Leaderboard

Wow. Just.... wow. It seems that there are at least three different questions here: Should abdominal palpation be done on this patient? Should it be done by an EMT or EMT student? Should it be taught to EMTs at all? Was the situation handled correctly by the OP? 1. Yes. Abd palpation is indeed indicated in the general examination of abd pain. However, it should be done at the proper time, by the proper person, utilising proper technique. And, of course, it should be deferred if the clinician determines a potential for exacerbation of the situation by the manoeuvre, or if it causes too much discomfort for the patient. Remember, it's going to happen again, probably at least twice, in the ER, whether yo9u do it or not, so there is little to be risked by deferring it in the field. 2. I'm a little mixed on this. There are instances where I would say this may be indicated. However, none of those instances would involve an acute abdomen, as in this case. And even then, it should be done only under the close supervision and guidance of an advanced clinician who has confidence in the EMT or student. 3. As already well stated by VentMedic, with the current state of EMT training in the U.S., I have to say 'no', abd palpation probably should not be taught in the basic EMT curriculum. Hell, for that matter, there are a lot of paramedic schools that shouldn't be teaching it either, because their students are neither the anatomical or physiological foundation necessary to properly implement and interpret the results. Most of them are wholly incapable of even identifying where organs and structures are located within the abdomen (and yes, my students get verbally quizzed on that within the first hour of showing up to my ambulance for a ride). And I am not for just doing shyte that looks cool, just to look busy, when it offers no benefit to the patient. 4. Should the OP have stopped the student from palpation as he did? Yes. No doubt about that. However, the reason he had to do so is because he FAILED to establish the ground rules and a clear line of communications with his student at the beginning of the shift (this, of course, is an assumption. He may have, and the student may have just been an idiot.). Before you ever make it to your first patient with a student, EXACTLY how things will work should be discussed, understood, and agreed upon by all parties involved. As an educator, I encourage my students to be assertive and pro-active, using initiative to be a part of the team. This should be tempered by the student's knowledge of his/her own limitations, of course. If a preceptor wants to play 'mother may I', then such problems are obviously going to arise quickly. For this reason, I also counsel my students to establish the communications and ground rules mentioned above, whether the preceptor brings it up or not. In this case, it appears that both student and preceptor FAILED in this, and both need to learn a valuable lesson from it. Ideally, the student would have known the limitations placed upon him by the preceptor ahead of time, preventing him from overstepping his role. This would have prevented the embarrassing incident in front of the patient. And it would have given the student a good question to write down and remember to ask the preceptor and instructors about after the run. I do believe I would like to have seen the verbal intervention handled a little more diplomatically, if for no other reason than to avoid worrying the patient. Instead of the old, "DON'T YOU EVER..." line, perhaps a gentle, "Uhhh... I think we're going to just defer the palpation to the ER, okay?" Yeah, I know that when you see something wrong about to happen, it is sometimes difficult to remain calm and diplomatic. However, that is what is expected out of a preceptor. You are, after all, a professional educator. Try to sound like it.

In my rural county, 2010 will see the demise of volunteers-both fire and rescue-after over 50+ years in service. We have a hot shot new fire chief from the big city, a new arrogant county administrator and a bunch of good old B.O.S. boys who jump every time a taxpayer whines. We now have 24/7 career coverage most of who would rather get a PT refusal than transport to the closest hospital-40 miles away. We have a bunch of paid EMT/FF who all pile on an engine and respond to calls, overwhelming most PT's. I'm a 10 year volunteer who see's the light at the end of the tunnel-and it's a train.

While I appreciate the theory of your concern, I am not aware of substantial evidence that suggests palpation is unsafe practice in a patient with a suspected AAA. I have seen evidence suggesting that palpation is one of a few manuvers (perhaps the only) during a physical exam that is of any value for detecting the said condition. While it can help secure a field diagnosis, I should also point out that palpation cannot exclude or rule out a diagnosis. So, no an assessment would not rule out a AAA; however, it can produce highly compelling evidence suggesting AAA. In addition, I do not see how doing abdominal palpation in the field would delay transport times? Therefore, I appreciate your concerns; however, I could not fault somebody who palpates a patient with an acute abdomen. Take care, chbare.

