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Of course it was me that gave you the negative. Normally you're whining and whatever nonsense you spout in the chat room keeps others feeling sorry for you and prevents them from doing so. But why do you assume that I'm a jerk for giving you a negative? Why can't you, like an adult, assume that I thought that your arguments were shallow, one dimensional, self serving, cookbook Basic level medicine and simply not good educational material on the board? Isn't that what the votes are for? To show others my opinion of your thoughts, either exceptionally good, or exceptionally bad? You continue to espouse 'proper' exam. And I couldn't agree with you more. You simply go so far out into left field that your opinion loses my support. Wasn't it you, months back, that said that if we let a speeding car pass, or one drive through a yellow light without calling the police that we may have just allowed a kidnapper to escape with his victim and that we should be ashamed? That's what I'm talking about. Your thinking is so one dimensional. It's too shallow. You sound as if you're constantly doing scared medicine. "What will the ER complain about? What can I claim that I do that everyone with think is very unusual and heroic?" I'm hoping that I misunderstood you when you asked why we take blood pressures when it won't change my treatment as I can't raise or lower blood pressure? I can do both...did I misunderstand? If so, then I apologize, if not, then they should shred your medic ticket today, right now. I hope that you're a good provider, but I don't believe that you are, and I'll tell you why. You are too inflexible. You take the first thing that pokes itself in front of your nose and makes sense to you and you commit to it, fully unwilling to change your mind. The very best educational moments in my short career have come from exposing my own process to others, having them say, "But what about X?" At which point I often said, "Holy shit...I don't know how I missed that..I screwed the pooch on that one." Also, your skin is so thin as to be near transparent. No one simply disagrees with you because they don't respect your opinion. They "don't like you" or "have it out for you" or some other such nonsense. I've been watching for the shout out, if we still have them, saying something that resolves in, "Oh poor me, everyone is so mean!" Ive not known a provider, and I've known a few really good ones now, that are so easily offended, nor so quick to discount a valid opinion as simply mean spirited harassment. I've gone to the friggin' mat with Dust, ak, an many others here much smarter than myself and at times left feeling pretty good, at other times bloody and beaten, but still I count each here that has intellectually bashed my head in amongst some of my closest friends. When Wendy used to correct my grammar and spelling I wanted to choke the shit out of her! But I know present myself, though not as well as I'd like, much, much better than I did before she took me to task. (Watch, now she's going to shred this post...and I'll say thank you, though perhaps it will be hard to understand through my gritted teeth.) Do I like you? No idea. I've not given you enough thought to develop an opinion. Why do I care then if you give opinions that I disagree with? For two reasons. First, I believe that there is great power in strong debate. If I confront your best argument with my very best argument, perhaps we'll both leave with some wholly unexpected piece of knowledge that neither of us would have gleaned on our own. Secondly, and much more importantly, there are many, many young, and/or new providers here that come with the belief that we are here to help them, as well as learn from them. You are willing to take an argument that you believe Dustdevil would have made, only he was most often right, and present it simply to feed your ego, to have the young/new come to you and say, "My God! You are so brave!! I would never ask a woman to expose her vagina and use her hands to spread her labia! You're a rockstar!" You plant the seeds that will send them into the ER glowing only to have the ER physician say, "What were you thinking? Where did you go to school? Are you an idiot!?!" Do I believe that you would always employ those interventions? I don't. I believe that often you simply present them, and then swear by them, for effect. What is a proper exam? Initial impression, good sets of serial vitals, an in depth current/past history to include current medications whether compliant or not, an attempt to get a decent feel for my pts frame of mind, and depending on their chief complaint exposure up to the point that I believe it is necessary to support or retard my working diagnosis. SPO2, monitor, etc? Sure, if indicated, but they are mostly toys and I can't really think of a time that I couldn't guess what they were going to say before I read their fancy little screens. And as expected, you ignored my questions, which I'd presented carefully to make them relatively easy. Do you spread the cheeks of your 70 y/o hemorrhoid pt? Palpate? Do you expose your kidney stone pt that has radiating pain into her groin? Ask her to spread her labia for a peek inside just in case your working diagnosis is incorrect? I worked with a new medic that wanted to put 15L NRB on every pt that she believed needed O2. I suggested that she use more appropriate amounts when required. She said, "Why? It's not going to hurt them, and it's better too much than too little." I told her that in the vast majority of cases that she was right, the pt was not going to be hurt, but she was. That the people that view her treatments, or take transfer of care of her pts are going to expect her to know how to determine, and then use, appropriate interventions. She