Abdominal Exam

[Lone Star]

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.

If I have to stop at EMT-I for a while...am I 'worthy' of being taught....or do I have to wait until I can go to medic class before I can stop schlepping gear and actually be taught something?

I've put forth the effort to not only go through the Basic course twice, but I've also advanced to EMT-I...

[NRPinNEPA]

Reasons to palpate the abdomen...

Apendicitis

Ruptured ovarian cyst

Gastroenteritis

Gastrointestinal bleed

Abdominal aortic aneurysm

Crohn's disease

Intestinal Obstruction

Diverticulitis

Intestinal perforation

Ulcerative colitis

Need I go on?

As for students performing actions while on clinical time, my paramedic program is designed to gradually transition the student from observer to being primarily responsible for the patient, like JPINFV suggested. In fact, our clinical time during our final semester is called "Advanced Pre-hospital Practitioner" and we actually get college credits for it. I am in the second semester, and the only ALS interventions I am allowed to performed at this point are IV therapy and phlebotomy, but my preceptors already have me interpreting 12-leads. They also basically let me run the call and do anything I am not allowed to do... medication administration, intubation, needle thoracostomy, etc. I fully support this type of training because it allows the student to make the decisions themselves while they still have a paramedic there to catch them if they fall.

However, when I started, I was allowed to do nothing more than EMT skills and assessments. Again, I fully advocate this approach because it allows the students to build good strong assessment skills before worrying about interventions.

[VentMedic]

If I have to stop at EMT-I for a while...am I 'worthy' of being taught....or do I have to wait until I can go to medic class before I can stop schlepping gear and actually be taught something?

I've put forth the effort to not only go through the Basic course twice, but I've also advanced to EMT-I...

Did you notice EMT-I will no longer be one of the levels?

[Lone Star]

Did you notice EMT-I will no longer be one of the levels?

Yeah, My 'official title' will be Advanced EMT (but only until I get through medic class)....

I've never been hung up on titles, so I'm not really sweating the 'title change'....

[daedalus]

"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

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.

[kohlerrf]

Reasons to palpate the abdomen...

Apendicitis

Ruptured ovarian cyst

Gastroenteritis

Gastrointestinal bleed

Abdominal aortic aneurysm

Crohn's disease

Intestinal Obstruction

Diverticulitis

Intestinal perforation

Ulcerative colitis

Need I go on?

As for students performing actions while on clinical time, my paramedic program is designed to gradually transition the student from observer to being primarily responsible for the patient, like JPINFV suggested. In fact, our clinical time during our final semester is called "Advanced Pre-hospital Practitioner" and we actually get college credits for it. I am in the second semester, and the only ALS interventions I am allowed to performed at this point are IV therapy and phlebotomy, but my preceptors already have me interpreting 12-leads. They also basically let me run the call and do anything I am not allowed to do... medication administration, intubation, needle thoracostomy, etc. I fully support this type of training because it allows the student to make the decisions themselves while they still have a paramedic there to catch them if they fall.

However, when I started, I was allowed to do nothing more than EMT skills and assessments. Again, I fully advocate this approach because it allows the students to build good strong assessment skills before worrying about interventions.

Palpating the abdomen could not rule out or rule in anything you have listed here. Your presumptive diagnosis for the above is easily obtained by taking a proper verbal history, a physical exam (excluding probing the abdomen)and a series of accurated vital signs. In additon by not delaying transport and not taking the time for auscultation palpation and percussion of the abdomen the patient will reach definitive care and feel relief sooner. Tell me sir can you yourself, through palpation, tell the differance between Gastroenteritus and Diverticulitus? Would it matter if you could?

Frankly, even if I could tell the differance I would still just tell the ER the patient has an acute abdomen along with the history, signs and symptoms I had found as I would not want to be responsible of possibly misleading the Doctor causing him to miss a real problem that I may have missed on my exam. The specific diagnosis of non traumaic belly pain is far beyond my skill set and scope of knowledge.

[Dustdevil]

Wow. Just.... wow.

It seems that there are at least three different questions here:

1. 
   
   
2. Should abdominal palpation be done on this patient?
   
3. Should it be done by an EMT or EMT student?
   
4. Should it be taught to EMTs at all?
   
5. 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.

Edited January 2, 2010 by Dustdevil

[Siffaliss]

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.

Good point ... proper technique and *hopefully* normal findings can be taught on a classmate/friend/whatever. It would be good to learn on several different shapes and sizes, as 'normal' will feel different on each one. So once a student learns what is baseline/normal they can progress to learning what is abnormal.

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.

Yup!

However, when I started, I was allowed to do nothing more than EMT skills and assessments. Again, I fully advocate this approach because it allows the students to build good strong assessment skills before worrying about interventions.

So, after a few hundred calls and several months or even a year or more of building on basic assessment skills, perhaps it's time to introduce something new (and in scope) if the EMT is ready. If not to practice, then at least for knowledge. Interventions of course come much later and with the additional class time.

Edited January 2, 2010 by Siffaliss

[Dustdevil]

So, after a few hundred calls and several months or even a year or more of building on basic assessment skills, perhaps it's time to introduce something new (and in scope) if the EMT is ready. If not to practice, then at least for knowledge.

I don't want to jack the direction of the thread, but I certainly agree with this. And I am not against giving basic students advanced concepts and procedures to practise. But the key term in your statement is, "if the EMT is ready". This is, for the most part, an anomaly in US EMS education. Consequently, it's not something I advocate tossing out there casually. But when I get a basic or basic student with a solid medical background (nurse, RT, corpsman, or other allied health professional), or a solid foundation of educational prerequisites (A&P, etc...), who has a good attitude, an intelligent demeanour, and a solid grasp of the basics, I am all for giving them as much education and experience as we can manage in the field. But again, this is just rarely the case here.

[kohlerrf]

Wow. Just.... wow.

It seems that there are at least three different questions here:

1. 
   
   
2. Should abdominal palpation be done on this patient?
   
3. Should it be done by an EMT or EMT student?
   
4. Should it be taught to EMTs at all?
   
5. 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.

I did not intend this thread to be about teaching styles, perhaps I should have been more clear about the events. Any one who chooses to ride on my truck knows me well. That is why they ride. I make it known that "your are not in Kansas any more Dorothy" Riders work on the patients on my truck and they are not mules. EMTs and Medics alike are given free reign and are also made responsible for their actions. I have ZERO tolerance when it comes to patient care and everybody respects that. Should I step in during patient contact there is no discussion, the patient is my responsibility and is treated my way and handed off to the ER. Afterwards we debrief and I explain and entertain discussions. Yes I yanked his hand away as I feared no good could come of this action and there was a remote possibility of disaster. There was no admonishment in front of the patient and care was seamless and continuous in route. The EMT continued and finished the balance of his physical exam on the patient and logged several sets of right and left B/Ps. This particular EMT, as well as many others have been back several time to ride with me again by choice because they want to learn and not just taught!