Did You Look And Feel? Hands and eyes on?

[Ridryder 911]

As they say, you learn off your mistakes.. I once had a call that a first day employee complained of testicular pain after a large amount of dirt (they were placing industrial sewer lines in) fell on top of him. Of course, the foreman pointed out it was his first day and he was walking around.. describing severe pain.

Being the jaded Paramedics we were, my partner was already beginning his PCR report before I had latched the stretcher. I noticed blood in the heavy jeans. I suggested we examine further (the look of shock on my partners face). Upon further examination, what was revealed was a eviscerated testicle. Now, real shock was on our face... even more so than the patients....

I learned off that experience. If you do not see or look, you do not examine. You do not examine, you do not assess... you do not assess, you are performing negligent care.

I get irritated from medics who describe... "their bleeding from down there"... not knowing if it is from the rectal or urethra.

Many will describe that it does not matter... again, how are they going to document on an assessment? Amount, color, origin or are they going to describe on what the patient described? Because of such assessments, one has to assume that further half arse assessments will occur. Remeber, high possibility of missing injuries on trauma patients, even GSW or stab wounds can be very small and difficult to locate.

I have always endorsed using all senses on patient assessment. As an educator, I always endorsed "hands on" practice with fellow students. Even blind folding the examiner, increases the awareness of palpation and tactile examinations. Many times our initial examination is in the dark. One can learn and recognize normal anatomical structures versus abnormal and the feel of wetness, warmth, etc with a gloved hand.

Again, we want to be a health care professional, we must perform as such.

R/r 911

[DwayneEMTP]

The fewer "auto-mated" equipment the better. I just don't trust those machines, i.e. BP cuffs, etc.

I was teaching a BTLS class a while back and a buddy of mine was guest speaking. He gave a true scenario where a 22yr. female riding a bike collapsed. No outward visible sign of trauma other than minor abrasions to left hand and shoulder. Got her loaded and started to expose for assessment. Removed her loose fitting sweater, she had GSW to the chest. Evidently with the loose sweater no entry hole noticed. Her padded bra was absorbing blood loss. Can you imagine what it would be like if no one had exposed or did a hands on assessment what would happen when they got to the ER and that wasn't caught in the field? Sad to say, but stranger things have happened.

I sometimes share Anthony’s point of view. Mostly, for example the way sexy 18 y/o girl that was out clubbing with very few clothes on and got in the fender bender...I want to be thorough, but am not yet comfortable with how much is enough...

And with my inexperience (about 350 pre-hospital patients so far) I have to wonder... if, after brining in 50 cute bicyclists without their sweaters, and without bullet holes, if you're going to have your medic ticket long enough to ever find the one patient with the bullet hole? Do you know what I mean? I've found that most exams can be done by moving clothes around, but that still doesn't eliminate the need for the ability to defend being under them in the first place...

I think for many of us new to the field, and with so many pervs on the news, there is going to be a tendency to feel hinky when getting under people's clothes, (Not so much with the less attractive it seems. Not because they are less valuable, but because perhaps we feel they wont be looking as hard for ulterior motives?) until we've done it enough to be able to defend our decision to others when the need to do so wasn't immediately obvious.

Don't misunderstand. Felling 'hinky' is certainly not synonymous with becoming mentally/professionally impotent in these situations. It won't effect my decision to deliver the best care I'm capable of. But I think that this might not always be the case for others though...which is why I feel the question is important.

The further I go in my education, the more I find that good medicine isn't mandatory, but is noticed by other's that take medicine seriously. But even good medicine isn't the complete picture..You need to keep your eye on the monitor and your drip rate while keeping politics, innuendo, and the perceptions/biases from associated disciplines firmly in your peripheral vision.

Dwayne

[AnthonyM83]

I sometimes share Anthony’s point of view. Mostly, for example the way sexy 18 y/o girl that was out clubbing with very few clothes on and got in the fender bender...I want to be thorough, but am not yet comfortable with how much is enough...

Exactly. I had a low speed TC, neck pain. Nothing else remarkable. I felt awkward doing a full rapid trauma assessment when she was transferred to us already on the backboard, seeing as she was hardly wearing anything and I wanted to check ribs, palpate all quadrants (gets close to pubic area), and check stability of arms and legs (which I always do even if they look/move fine just as routine).

I guess best defense is documenting how you do your trauma assessments each time. That PCR will save you...but even if they're not actually going to complain, there's the fear of just seeming like the creepy EMT (I was more worried about it when I was weeks new b/c I was hesitant about everything and realized it might seem like I was hesitant b/c I was making up reasons to touch).