Wow you're arrogant. What was your reasoning behind yanking your EMT's hands from the patient? Was there an obvious pulsating mass that they didn't recognize? You very likely made that EMT feel like a piece of crap, and for what? What could you possibly have taught them by acting out like that? Palpation is an important part of an abdo assessment, unless of course that action is contraindicated. Being an EMT is NOT a contraindication.

I will probably get negatives for this, but whatever. I though it was hilarious.

What every man figures every woman should see:

Hey Lisa. I'm not sure how old you are, but the only time I hear how valuable 'time in cert' as a basic is is when I'm talking to the part time firemen/medics and basics, at my service. They love the whole, 'whoever last that longest wins' concept. Most of the rest of us think it's utter bullshit. I like to believe that I am considered a competent medic where I work/have worked, both here and in Afghanistan, yet I've never worked a paid day as a basic. I truly believe that the most valuable things I use in paramedicine I brought with me. Kindness, attention to detail, a solid work ethic, a half decent ability to problem solve, a hunger to be a better medic tomorrow than I am today, the maturity necessary to talk with patients, make mature decisions, and the life experience to understand the pain of my patients and those that love them. Oh yeah, and an almost unlimited ability to haul the same drunks/drug addicts/psych patients over and over week after week without choking anyone. :-) In fact it's been my experience that the vast majority of the terribly difficult decisions I've made have been moral/ethical, not medical. I chose to go straight to medic school from basic based on the opinions mainly of Dust, chbare and akflightmedic, though many others were influential as well. I earned my AAS in Emergency Medicine and have never, ever regretted it. As chbare mentioned, EMS is the only medical field where many believe it is best to gain experience before knowledge. All others do it the other, and seemingly more logical, way around. If you choose to go straight to medic you WILL catch some shit from those that don't have a significant education (which is why they need the 'experience' scaffold to support their self esteem)...but f*ck em...this is about you, not them, right? Best of luck to you in whatever you decide. Dwayne

This is really two separate questions: 1. How long until your unit is available for the next run. 2. How long until you actually clear the hospital. It should rarely take any more than fifteen minutes to make your unit available for the next run. It is the driver's job to IMMEDIATELY take the cot back to the ambulance, clean it and the ambulance, replace linen, restock supplies, and notify dispatch that we are available, but still out at the ER pending paperwork. The driver shouldn't be dicking around in the ER, flirting with nurses, gawking at patients, eating and drinking snacks, smoking fags, or just generally being useless until AFTER the unit is ready for the next run. In my experience, the problem is usually that the driver fiddle-farts around forever before returning to the truck to ready it. As for actually returning to the street, it takes as long as it takes. If there is opportunity to do so without neglecting my patient, I will do some basic charting enroute. Mostly, I only get demographic info during the trip, as well as charting vitals and other immediate concerns. The narrative will all be done at the hospital when I can concentrate solely upon it, with all information finally available. That usually takes no more than thirty minutes max, and unless a priority run comes in, will always be completed before leaving the hospital. Of course, if you're using the lame-arse charting system (whether electronic or hardcopy) that is a simple system of box-checking and drop down answers, then this should all be happening in about half the time of a narrative. In that case, the medic should be ready at about the same time as the driver, unless there are unusual complications.

5 crashes in the same year? OMG! In 35+ years, I've only been to 4 plane crashes over all. So, as to predicting plane crashes, are we now employing Allison Dubois, or others with similar abilities of ESP-Premonition? If anyone asks, Eastern Airlines Flight 66, JFK, 1975; US Airways Flight 1010, LaGuardia, sometime in the 1980s; American Airlines Flight 587, Belle Harbor, Queens County, New York City, November 12, 2001, a half mile from my residence; and a single engine plane in forced landing on the beach, Atlantic Beach, Nassau County in, I think 2004. Actually, per members of my old VAC, a crew member taking a mid afternoon nap woke up with a start, and declared "We're going to have a plane crash this afternoon." 2 hours later, he was a part of one of our 3 crews working the Eastern crash.

