To Expose or Not To Expose, That is the Question.

[spenac]

So here you are on the way back to the station for shift change when you are toned for a sick female. You cuss and scream while on the way but are the professional once on scene. Patient complains of pelvic pain. Do you just load and go and make sure she's stable or do you examine her properly? Do you ask questions then expose and see if there are any visual cues as to the problem? Do you have her open the vagina to expose any possible injury? Do you palpate to check for swelling, deformity, tenderness?

Ok same if a guy. Do you expose if complains of testicular or penile pain? Do you palpate?

[Ronnie]

I simply apply to this to the benefit/risk ratio. There will be no benefit or change to your treatment by exposing and assessing, that is barring imminent delivery or profuse hemorrhage. I have transported women in the past with complaints of vaginal pain with a known diagnosis of PID. I believe it is appropriate to give supportive care and give report to receiving hospital of signs and symptoms. The negative or risk would be that you are setting yourself up for customer complaints and possible lawsuits.

[island emt]

First off We are not gynecologist or proctologist. start doing pelvic exams is a sure bet to end up in court.

If the chief complaint is pelvic pain of unknown origin , I would ask appropriate questions to make a determination of whether there is bleeding, foreign object impaled, or is it caused by trauma. Is the pain sudden onset or has the cheese factory been fermenting for weeks.

Any unusual discharges ? if so color and texture, smell or no smell?

Is she pregnant?

Recent miscarriage or abortion?

If there appear to be no life threatening problems , then it's a transport in position of comfort and treat for shock or pain as appropriate.

Same goes for a male pt. Treat immediate life threats and let the ER folks sort out the fungus.

[Bieber]

I don't think it's inappropriate to visually inspect the genitalia. Outside of obstetrics I don't think there's much reason to manually palpate the genitalia, but I think it's acceptable and appropriate to visually assess when indicated.

Edited October 6, 2010 by Bieber

[P_Instructor]

Based on proper requests of further history and information obtained, this should lead to the aspect of visual/palpatory examination. However, full vaginal exam on female, no. Patients can be very vague in their complaints of discomfort in the pelvic region. A good paramedic should be able to acertain pertinent information with proper questioning to warrant a proper examination if needed as without the this, how the hell can they know what is really happening, and can they do anything for the problem. There are many things that you can inspect/palpate for so you have (no pun intended) a better handle on the situation (crowning, swelling, trauma, bleeding, drainage, etc.). There are proper times and improper times when examinations are needed. Either case, you should always have patient consent and hopefully a witness with you.

[spenac]

We are medical professionals and if we do not see the vagina or the testicle that the patient says hurts we can not help nor can we relay accurate report to the doctor. We must do a complete focused exam on the area of complaint and that means looking, listening, feeling. Do not be bashful, do it like you have done it a million times and the patient will have no problem with it and the doctor will respect your report more as you actually relayed patients complaint combined with what you found during exam.

It is my pet peeve that so many do not act as professionals and do the job that needs done. As soon as it deals with a persons no-nos they refuse to touch or look, lets just load and go. Vital information could be missed that could delay the care they need.

[HERBIE1]

We are medical professionals and if we do not see the vagina or the testicle that the patient says hurts we can not help nor can we relay accurate report to the doctor. We must do a complete focused exam on the area of complaint and that means looking, listening, feeling. Do not be bashful, do it like you have done it a million times and the patient will have no problem with it and the doctor will respect your report more as you actually relayed patients complaint combined with what you found during exam.

It is my pet peeve that so many do not act as professionals and do the job that needs done. As soon as it deals with a persons no-nos they refuse to touch or look, lets just load and go. Vital information could be missed that could delay the care they need.

So if the woman has PID or the man has an STD type symptoms, exactly what will we be doing for them? We are not obtaining cultures, we are not getting a UA, we are not doing swabs, we are not doing an internal exam. Ask the appropriate questions, and you can give more than an ample report to the ER.

Probably 99% of any situation can be assessed with a few pointed questions. Bleeding? Vaginal bleed- how many pads have you used? Discharge? How long? Trauma? LMP? Pain?

Unless you have an imminent delivery, massive bleeding, other extreme gyne EMERGENCY, or it's a trauma situation where you need to expose everything, there is no reason to be examining someone's genitalia. There needs to be a damn good reason. It doesn't matter if WE consider ourselves medical professionals, in delicate situations like this, the opinions of the patients, family members, or bystanders are the ones that count. Again- if it's necessary, then by all means, but my point is, it is RARELY necessary for us to do such an exam.

If it's appropriate, then you need to examine- while maintaining the patient's privacy and dignity, and with a female witness(or provider) if at all possible.

