Abdominal Exam

[VentMedic]

So, is there evidence that basic EMT abdominal assessments are inherently unsafe in a patient with a suspected AAA?

Take care,

chbare.

Anyone can poke around on a belly and say "gee that feels weird".

Will an EMT-B be able to make the diagnosis of AAA vs Bowel obstruction vs necrotic bowel or vs any of the many other adominal abnormalities?

But, anyone can also stick a piece of plastic down someone's throat and call it intubation.

When do we stop in EMS with doing a "skill" without proper knowledge and education as to why, when or when it should not be done?

Edited January 1, 2010 by VentMedic

[chbare]

However, some of the people have questioned the safety of an abdominal assessment. I cannot find any evidence where a patient acutely deteriorated when a basic EMT palpated the patient's abdomen, precipitating rupture of the aneurism.

Take care,

chbare.

[treaux]

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.

[Siffaliss]

Sure it's probably safe to say that an entry-level practitioner does not have as much knowledge of pathophysiology as a paramedic does. So the entry-level person cannot interpret or treat their findings as someone of a higher level can. The way this situation in particular was handled while still on car in front of a patient however, was not appropriate.

[VentMedic]

In any healthcare profession you are not allowed to do certain assessments until you have mastered a certain level of education and training. A CNA can not do the same assessment a nurse can nor would they ever be expected to. A doctor who is a general practitioner will not do a neuro exam the same as a neurologist. If you are a med student, you will be told when you are ready to do complete physical exams.

Before one embarks on exams, for the sake of the patient for both safety and hands on intrusiveness, one should have some base knowledge and confidence of what they will be assessing. Thus, it doesn't matter if you are going to do more harm to the patient or not but if you understand what you are doing and not just coming off like you are poking around.

Also, one has to remember all the other health care professions do have strong prerequisites before they do hands on thus they have the background to associate what they are feeling with what could be a disease process.

We could also use EKGs as an example. How many look at an EKG and say "that looks like what I saw in the ED a few years ago and I think it was.." rather than actually having an understanding of how to interpret an EKG piece by piece? How many look at a patient and allowed their past experience skew their judgment because it "looked like" rather than doing an assessment to gather actual facts? This comes when some do not have the base education to create a foundation of knowledge to properly assimilate the physical data they might come across. Thus, you end up making the patient uncomfortable and can do little to change their "abdominal pain". You may increase the pain and who knows if you did more damage since there is not a CT Scan immediately prior to you touching and one immediately after.

I have seen patients crash during a physical exam and who is to say it was due to the exam or just time for the AAA to become a serious problem. As well, one has to remember, a physical exam can be stressful for the patient especially if it causes pain or the provider is inexperienced and lacks the knowledge to know when, how and why. That in itself can exacerbate some conditions by changing the vitals according to stress levels.

[Lone Star]

I didn't confuse 'basic tools with Basic skills'. I DO know the difference, and DO know they are not 'interchangeable terms!

Before you worked your way to your current level of medical knowledge...what did you REALLY know?

At what level do you finally agree that the new EMT should actually start learning what to do and WHY to do it, as well what the findings actually mean?

MFR?

EMT-B?

EMT-I?

EMT-P?

Where do you draw the line between actually teaching them, and just letting them wear the uniform to schlep gear?

As far as Pre-med being the 'Doctor Basic course', the analogy is valid. Education has to start somewhere....

Why crucify the EMT-B for their 120 hour course? It's not like THEY are the ones that set the requirements! You want to crucify someone for the 'minimalistic approach' to education....then go to the NREMT and the State EMS office that sets the requirements! These new EMT's are only doing what is required of them.

Just as secondary education builds off of what has been taught in our primary years, the EMS cirriculum copies this concept. As the new EMT progresses through the license level 'food chain', they learn more and more about what they're doing, when to do it and what they find actually implies. The EMT-B course gives the 'basic tools', and as they progress through their education, they learn how to use these 'basic tools' to provide the definitive care their patients need.

Sitting around bitching about how the 'new crop of EMT's don't know anything', maybe the solution is to teach them! Rather than sit around bitching about how the field is 'short handed'...maybe encouragement to advance would be more beneficial than running off those just getting into the field....

Something HAS to give here. It can't be both ways.

If people that are veterans with field experience are consistently running off the 'newbies' and not helping them to learn; then you are part of the problem, as opposed to being part of the SOLUTION!

*DISCLAIMER*: The 'you' being referred to in the above statement is NOT directed at any single individual, but at a speciffic mentality.

*edited for spelling errors*

Edited January 2, 2010 by Lone Star

[VentMedic]

Before you worked your way to your current level of medical knowledge...what did you REALLY know?

Once I got to the next level I realized how little I knew and probably shouldn't have been allowed to do half the things I did. Those just starting in the lower levels really haven't gotten even a good sampling about medicine or Paramedicine.

You can palpate an abdomen all day long but if you do not know what you are palpating or just know one big disease process, what exactly are you doing?

Why crucify the EMT-B for their 120 hour course? It's not like THEY are the ones that set the requirements! You want to crucify someone for the 'minimalistic approach' to education....then go to the NREMT and the State EMS office that sets the requirements! These new EMT's are only doing what is required of them.

But who makes them stay at the EMT-B level either by certification or by education? Who says they can only have 120 hours of training and can not take any college classes to expand their knowledge? Often it is the provider themselves that sets the limits to what they know regardless of what they are or are not allowed to do.

But, some still complain 120 hours of training is way too much for them and what little book learning is in that class should be eliminated.

And going to the NREMT and state offices is exactly what has been done and hopefully the changes in 2014 will be a start although not near enough.

Have you reviewed the new levels?

Edited January 2, 2010 by VentMedic

[chbare]

Even so, you may be able appreciate something, then relay that information to the best of your abilities. If performing an assessment were somehow harmful, I would be more concerned.

Take care,

chbare.

[Lone Star]

I've seen that there will be a change in the EMT titles. I haven't seen anything on the new scopes of practice yet.

But My question still remains unanswered....where do you draw the line between only letting them schlep gear and actually take the time to teach them something that they don't know?

[VentMedic]

I've seen that there will be a change in the EMT titles. I haven't seen anything on the new scopes of practice yet.

They're everywhere on the internet.

But My question still remains unanswered....where do you draw the line between only letting them schlep gear and actually take the time to teach them something that they don't know?

Yes I have. When they put forth the effort to learn a little more A&P to actually know what they are palpating.