One thing that's unique with us is our PCR program.... Its all electronic. The hospital can access our PCR once its posted to the server for reference and doctor veiwing. Priortiy 3 and 2 Calls (BLS / ALS Non-emergent): Whatever time it takes for the ED to give us a bed (average time is 15 min) with a RN to give report to and get a signature. After we have given report we call "patient offload" on the radio. We have 10 min from the time we call offload to clean the truck and restock. At that time we have to become available for call. Our PCR's are all done on Toughbooks (The one with the Rotatable Screen), with WiFi, Sprint Aircards. The EMT usually puts the info in the computer on scene. After we get to the facility. It has WiFi where we can download our CAD data (times, call numbers, addy's, milage etc....) into the PCR, our Zoll data cards record all of our ECG's, B/p's, Etc. in electronic format and all we do is import it all into the PCR and post what we have in the com,puter (can be finished at another time) it to the server before we leave the hospital. Usually takes about 20 min to complete this process Priority 1 Calls (ALS Emergent): We get the bed, give report and get the signature. (probably 5-6 min) Call "patient offload with extended clean-up" (The 10 minute rule becomes not applicable) on the radio and we then move to clean the truck. When the truck is ready to go, we begin the documentation. The patient info is typically already in the Toughbook (done by the EMT on scene). We import our CAD and Zoll data. Complete the PCR and upload it to the server before being able to go back into service. Usually takes about 1 HR for this process to be complete this process.

We are given "30min" before the dispatcher starts checking on you. Most don't use all the time and with echarting with the drs tatical computer (yes I love to preach its wonders) most of the chart can be done before arrival at the hospital. If the hospital is busy I'll just finish my narritive there, and our trucks are typically overstocked so resupply is usually not needed. Only once or twice have I had a string of critical patients and needed to return for supplies.

Well, the program sees 20 min into the future based on 10 yrs of past data. So if we've had 5 or 6 plane crashes in the same year and same time near the airport (which we've only had 2 or 3 (priavte aircarft, no commercial) in the past 5 yrs), and we're getting sent to the same general area. I'll just make sure to have my extra jump kits ready...... The thought process behind the milage and over usage of vehicles is based on our current stand-by policy. When two trucks which cover a response zone are out running calls, we have to send another truck to that area to cover the zone to maintain response requirements. Based on the new theory or program, if two trucks are out and a zone left uncovered, but according to the program no call will be dropping in the area and it does not reccomend a unit for stand-by, you don't go. Taking that same theory for one truck, apply it to our fleet of 37 trucks and it adds up in a yrs time of numerous cost savings for fuel, wear/tear on our vehicles, and wear/tear on employees. The county in which we live and work in believes in providing the best service possible to the residents and vistors. If that means we're supplied with the lastest in vehicles, equipment, and technology to accomplish the job and be finacially responsible and efficient, then that's what we're given. Our PCR program enables us to collect for this year, 18M out of 25M billed. In which essentially means our service pays for itself, and we're not private! We've been able to keep the priavtes out of our county....

As far as the situation was described, I understand the pulling his hands away part due to the fact that you didn't know how he would asses. However, that would be best followed up by an explanation of why you were concerned and then a demonstration of how to gently palpate the abdomen and assess for a AAA. Who knows, maybe that mass was pulsating and maybe that lowly EMT-B student could have known what that felt like so early in his new career. However he won't know and neither will you for that matter. Assessments must always be complete, though you are right to have regard for where your assessment could potentially cause harm.

Lets try this approach in teaching this new basic, first don't yank his had away you will freak him and the patient. You need to have control of your student prior to the call as a preceptor. Second try out this explanation on palpation " you are looking for lands mines if you see one or find one don't play with it but you do have to look'. What I am trying to express is that you need to palpate the ab to locate any problems but once that is done we (as basics) really don't the skills to produce any more useful findings threw continued palpation. In summation a palpation of the abdomen should be done at all levels but once a significant finding is found then further examination should be weighted with a cost verse gain approach. It is assumed that all other investigative avenues are being used like history vitals etc.

Very lucid thinking. I agree, I too have not seen compelling evidence either way regarding palpation. I think we both agree that palpation cannot rule out this or any critical abdominal issue. Furthermore while palpation can support other findings leading to the r/o diagnosis my point is that your conclusion cannot be based on it. After all I have examined perfectly healthy individual and looked at their abdomen only to visually see the normal pulsing of the abdominal aorta. Does this runner with a twisted ankle get treated for a AAA? If we stand back and think of a AAA or hot appendix or perforated bowel, these situations have swollen distended tissue that if left unattended do in fact burst and then the patient dies in seconds. Although there is no study that I am aware of that proves pushing on a thin wall aneursym or a swollen appendix will cause it to burst it would seem a logical assumption, as I have been successful with balloons. In light of the fact that nothing we find during palpation would change our rule out diagnosis that we based on the history vital signs patient presentation etc... I see no need to take the risk because what are the chances of the patient living long enough to make it to surgery if we are wrong. By telling the ER that you suspect an acute abdomen based on history vitals etc...and not pushing and probing you may buy the pt the times he needs to see the pro's on this subject. Above all do no harm.....