thought I was silly and is now little respected around her peers, and worse, her betters. That seems to be what you're suggesting here. I will expose the genitals and ask an already damaged pt to spread her labia so that I can best examine her whether or not my thorough exam reveals that this is a prudent step. A vagina is an amazing and wondrous thing, but I promise you this. No matter how macho you think you are, how many "babes you've bagged", nor how many books you've read or videos you've watched, you will never know more about the inner workings of that freaky little machine than it's owner. Peds and trauma excluded of course. Is it leaking icky stuff? Sure, and it smells nasty! I can't justify being down there under the guise of alerting the ER to this fact. Is it swollen? Yeppers! How come? Beats me, and I can't justify collecting that information under the guise of alerting the ER. Is she tachy, diaphoretic, appearing to be trying to smuggle a giant watermelon under her shirt while she screams "I think it's coming!!!" Ah, see, this might dictate not only a peek, but a good hard look. But my physical exam already told me what to expect before I dropped her drawers, right? I once exposed a rape victim and examined her genitals because she claimed that her attackers had stabbed her multiple times in the rectum and vagina with an ice pick. And the area was a mess. It was ugly, disturbing, but it turned out that she had inflicted the wounds herself. Did I need to expose her? I believe that I did, as I could see blood through her clothing at the vagina and rectum and believed that bleeding control might be necessary. Would I have exposed her if I hadn't seen blood? Absolutely, as she told me that she had been stabbed in that manner and I'd want to look for signs that she had compartmentalized bleeding or that it had perhaps been tamponaded (? Not sure that that is a proper word) in some way. I also checked femoral/pedal pulses, checked cap refill, and did a lower extremity neuro exam on the way to the ER (as well as prudent, associated interventions) in case there was hidden vascular/nerve damage. Those are things that I believe the ER might benefit from knowing at, or prior to my arrival. A lot of people here have tried to express their views of your opinions and you've narrowed it down to "everyone thinks I'm right except those that don't like me" again. You need to let that go brother. Many here, such as Wendy, Matty, Dust, akflightmedic, Kaisu, etc, etc, have told me that at times I'm an arrogant, ignorant asshole. And you know what? In each case I went back, reread the posts that caused them to draw those conclusions, and I can't think of a time that they were wrong. Despite my best efforts, sometimes I simply go off into the ditch. And I thank the powers that be that there are people here willing to say, "I know you think that you're right here, but you need to trust me when I tell you that you are thinking and behaving in a way that you wouldn't like if you could see it from the outside looking in." Step back from the self pity man. Stop making an argument simply because you believe you will look ignorant if you reverse your position once chosen. There is not a single person here that I respect that doesn't say, on a regular basis, "I don't know" or "ooops, I see your point." It won't kill you...trust me. Dwayne

Spenac, time for you to go back to the basics... It'd be a good idea for basics to sit a patient up that has a high blood pressure, and lay a patient down for low blood pressure. There, that was simple. -5 for a stupid question. If you don't know how a cat scan can change the treatment, then go get a book. -1, for simple ignorance. Spenac, this could be such a great topic, but, being such a poser, you sure can run it into the ground. The sad thing is, I agree with a lot of what you say, but you're merely an echo, IMO. You have also echoed yourself, multiple times. Please, let me reference everyone to these posts, by none other than Spenac. This fetish of your's about exposing patients is really starting to be an old tune... You first posted about this subject on 06 May 2007 Here is a link. On 21 Jan 2008, you brought up the subject again. Reading through, its not a bad thread at all. Its title is "Did You Look And Feel? Hands and eyes on?". But, after your last post on 7 April 2008, why, I guess you just love talking about exposure so much, you bumped it on 22 Oct 2008. If you would like the link, Click Here. Oh, I almost forgot ! -5 for not using the search feature and duplicating a topic. But that just was not enough. On 17 March 2009, you just had to revisit the topic. And by the way, I just loooove the name of this thread "Proper Exam Technique - Expose or Fail". So, you apologized earlier for what seems to others to be an attacking delivery message. With a topic title like Expose or Fail, what makes you think we'd take it as attacking... Anyways, I'm sure everyone would like to see a link. Click Here -10 for not using the search feature and duplicating a topic, twice now. Also, another -5 for being hypocritical towards others about using the search function. Then there is the current thread. Here. The 4th time now that you have discussed it. Except now, as I have observed over the years, you have become much more pompous about your position. So, I guess -20 for a triplicate post and not using the search function, another -10 for being a hypocrite again, and another -5 for not using spell check, and other -5 for just being egotistical about this topic. Folks, honestly, this is a good topic to discuss, if you read some of the older topics, you'll see some posters from back in the day with some good things to say. Again, all Spenac is doing is echoing others, and then himself. I just hope people can see it for what it is.

