Abdominal Exam

[Eydawn]

Lone, I see a lot of my earlier attitudes mirrored in your posts. I used to think that it was foolish to view lower level providers as somehow detrimental to the system. The pure and simple fact of the matter is that it is not about the *PEOPLE* at the lower levels, it's about the basic education all of the levels receive (or lack thereof) and the culture surrounding education. You can only do so much with limited understanding, and unfortunately, since school is expensive, employers and unions fight to keep the lower standards.

You, my friend, are the EXCEPTION, not the rule when it comes to the whole "intelligent provider" thing. You seek to expand your understanding and advocate for a teaching culture. Most people functioning as EMT-B or EMT-I simply are not aware of their educational shortcomings, and as such, fail to appreciate the greater understanding that comes with education that is appropriately approached. You're right- someone can have had all the "education" (aka: classes, degree, etc.) in the world and still be a freakin' AWFUL paramedic. No bones about it. However, the best EMT-B in the world will only EVER be able to practice with a shallow understanding of medicine unless they avail themselves of the educational opportunities that are out there.

Nobody is saying that by virtue of only having had EMT-B or EMT-I education that someone is an intentionally shoddy provider... what we are trying to say is that our patients deserve the best possible medical practice we can give them, and that involves educating ourselves and promoting a climate in which knowledge is valued and put INTO PRACTICE in our every-day interactions with our patients.

EMS providers who are preceptors and educators should without a doubt try to explain material and provide more education to those they are responsible for. However, there is only so much you can teach someone about medicine if they haven't had the building blocks, per-se. It's like teaching someone who hasn't learned the alphabet to read in multiple languages. And sure, you could teach every single student who crosses your path the alphabet- but maybe that isn't really your specialty and you aren't the best person to teach them that system. It's the same deal with human anatomy, physiology and psychology. Sure, any of us who have learned something in those fields can pass on what we've learned to others, but students should receive the best instruction they can from people who specialize in those subjects.

Irritation with the system in general is what promotes the "eat the young" mentality. I got chewed pretty hard when I made my first attempt into the field... because I wanted to use knowledge and think about medicine (being younger in that regard, it takes me more time to synthesize and put it all together), and was trying to do so in a system that didn't value that approach. It's easier to brow-beat someone and get them to accept half-ass practice at their level than it is to bring every single person up to your level, especially if your system rewards that kind of mentality and n00bs learn that you can coast by WITHOUT learning more as long as you keep your head down and your mouth shut.

Don't think it's just EMS though. There's entire journal articles written about "horizontal hostility" with regard to nurses and the in-fighting and bullying that happens in the field of nursing. EMS isn't the only field with its head in its arse (generally speaking)with regard to how students and newer practitioners are treated--not to say that all EMS companies and all avenues of nursing have this problem, but that it's wide-spread enough for there to be articles written on it...

I hope this makes sense.

Wendy

CO EMT-B

[Kiwiology]

I'll have to disagree with the assessing to things we do not fully understand (as even a paramedic doesn't fully understand every finding he has). In high volume hospitals with wait times up to several hours at time, the information we present to the triage nurse can greatly influence whether patient is sent to the primary ER, the secondary ER without monitored beds, or the outside waiting room or lobby. The nurses do not have the time to perform a full assessment on each patient. It's not uncommon to have 2 codes going on at a time, STEMI patients waiting for a few minutes in a hallway, SEVERE respiratory distress, and so on (you get the picture, sure you've seen it more than I have), so incoming patients get a quick report from us and frighteningly if we don't give any indications that there's something urgently wrong, then they don't necessarily ask.

This supports my view that while ambo's may not be internal medicine registrars or consultants by any stretch of the immigination that what findings are passed on even if they are nothing more than "abomden rigid to palpate" when combined with MOI can assist in triage. Not unlike serial 12 lead ECGs on a chest pain patient who when hooked up to the hospital monitor has no ST changes.