"The clinician need not be afraid of properly palpating the abdomen because no evidence exists that aortic rupture can be precipitated by this maneuver." Article by Dr. Robert E. O'Connor MD Proper assessment provides a differential for the provider to work with..I believe that the OP should have shown the student or basic the proper method to palpation. Definitely using this tool to differentiate (potentially) between a hernia, bowel obstruction, or AAA could be valuable..although all are potential surgical emergencies. Palpation, percussion, and auscultation are invaluable tools, if skills are honed appropriately..IMHO

http://www.ncbi.nlm.nih.gov/pubmed/9892455?dopt=Abstract A little dated, but clearly data gained from palpation can strengthen your field diagnosis and it does not appear to be inherently unsafe. Of course, I believe the studies quoted involved physician assessments. Therefore, I would not necessarily fault somebody for deferring the exam and initiating rapid transport based on other signs and symptoms. However, the same is true of somebody who does palpate. An anecdotal situation; however, when I was a new nurse I took care of an otherwise healthy patient complaining of nausea. Clearly, a BS situation. I asked a few questions, listened to lungs, and obtained vital signs thinking the patient was not all that remarkable. Clearly, this may have led to a delay in the physician seeing the patient. When he did, he noted a pulsatile mass and we quickly changed gears. The patient ended up having a 6.5 cm AAA. It was "stable" fortunately and the primary diagnosis was a viral gastritis; however, the patient had follow up and repair. So, a good assessment can in fact make us change gears and consider additional problems that may otherwise go unnoticed. In the situation described here, a high index of suspicion already existed however. With that, it is always nice to have as much data as possible so you can paint an accurate picture and emphasize the potential gravity of the situation to the receiving facility. Take care, chbare.

But how many EMT-Bs in the U.S. are taught all the things that can go wrong in the abdomen or the complications? How many are given step by step instruction on how to or how not to palpate an abdomen? How many have felt a AAA in some of the ways it can present? How many know the many differeentials? Other than, tender or not and rigid or soft, there is not much instruction and these can be dependent on the patient and one's cold hands or comfort. I have seen med students and residents get their hands smacked by attendings when they just started poking around in a situation that warrants caution. Of course, that rarely happens because they generally have the education base to know they should wait for proper instruction and training to approach various situations. I have seen various aneurysms start leaking for a variety of reasons and there is nothing more frightening for a physician than to have a patient scream in pain or just die on the stretcher during a physical exam. Perforations, foreign bodies, aneurysms and a few others that are suspected may need caution and if a physician suspects something serious, he/she may send the patient to CT Scan or do an ultrasound rather than aggressive palpation.

1. Abdominal exam not addressed in protocols? This is a standard. How can you potentially treat a patient without a complete and thorough assessment? 2. Do the exam, and if taught properly (non 'poking', but gentle palpation) you could find out much good information that can be disseminated to the ER to prepare them for whatever event. You need to assess for lumps, bumps, masses, palpations, etc. Who knows, it might only be a 'diastasis recti', but without exam, you could hinder the idea of rapid transport of a dissection. 3. We don't teach what is in the chapter per say.....teach the curriculum which includes a good thorough abdominal exam along with history of the event. Teaching the newby Basics any other way could compromise good assessment tools in the future. Don't jump down their throats, teach them the proper way and what to look for, whether they or you can do anything for the complaint or not. Complacency can be a killer. This is only the opinion of this poster.