Now, I have more of a routine and will say "Okay, I need to check the stability of your chest wall and ribs like this" as I turn my hand sideways and they can see I'm taking care to push down with the side of my hand (karate chop style) and not just groping.

Of course, if it's a clear-cut critical trauma, then it's easy b/c you HAVE to do it...and pts usually not even thinking about what you're doing

[spenac]

In a court of law the question asked will be what is the standard of care.

If you answer I do it based on what I feel is appropriate you will lose. The lawyer will show you were not acting in accord with the accepted standard which will be PHTLS or equal for trauma.

Now if you are accused and asked why you removed clothes and you produce the book to back your reason, you have proven that you have done what is standard care.

Obviously we want to protect peoples privacy, but we must do a complete professional exam to avoid risk of negligent care.

[captainstandup]

On a couple of other topics I was just surprised at how hands and eyes off people are in treating their patients. I was taught in all 4 levels of EMS school I have taken or taking that to do a good exam requires all our senses except taste, and sometimes taste comes into play as odor is so strong you taste it. What do you see, feel, smell, hear? I was taught that if a person complains of something say stomach pain you expose and see if anything visible, then you palpate starting on the areas w/o pain moving to the painful area, finally you auscultate the area. During this you may note various odors. Even in clinicals a the hospital I was asked to do all the above and even had Docs bring to my attention some of what I was feeling or hearing.

So my question is am I the only one taught this way? While it may not affect our immediate care of the patient do you feel it is still part of a proper EMS exam? What are your thoughts?

Only posers & mutts "assess" without touching the patient and utilizing all of the senses spenac mentioned. Although it may look good in a report to list all of the crap one allegedly does for a patient, there is no substitute for actually utilizing our education & training to the benefit of our patients. Who knows, we just may become better at it!

[ccmedoc]

Really this made me think back to an old topic:

http://www.emtcity.com/phpBB2/viewtopic.ph...71&start=45

While it was agreed not all need to be naked, based on what people are saying here definitly need to expose area of compaint, touch, and listen.

There are a multitude of ways to expose areas of the body while maintaining modest privacy. Blankets, towels, etc. There is no good excuse for listening through clothes, or missing wounds from not visualizing. There is also no good reason for having a totally naked patient in the back of an ambulance.

Inspection, Auscultation, Palpation, Percussion (Look, Listen, Feel, Thump). In that order.

Nearly correct... Inspection, auscultation, percussion, palpation for abdominal assessment. All others should be inspection, palpation, percussion, and then auscultation. The reason for the abdominal alteration is to minimize the increase in peristalsis due to the palpation. This could give a false increase in bowel sounds, thus a false assessment.

And, again, always palpate the area that is noted as painful last. Minimize guarding and such.

[spenac]

Patients should be completely naked but covered for privacy. We can not be bashful. Get in there look, listen, and feel.

[firedoc5]

Patients should be completely naked but covered for privacy. We can not be bashful. Get in there look, listen, and feel.

We had a young lady ejected from a vehicle. Got her loaded and started to assess her. She balked at having her blouse opened. Understandably thought she was concerned of exposure. But when we cut her bra, BOING, out flew the foam rubber. That's what she was embarrassed about.

[spenac]

We had a young lady ejected from a vehicle. Got her loaded and started to assess her. She balked at having her blouse opened. Understandably thought she was concerned of exposure. But when we cut her bra, BOING, out flew the foam rubber. That's what she was embarrassed about.

Women do get embarrassed by things like that, just like if they cut your pants off and the socks fell out. Another thing is when they are menstruating. I always made a habit of asking if they were on their period. If so made sure I had a pad to put in place after quick check that not bleeding excessively.

[Ridryder 911]

Patients should be completely naked but covered for privacy. We can not be bashful. Get in there look, listen, and feel.

Usually most learn to use common sense. The very minor fender bender, falls, etc. non major traumatic patients with specific isolated injuries may not have to be exposed. The difference is knowing and being able to determine those that have potential injuries and those that do not.

Because someone twisted their ankle does not give us the right to totally strip the patient. I had assume that this would never occur, but unfortunately I have seen in the past such occurrences, again for no reason other than they were told to "strip all trauma patients" . At the oppossite end, those that should have exposed and examined patients and did not because of hestitation.

Unfortunately medicine and EMS is not black & white, it is gray. One has to make decisions based upon education and experience. This is what gets many into trouble.

R/r 911