Good example from the other night was an MVA patient who was the driver of a car that rolled at high speed; his abdo was very rigid to palpate.

Lets say that bit of info doesn't get passed out; ok guy rolled his car, yeah its bad but hmm no beds in monitoring, GCS is 15, bit of gravel rash and thats it, hmm, put him in the hall .... go back to check in 20 minutes oh dear, he bled out from a lacerated liver whoops.

I am the first person to admit I'm shaky on patho of abdominal trauma and it might mean something totally different than in internal bleed but eh, one and ome make five right? Just because I do not understand something fully doesn't mean I won't pass it on and go "eh, by the way ..... "

Edited January 14, 2010 by kiwimedic

[VentMedic]

Don't think it's just EMS though. There's entire journal articles written about "horizontal hostility" with regard to nurses and the in-fighting and bullying that happens in the field of nursing. EMS isn't the only field with its head in its arse (generally speaking)with regard to how students and newer practitioners are treated--not to say that all EMS companies and all avenues of nursing have this problem, but that it's wide-spread enough for there to be articles written on it...

There are also many good reasons for a firm hand and even what some take as "bullying". I personally have been greatful either as a new Paramedic or RRT when someone prevented me from pushing the wrong med or inserting an A-line in not the best location because I didn't check other meds or history. I didn't forget those lessons. As well, if you crawl off to a corner each time someone raises their voice to you, how are you going to handle difficult patients, families and doctors who might want you to do something that clearly is either not within your scope or give a medication that may harm the patient? Also, if you resort to foul language or just being defensive about everything, are you really going to accomplish anything? The "bullies" will teach you self control and how to plan your approach to where there will be very few situations in your career you can't handle. If you have even seen some that have been chased off in nursing, EMS or RT by the "bullies", you might have to change over and defend the bully a little.

While there are some really good mentors in all professions, the better ones are not those who help you find excuses for your incompetencies. If they know you've got the right stuff they will push you to reach your fullest potential. No one wants to work with someone who can't stand on their ground and do what is right for the patient and their co-workers.

That should include EMS as well. Why do we continue to make excuses and baby this profession like it was born yesterday when it is very much middle aged? If you want to do a "skill" you should have the education to back it up for at least the hands on part even if you don't understand all the pathophysiology. You should also have enough education and training to know when not to do a skill. If a knife is protruding from the abdomen are you going to palpate because your protocol says you can even if you waste time and can do more damage pushing the organs into the blade?

In the original post there is a visual of the situation and a good description from the patient. Do we really need to poke at the belly to make sure it really hurts or if another lump will appear?

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.

There are other situations in EMS where one will have to make a decision of what to do and what not to do. Trauma brings in many factors with "stay and play" or "load and go". For years we were taught we HAD to get to the hospital real fast and then it changed to where we HAD to do everything on scene. Then it changed again for some to where those who had a proper education could decide what was best for the patient. We've seen this with IV fluids, intubation and now backboarding GSWs.

[medichopeful]

I'm not trying to invalidate education, I'm standing up for those that are just coming into the field and getting hammered because of the mentality that 'if you're not a paramedic, you don't have a place in the EMS system.

We do have a place, but it should only be under direct supervision. Let's face it, we (EMTs) do not know ANYTHING when it comes to the field of medicine. The education and training is a joke. It is nothing more than advanced first aid. So we do have a place, but only as first responders OR as part of an ALS unit in a supporting role.

[Eydawn]

There's a boatload of difference between a firm, professional correction or intervention and flat out bullying and hostility. I'm not talking about getting yelled at when you're about to majorly screw up, I'm referring to unprofessional behavior, much of which happens BEHIND the care scenes... It is one thing to yell "Where do you think you're putting that line, STOP!" and "You f*cking moron, you have no idea what you're doing, give me that and get out!" You can't tell me that politics don't affect how students are precepted, and that it is not always beneficial. Also, many of the more "bully tactic" type instructors resort to that because they feel threatened in some way, or because they simply don't care to take the time to actually teach. All of us do things that we deserve to get chewed for. It does matter how the chewing is delivered, and for which reasons.