Why 'duh?' Do you then feel that the poking, prodding and percussing have an intrinsic value, even when done by those that gain little if any clinical information from it? I didn't get the feeling that the OP, though he seems to have chosen to no longer participate in his own conversation, felt that these were worthless skill on all levels, only those at the basic cert. Why then are they valuable? Should the hospital give me all lab values of the pt I'm helping to resuscitate after transfer of care because it's a standard of care, despite the fact that I have almost no knowledge of their significance? What is gained by that? Dwayne

It sounds to me as if the OP is trying to paint the picture of a dissecting AAA. And if so, there is little to be gained and much to be lost by palping by an inexperienced, likely heavy handed, new EMTB. It also sounded, (playing devils' advocate) the the OP may be asking why we continue to teach abd palpation to students that, most often, won't have the educational background to do anything educated/intelligent with that information. I can agree to a certain extent on both points actually. Though without giving it some significant thought, which often involves waiting to see what Dust thinks, I can't really argue either way at this point. I do agree that if you're 'yanking the hands' of anyone off of a patient, most especially those of an already insecure, terrified 3rd ride EMTB then you need to take a chill pill. These folks have gotten into the back of the ambulance, again, most often, without the knowledge/education/training necessary to feel confident and productive, which often causes them to do some pretty dorky things. Making them feel even dumber by reacting to those dorky things in a foolish manner simply sets them back, when our job is to attempt to elevate them to a new level while in our care. I look at 3rd riders almost exactly the way I do my patients. They are in a place that they've been convinced by books and teachers that they belong, only to find that nothing actually works the way that they were taught. They are insecure, scared, have no control over the events occurring, and will be gone before they have even a tiny chance to remedy that. Chastising them for unprofessional behaviors that are predictable, in fact unavoidable does no good to anyone. In fact the new EMTB that steps up and gets in my way by being overly aggressive immediately gets kudos in my book. EMS is a contact, not spectator sport. It takes balls to put yourself 'out there' when on early rides, timidity should be discouraged even if initial brazenness is at first unproductive. Why teach it? Because a small percentage of them will stay in the ambulance long enough to learn it's value. Because it's a standard of care regardless of their ability to use that information. Because it forces them to actually put their hands on patients, one of the skills that many have a terribly hard time learning. Because for every DAAA 'near miss' there will be 5000 abds that have exactly nothing wrong with them reinforcing the more important skills stated above. Though you've taken a bit of a beating here, I think this is a great thread! At least it caused someone with my limited brain power to sit and think for a few hours. Thanks for the post brother. Dwayne

Depending on how the preceptor/student relationship is, yes. It's the preceptor's patient first and foremost. In my mind, ambulance clinicals should work similar to field training with the student starting as more of an observer and progressing to being primarily responsible for the patient. If the student is doing the assessment, then I wouldn't expect him to be asking the preceptor if he can palpate. However, the student shouldn't just jump in because he thinks that something was "missed."

You bet. I am almost done with paramedic school, and while I am working at my EMT job I still ask my paramedic permission before doing certain things. As a EMT ride along student, your primary responsibility is just to observe. You may be asked to assist with vital signs or other simple procedures within your scope of practice, but other than that, you should not start conducting your own examination of a patient or starting to do something on your own without being asked. My two cents, anyways.

Standard part of a physical exam of a patient with a c/c of abdominal pain. Inspect, auscultate, palpate, percuss. Although, a ride along should have asked before he/she preformed patient care in your ambulance.

I don't forsee any major changes to EMS itself, but there will be continued implementation of the educational standards and other Agenda For the Future items. Things that field employees might not directly see effects of other than perhaps additional education requirements.

I don't want to sound negative by saying this because the theory is interesting, but I'm curious to see what the yearly stats turn out to look like. There are tons of positioning systems out there, and they all have their bugs, but this one seems to be more "high tech" (for lack of a better term) than anything I've ever seen. It’s been a while since I have worked in an area that moved trucks based on potential calls. The one thing that I have a hard time believing is that they are going to add 2 years to the life of the trucks. The mileage is still going to be there, isn't it?

New provincial Medical oversight and Lifepak 12s for us.