So following your logic then spenac, when the 70 y/o male calls with bleeding hemorhoids then you must bend him over, ask him to spread his cheeks widely apart and examin his ass? I mean you must, as he called 911 which in your mind seems to imply that he is incapable of any type of reasonable thought without your intervention. Of course his 20 year history, list of meds and cases of Tucks pads is irrelevant? Do we expose a trauma pt? Of course? Do I expose the vaginal area of the female that claims to have fallen off of a ladder and landed spread eagle on the edge of her wheelbarrow causing blood to soak through her pants and undergarments? (real pt) No question. In both of those cases there is the near certainty that I will have some knowledge and expertise that can be of benefit to my patient, warranting the exposure. Do I expose the female that complains of spotting and some vaginal burning x 5 days? Of course not. She is the expert in that case. Good vitals, (And come on, you're not talking to children here when you describe compesated shock, as much as you'd like to believe that you are), good history is all that I'm likely to need to properly care for this pt. The female pt that complains of lower flank pain radiating to her pelvis and groin...Do you truly expose the genitalia of all of your kidney stone pts as they writh on the bed puking? I have to assign a meat gazer label if that were the case. I have examined many penis', vaginas and rectums overseas where longer term pain management, wound care and antibiotic therapy was within my scope of practice. In the U.S? Only if my intelligence, history, and index of suspicion would lead me to believe that it was a prudent medical intervention. How do you know if she's lying when she says she's spotting but is actually flowing heavily? You, as a medical professional should not only notice the change in vitals, but the giant blood stain at her crotch should cause some suspicion. As Matty said, your entire argument was predicted by the way you phrased the question. I've not been around much for a bit, but I'm guessing that the City has a bunch of new, eager, curious young minds, as that seems to be the time that you throw this type of silliness out there. Always properly assess your pts kids. We don't put a splint on for chest pain, we don't use CPAP for a twisted ankle, and we don't put pts in compromising, possibly humiliating situations without first developing an index of suspicion. Besides, if a good set of vitals, good physical exam (non traumatic, clothes on), and a rockstar history isn't enough to tell you that you're pt isn't bleeding to death through her vagina, than it's back to Basic class for you.... Of course, having said that, there are more than a few providers at the City that I would gladly allow to do a genital exam, regardless of my physical complaints... :-) Just sayin'... Dwayne

What we should have done was get our drink on as soon as the flight started, then we could avoid this whole situation. Since we missed that opportunity we need to start working the guy. I wouldn't divert the plane just yet. Let's work this guy through a few rounds of drugs and see where we are at that point. If we have no pulse, confir with the medical control and pronounce. Continue on to the final destination and let the airline handle the body however they are supposed to. If we are able to get a pulse back, then divert the plane and hope he doesn't code again. Diverting a plane is no small decision. There are far reaching affects that the airline has to consider. If you have someone that you are going to work for 45 minutes while you divert, there is no benfit in diverting as this person is not going to make it.