[spenac]

So because it does not change how we treat we should just ignore it?

How many patients lie about what is actually going on? So you ask a female are you bleeding a lot they might answer no only a couple of drops when in fact they may be flowing. But you choose not to look because mommy said it is wrong to look at a girls private parts. Now at the hospital you tell them what she told you. They place her in a low priority and later they find her dead. Why because she bled out because you did not do a complete patient assessment.

So do what is right and at least look at the affected area. I mean with the logic provided we should not be removing clothes from the affected areas of a trauma patient. So a patient reports no my arm is not bleeding so we don't roll up or cut off the sleeve to find the bone sticking out of the skin because we relied on what the patient said? Makes no sense does it. Same goes with the no no's, the private parts, the what ever you call the parts you are afraid of looking at.

Do the job, do the job right. You are a medical professional and a patient advocate, do a proper assessment so you can properly advocate for your patient.

[uglyEMT]

Good thinking question!! +1

1 I would check with your local protocols on the issue. I know in my area if we are going trauma naked we are supposed to leave underware on. Babies are a different protocol of course. Vaginal bleeding it says to apply a trauma dressing or a femine pad and apply pressure. Only time a finger should be inserted into a female is if we have a prolapsed cord and its for the babies survival or if the sac hasnt ruptured and we need to break it. Nowhere does it say to examine by removing clothing unless absolutly necessary.

2 If in doubt contact medical control! If I call ahead and the med control doc says yes visually examine then I will DOCUMENT DOCUMENT DOCUMENT and with proper tact and all manners of professionalism do the examination.

3 If I had to do it and it wasnt life threatening I would ask for a female officer or EMS (bls or als depending on your system) to be present to witness. I would also try and do it in the rig unless we are in the patients own residence.

4 Patient consent with DOCUMENTATION

as far as what has been discussed, if the patient is really bleeding badly it would show through clothing thus no worries, cut and expose and stop the bleeding. I do believe if the patient called us for pain in their genitalia then it would have to be pretty bad and I dont forsee them holding back information. I guess in the end it would be up to your own judgment if it would be necessary but I would definatly not go outside protocols and if its a grey area in your protocols I would conact med control.

[HERBIE1]

So because it does not change how we treat we should just ignore it?

How many patients lie about what is actually going on? So you ask a female are you bleeding a lot they might answer no only a couple of drops when in fact they may be flowing. But you choose not to look because mommy said it is wrong to look at a girls private parts. Now at the hospital you tell them what she told you. They place her in a low priority and later they find her dead. Why because she bled out because you did not do a complete patient assessment.

Here's where the professional part comes into play. Does the person have normal vital signs? Is their story consistent with how they present? What is their affect/demeanor? What is the circumstances surrounding the story- the scene, the family members or bystander attitudes?

Will someone lie? Of course. They can lie about drug use, they can lie about the chest pain they are having or how long they have been dealing with it. Do they lie about taking their medications appropriately? Of course they do.

Now if a woman is claiming they are merely spotting(as in someone who is in denial they are having a miscarriage), yet they are tachycardic, hypotensive, pale, and clammy, then yes, IGNORE what they say and do your job. Common sense.

So do what is right and at least look at the affected area. I mean with the logic provided we should not be removing clothes from the affected areas of a trauma patient.

Wrong.That is EXACTLY the scenario where I said that we DO need to expose.

So a patient reports no my arm is not bleeding so we don't roll up or cut off the sleeve to find the bone sticking out of the skin because we relied on what the patient said? Makes no sense does it. Same goes with the no no's, the private parts, the what ever you call the parts you are afraid of looking at.

Do the job, do the job right. You are a medical professional and a patient advocate, do a proper assessment so you can properly advocate for your patient.

Yep. We are medical professionals, but we also are supposed to have common sense and use good judgment, based on our experience. Blindly following some protocol is not the hallmark of a true professional. Making a patient uncomfortable, embarrassed, anxious, or upset is the exact opposite of what we are supposed to be doing. Until we are required to test for STD's, obtain a UA, or do an internal gyne exam, I am using common sense. I feel no need to "prove" I am a professional. Obtain a good history- especially relating details from the scene(anxious family members, curious behaviors, etc). Countless doctors have told me that is one of the most valuable things we can do for them- give them info they simply cannot obtain from the patient or family members. They are diagnosticians by training- why do they need us to verify something we cannot treat or alleviate? We all have a role to play in medical care, and we need to understand our place in the process. To me, this is like some ER doc attempting a procedure usually handled by a specialist. Yes, he is a doctor, but is it really appropriate to do something that may have minimal benefit, just because he/she CAN? Doctors call in specialists all day long for something beyond their area of expertise. Why should we be any different?