-erate, and fully portable .

vice described herein is designed to mimic the visualpulsations of the internal jugular vein and the palpablepulsations of the carotid artery in both health and dis-ease .

The InstrumentDescription: The device (Fig . 1) consists of 3 systems

driven simultaneously by a single-gear motor . The mechanismmimicking the jugular venous pulse is on the right and thecarotid pulse simulator is on the left . Small lights are used tomark the occurrence of the first and second heart sounds aswell as any murmurs associated with pathologic conditions .The device does not reproduce these sounds audibly .

The position of the examiner is similar to that for an actualphysical examination . Situated on the right side of the device,as in the bedside examination, the examiner places a fingerover the anatomic position of the carotid artery . Visual at-tention is directed at the tubing representing the internaljugular vein . As in the live patient these pulsations should beviewed tangentially, The small lights are observed to mark theoccurrence of heart sounds or any murmurs . Tactile stimulifrom the arterial pulse as well as the heart sounds are used forproper identification and interpretation of venous pulsa-tions.

The cams (Fig. 2) are carefully designed and shaped to re-produce accurately and reliably the various normal and ab-normal pulsations. The accuracy of reproduction is demon-strated by graphic tracings (Fig . 3) obtained from the devicewith an external pulse recorder and comparison with knowl-edge of physiologic recordings from patients)

The pulsations currently available are listed in Table 1 .Cams are easily changed within seconds to reproduce thedesired abnormality-

December 1982 The American Journal of CARDIOLOGY Volume 50

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PULSE TEACHING DEVICE-KREITENBERG ET AL

FIGURE 1. The instrument is the approximate size and shape of ahuman neck . A, visible venous pulsation . 8, lights marking the oc-currence of heart sounds . C, palpable arterial pulsation .

The device is designed to be portable and needs only astandard electrical outlet. Experience with medical studentsshows that the device is readily accepted and simple to op-erate .

Assessment: A study was performed to objectively assessthis new teaching tool . Because it is logistically difficult toassess the learning of a physical examination skill, we electedto determine whether the device indicates a person's present

TABLE I Number Correct for Each Pulse

1392 December 1982 The American Journal of CARDIOLOGY Volume 50

04D410404D4)

FIGURE 2. The cams are carefully shaped to reproduce the appropriatewave forms .

level of that skill. We therefore compared the performancesof a group of cardiologists with a group of third and fourth yearmedical students. Both groups have a knowledge and under-standing of the pulsations . However, the cardiologists werecertified by the Internal Medicine Board and had specialtytraining in cardiology and clinical experience .

F test of 3.18 (p <0 .01) and t test of 3.54 (p <0 .01) between meanscores of the 2 groups . SD = standard deviation ; VAR = variance .

CardiologistsCorrect )n = 11)

Medical StudentsCorrect (n = 14)

VenousCannon waves 11 7Normal venous 4 5Bogus 2 0Giant a waves 5 9Prominent y descent 7 5Ventricularlzation 9 7

ArterialDicrotic 8 10Pulsus aiternans I1 13Normal arterial 10 12Hyperkinetic pulse 11 13Bisferiens pulse 9 7Parvus et tardus ID 12

TABLE It Distribution of Scores (Number CorrectOut of 12)

-~

-_

Cardiologists

MedicalScore

(n)

Students (n)

12

1

011

2

010

4

19

2

18

1

67

1

2B

0

15

0

24

0

03

0

02

0

11

0

00

0

0Total

11

14Mean

9.73

7,07SD

1 .42

2.02Var

_

1.84

_3.78

GIANT a WAVES

VENTRICULARIZATION

CANNON WAVES

NORMAL

ALTEANANS

DICROTIC

FIGURE 3. Neck venous (left) and arterial (right) pulses : graphic tracingsof waves generated by the device. recorded with a clinical externalpulse recorder_

Name labels on the cams were removed . Venous cams werelabeled I through 6 and arterial cams were labeled 7 through12. One cam (venous) was bogus. The examiner attempted toidentify each arterial and venous pulse on a test sheet (TableI). All testing was supervised by the same person (AK). Eachsubject was given the following set of rules: (1) There is at least1 (of the 12) bogus pulse ; (2) no choice is used more than once ;(3) you may return to any cam to recheck your answer ; and (4)the variable speed control may be used . The device was ini-tially set at a rate of 70 beats/min . Arterial pulsations weretested first . Then, the normal arterial cam was disclosed andused in the identification of the venous pulsations .

Results

Table 11 shows the distribution of scores (numbercorrect out of 12) for each group . The cardiologistsperformed better than the medical students . The dif-ference between the 2 groups is significant at the p =0.01 level .

Table I displays the same data by pulse for eachgroup. Analysis of these data shows several interestingpoints. There was a significant difference in the 2 groupsinterpreting venous pulsations but no significant dif-ference in interpreting arterial pulsations . The largest

PULSE TEACHING DEVICE -KREITENBERG ET AL

differences between the groups occurred when the fol-lowing pulses were tested : cannon waves, prominent ydescents, ventricularization, and bisferiens pulse . Thepulses most often correctly identified were the pulsusalternans and the hyperkinetic pulse. The pulses leastoften correctly identified were the bogus and the normalvenous pulses; these were correctly identified by lessthan half in each group .

Analysis of individual test sheets showed that themost commonly confused pair were the double-peakedarterial pulses, bisferiens and dicrotic . This error wasmade by 2 cardiologists and 3 medical students .

Discussion

The results of the assessment demonstrate thattrained cardiologists can effectively recognize most ofthe pulses mimicked by the device, and that trainingenhanced the identification of venous pulses mimickedby the device. The fact that a greater difference was seenwhen testing the venous than when testing the arterialpulsations may be attributed to a number of factors .Among these are greater ease in learning the arterialrather than the venous examination and technical fac-tors involving the device or study .

A subjective conclusion that may be drawn from thepresent study is the acceptance of the device by thesubjects. It was viewed as fun, worthwhile, and valuable .The device has shown itself to be practical and easilyoperated .Conclusions: The device has been named "LeNeck"

(patent pending) . The design is original and unique .LeNeck is likely to be a useful teaching aid . Direct vi-sualization of venous pulses and palpation of arterialpulses of rare prevalence will be especially useful tostudents with limited contact with uncommon abnor-malities. The device is intended to be an adjunct toproper and thorough training of physicians and otherhealth care professionals .

Acknowledgment: This device was developed as an inde-pendent medical student study project by Arthur Kreitenbergwith support from the University of California, San Diego,School of Medicine, Office of Learning Resources .

References

1 . Tavel ME. Clinical Phonocardiography and External Pulse Recording . 3rded . Chicago : Yearbook Medical, 1978 :187-220, 250-272 .

2. Hurst JW, Schlant RC . Examination of the venous pulse . In : Hurst JW, ed .The Heart : Arteries and Veins . 4th ed. New York : McG'aw Hill, 1978 :183-202.

3. Marx HJ, Yu PN . Clinical Examination of the Arterial Pulse. Prog CardiovascDis 1967 ;10 :207-235 .

4. Massumi RA, Zells R, All N, Mason DT. External venous and arterial pulses .In : Weissler, AM . Non-Invasive Cardiology . New York : Grune & Stratton,1974:401-442 .

5 . Benehlmol A. Non-Invasive Techniques in Cardiology . Baltimore : Williams& Wilkins, 1977 :39-161, 373-382 .

6. Fowler NO . Cardiac Diagnosis and Treatment . 2nd ed. New York : Harper &Row, 1976 :32-48.

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