Expose if pertinent to your imminent assessment and treatment. DO not expose if no purpose other than just to have a look-see. Testicular pain? Expose. Might be swelling, torsion, something indicating immediate surgery. You may need to speed along the ER a bit. Pelvic pain? History-->expose if indicated in history... do not expose for just any complaint of pelvic pain. History is the key here. Building patient trust leads to a more accurate history. Pelvic exams won't tell you if she's ectopic, PID, menstrual cycle, etc... that is something that requires a doctor's evaluation to definitively establish, and they will be looking for clues in the history first before performing any exams or tests. Also remember that preserving patient dignity is paramount for us... where will they be most comfortable and who needs to see it the most? My answer: A hospital room, and the doctor. If it won't change your immediate course of treatment, and won't greatly add to the info you will be passing along from your assessment, don't do it. Rectal bleeding? Not much you can do for it... and gross bleeding is evident... so don't expose, unless suspected trauma or obvious gross bleeding. Spenac- I *like* you and I think it's dumb that you started this topic again. Round 2, same arguments, same viewpoint from you (always expose no matter what) and same people agreeing/disagreeing. So... it's not just the spen-haters who are going to rag on you for this one. Sorry bud! Wendy CO EMT-B

Triage is at the heart of what we do. In a multiple victim scenario, what do we do if a person complains of a sore finger? Do we do a complete 20 minute neuro exam, functional ability test, ROM, etc, or do we note the patient's complaint, classify him as nonemergent/green/etc, and move on? Same with someone who complains of a problem that we do not have the training, diagnostics, or permission to provide definitive treatment for. Do whatever is in the scope of our practice, and bring the person to a place who can properly assess and treat the patient. Does a triage nurse make a patient disrobe to verify they are having a vaginal bleed-with no obvious signs of excessive bleeding? Do they make a person display their hemorrhoids to confirm their existence and quantify their size before the person sees the doctor? Does that somehow make the triage nurse less of a professional, or not doing her job properly? Yes it is- if it is not in the proper context. Doing "more" is not always better, prudent, or even appropriate. But we are supposed to be "professionals". That means that by gawd, we need to expose- because we CAN. After all, simply telling the doctor a woman was sexually assaulted is not enough. We need to verify that statement and examine her. What professional should be afraid of a bit of legal trouble? Context. Proper time and place. I'm not big on mindlessly following orders without also engaging a bit of reason, logic, and common sense based on my experience and knowledge. That is what separates good providers from average ones. That's a big leap- from making decisions on the care we are trained to do, what we are allowed to perform, and where we transport to vs subjecting a patient to something for our own edification or an ego boost- especially when we KNOW that we have no way to definitively treat that person's problem or even alleviate their anxiety in any way. In fact, we would be making their unease even worse. Not happening. In some cases, a "proper" exam may actually be no exam at all. Exactly. So show me where in your statement that forcing someone to disrobe to see their hemorrhoids or purulent penile discharge fits into such a belief. I see no way how an STD or "piles" would ever be triaged as anything emergent, or even urgent. No, but things like vitals or a pertinent history can and often DO change how a doctor does things. Don't worry doc- our head injury patient- I saw no blood in the ears with my otoscope, the fundi look clear, and I see no signs of a brain injury- that CT can wait for awhile. Come on- really? Our opinions are nice- and depending on your relationship with the local ER docs, they actually may carry SOME weight. BUT- and this is a big BUT- if that doctor does not essentially ignore what you said and do the exam himself, he is being irresponsible, bordering on malpractice. It is now HIS patient, and HIS license on the line, not yours. You get to say- oops, I did an exam, I didn;t see anything, but I guess I was wrong. Then again, I'm a paramedic or EMT, so that's also really not within my realm of responsibility. A doctor has no such luxuries. Understood.