I hear you man. But here's the catch. If you truly want to get your hands dirty, if you really, really want to be a good EMT/Paramedic, then start today. Use spellcheck. Noobs rarely want to hear this, but let me try and make my point this way.... Those that responded, most noted Ventmedic and Dust are terribly competent and experienced. Do you see the difference between their posts and yours? Did you get a feeling for the value of their opinions and advice simply by reading their posts? I'll bet you did. That is what you need people to see of you. Not the 3rd grade posting you've done here. Use punctuation, capitalization, paragraphs, proper spelling. Show those that take the time to respond to you the respect of at least rereading your post before you post it. Intelligent presentation of your ideas counts here. Not always perfect presentation, but something that shows that you can be bothered to spend at least two minutes looking for the information you need. Not to mention that you'll be spending the rest of your career writing untold numbers of reports should you choose this path. So far you've presented as a young, "Show me the guts! Oh, and which way is it to the fire station??" kind of guy. I have a feeling that there is more to you than that...give folks a chance to see it, OK? I'm not sniping, simply trying to give you some information that is often too long coming. Good luck to you. Dwayne

This was actually the Berkeley Police Department and the University of California in cooperation with Alta Bates Hospital who produced this film. BPD provided the emergency ambulance ambulance service for the City of Berkeley until the late 1970's when the Berkeley Fire Department took over the function. Dr. Heinrich Beernink who plays the fledgling BPD officer still maintains an office in OB/GYN practice.

Just because one is a paramedic, doesn't mean one isn't a cocky jackass who wouldn't crap the bed on a call

Yep, had partners of ALL levels freeze, including pre hospital doctors, on calls and some even needed a slight gentle nudge across the back of the head to get them moving. That is not a ALS/BLS issue that is a person to person issue. What I am saying is that the ambulance crew should be just that - a crew - not two individuals working the same truck. Maybe it is just me expecting too much from my partner and maybe it is a good reason to ahve two paramedics on each truck???

I'm sorry, but you do not let a student jab at a patients abdomen who has a c/c of abd pain, and than proceed to tediously press again and again on the patient's belly to show proper technique. If you want to teach the procedure, that can be done on a patient who is not in pain, or another classmate. And while I find the cited article interesting, it is not enough to convince me to abandon my practice of palpating an abdomen with a suspected dissecting AAA as little as possible, and I sure will not be letting a student do so.

My cut off for waiting for a bed without starting to complain comes when I finish my chart and am still sitting with the patient on my stretcher. Which ment that its actually a patient in need of a bed and I just using the onscreen keyboard chicken pecked out an entire narritive. When it comes to "stocking from the hospital" I think the places that have to do "hunt and steal" supplies a)don't have a high enough call volume that hospital turn over time is important b)don't have the money or want to spend the money to supply themselves

On scene the patient was outwardly stable. From the history, visualization of the abdomen and vital signs this pt was potentially unstable 2 large bore were started in route, and run kvo, on arrival I advised the ER staff I was treating a rule out AAA and they confirmed it by a sono. Patient was taken to the O.R. he burst on the table but was saved. I did not palpate , auscultate or percuss in the pre-hospital setting did I harm the patient? What was a the very real possibility here had I delayed transport and started "gently manipulate, palpate, percuss and auscultate" this abdomen while the patient was sitting in his office chair? More importantly would your full abdominal exam rule out a AAA in the field? And just to set the record straight. While I did yank his hand away I did not reprimand him in front of the patient and to be more specific after the pt had been handed off it was during our debeif I asked him not to palpate the abdomen of my patients and gave him the above mentioned reasons.

When we transport a patient related to a fire incident either normal citizen or FD personel name, date of birth and something to the extend of "first aid and transport" are added into the incident histories notes. Other then that our dispatch center never sees any patient information. Our field supervisor (lieutient/captian) can't even pull runs without speaking with the CQI office/officer.

I don't know what the issue is in charting en route. Most of my assessment is done and interventions complete before we even begin transport. Our charting system is very basic and designed to be quick as it is. On critical cases I may only enter demographics or nothing at all. I know what its like to be "in the hole" with multiple charts and its not ideal.

I was called to a 57 y/o man complaining of a sudden onset of mid line abdominal pain while sitting in his office doing some paper work. Patient has a history of hypertension and high cholesterol and is non compliant with his meds. Patient had not eaten lunch yet and tells us the pain feels as if something is "pulling apart" in his belly and lifts up his shirt to reveal an vertical 5-8cm oval lump in his abdomen just off the mid line. While in route to the hospital my EMT "ride along" placed him on oxygen, moves down and begins to palpate the abdomen? I yanked his hands up telling him not touch the any of my patients abdomens, ever! Regardless of what anyone thinks is wrong with this patient, could someone please tell me why we still teach EMTs to palpate the abdomen!