Thanks. I had no idea. (sarcasm) Otoscope? I would love to know how many prehospital providers use those. Anyway... We report what we see. Let's pretend we did use an otoscope and see an inflamed tympanic membrane,and the person seems to have a case of otitis. We don't carry antibiotics, so what exactly do we do? We report this to the doc, and will he simply write a script, based on our findings, or will he also take a look? We could tell him we think- or a patient suspects- she is pregnant and is having abdominal pain, so will he order an ultrasound simply based on our word, or do you think he might confirm that pregnancy with a beta-HCG test? I've never had a complaint either, but I also do not go beyond beyond my scope of practice. I do not pretend I spent 4 years in medical school plus a residency, plus having a whole tool box full of diagnostics.tests, procedures to confirm my diagnosis, nor do I have a definitive way to treat something like an ear infection, hemorrhoids, an STD, or PID. I can SUSPECT- and am usually correct- what may be going on with a patient, but unless I can definitively treat a condition- based on my training and available resources and protocols, I also stay within my well defined boundaries. Actually, an ER doctor CAN "fix", or at least begin to mitigate many "cardiac" problems. If he runs his tests he may see no reason to immediately activate the cardiac cath team because the patient is suffering from a muscle strain, angina, or indigestion. He will probably call for a consult in such cases, but the person will also not be immediately rushed to the cath lab for an angiogram. Again, we use our powers of observation, any tools we have, a detailed history, and an APPROPRIATE exam, and we can paint a very good picture of what we think may be going on. It's up to the doctor to confirm or shoot down our suspicions. I am very good at what I do, but I also do not expect ANY doctor- even ones that I have known and worked with for years- to simply accept what I say at face value. God forbid- if anyone I know is sexually assaulted(barring a massive bleed), and I find out someone in EMS wanted to do a vaginal exam just because they want to prove they are a professional- I will be doing business with that provider. First, we are not trained as ob/gyne's, we are not trained to look for, evaluate, or collect evidence, and we may very well even compromise a criminal case- and the benefit is only to the ego of the provider, not the patient. Good luck convincing an attorney that you are a "professional" while trying to justify why you did an internal or even cursory visual exam on a rape victim who is not in any way medically unstable or having massive trauma. Just be sure to provide the documentation of your rape advocate training, of your evidence technician background, and the protocols that allow you to do all this. If someone is complaining of penile discharge, tell me exactly WHY I need to expose and evaluate that discharge? What benefit would that be to the patient? Will I be inserting a swab to obtain a C&S? Will I be confirming a case of syphilis, chlamydia, or gonorhhea, while prescribing a course of antibiotics? I have no protocols for STD's in my system. Describe what the patient says with as many details as possible, evaluate their vitals, add any pertinent subjective data(appearance, demeanor, scene information, etc), and report your findings to the doctor. THAT is our job. We are VERY different than the ER doc. In every way. In terms of training, skills, experience, available resources at our disposal, responsibility, and liability. The proper expert in our case is medical control- the person who wrote your protocols, the person on the other end of the radio, or the ER doc where you deliver your patient. He/she is the EXPERT in their field, and has far more training and tools at their disposal than we do. Would you simply take the word of some bystander who claims they are a medic, and tells you that the trauma patient you are called is not really injured? Would you walk away, would you base your care/treatment/transport based on their statements, or would you provide the care and treatment you are trained to do? EMERGENCY medical services. That means we are trained to mitigate, fix, or maybe only transport- someone within very specific guidelines, in very specific situations, to obtain very specific- and generally temporary- outcomes.

OK, I am going to throw a female opinion in here. I would not under any (or at least any I can think of now) circumstances allow any provider who did not absolutely 100% necessarily need to to examine ANY of my privates. Even if the pt is in severe pain, there is nothing we can do by examining her that we can't do without the detailed exam. If she is bleeding, it will show through clothes and onto the sheets if it is heavy. Ask the pt if anything is stuck/ impaled, and if they say no, just trust what they say! Yes, some pt's will lie to you, but as someone else mentioned, pts lie and there is nothing we can do about it. Get a detailed history of the pt, when the pain started, type of pain, last menstrual cycle... Oh, and uglyEMT, " I do believe if the patient called us for pain in their genitalia then it would have to be pretty bad and I dont foresee them holding back information" You would be surprised some of the calls I have taken... let me just say that yes, I have taken a vaginal pain call where the pt was not in severe distress, just 3 am and mild discomfort... Again, as others have said, I think it is situational. If a woman is pregnant, and birth is imminent, than by all means, expose and do what you need to. Unless the call is very critical (and I mean, severe bleeding, pt unconscious... ) I would not expose. Sorry if this is disjoined, I went on a call in the middle of typing it...

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.