There is absolutely a trial by fire that must occur for a provider to become worthwhile. This idea cannot become a convenient excuse for workplace hostility. There is a difference between "rougher" teaching methods and methods of "teaching" that are wholly unproductive and even counter-productive, allowing those with poor practice to remain in charge because they have made themselves unassailable. You can have all the 'nads in the world and learn as much as possible from every encounter, and still end up with the short end of the stick because your instructors are less-than-optimal. And yes, we have to run off the chaff somehow... but having seen some of the folks that STILL somehow make it through nursing and EMS, I'm all for implementing more modern and psychologically adept teaching methods in order to better the odds of keeping the good ones and tossing the losers. What we do now, as far as I can see, could definitely be improved upon.

As far as me personally, I will *not* exceed my scope as long as that scope is clearly defined. Patient advocacy is first and foremost. Of course there will be rough situations- it doesn't mean that your instructor somehow needs to bully you in order to teach you critical thinking skills, which is what I'm kind of inferring from your post, Vent.

Wendy

CO EMT-B

[Kiwiology]

We do have a place, but it should only be under direct supervision.

I wouldn't perhaps go that far ....

Let's face it, we (EMTs) do not know ANYTHING when it comes to the field of medicine. The education and training is a joke. It is nothing more than advanced first aid. So we do have a place, but only as first responders OR as part of an ALS unit in a supporting role.

The truth is finally spoken

[VentMedic]

It is one thing to yell "Where do you think you're putting that line, STOP!" and "You f*cking moron, you have no idea what you're doing, give me that and get out!" You can't tell me that politics don't affect how students are precepted, and that it is not always beneficial.

I don't know where you work Wendy but I suggest you quickly change employers. In over 30 years I have not come across any ambulance service, FD or hospital that would ever tolerate an employee to be spoken to in that manner either at the bedside or behind closed doors. Once the foul language comes in, they are out of there. That also includes doctors who once tried such stunts and quickly learned the expectations of their peers.

As far as me personally, I will *not* exceed my scope as long as that scope is clearly defined. Patient advocacy is first and foremost. Of course there will be rough situations- it doesn't mean that your instructor somehow needs to bully you in order to teach you critical thinking skills, which is what I'm kind of inferring from your post, Vent.

If you can not stand up and state that you can not push 20 mg of morphine when 2.0 is appropriate or if you don't know one may not be correct, it is the preceptor's job to learn what you may not know before you kill someone. The "instructor" should already have taught you this. There is a big difference between the instructor managing a clinical situation and a preceptor in a hospital or on an ambulance orientating someone who already should have some basic knowledge of their job if they now hold a license and had a decent instructor. However, too often some instructors are overly nice for a popularity contest to get good marks on their evals from the students and will pass some who don't know crap probably because the instructor didn't want to hurt their feelings by pushing them a little. However, again, a preceptor or instructor can only do so much if they don't have much to work with due to inadequacies in the EMS education system. I have run into that quite often when precepting new Paramedics on intubation. If their training and education in their program was subpar, I will then have to take time to play the role of instructor and preceptor which then takes time away from other things and other Paramedics. If I am trying to show them how the medication system works within our protocols and they have no clue what epinephrine is, then there has been a failure on the education system. If I am given 30 minutes to teach CPAP to Paramedics who have no clue about hemodynamics but I am told by their employer to just show them how to hook it up, am I a bad instructor?

Part I can blame the education system and some reponsibiity also has to fall upon the new hire. If they were through a spoon fed program, they may expect the same spoon feeding and coddling in the work place. They will soon have to realize their own responsibilities.

This is also why I would push for more educators in EMS rather than just instructors.

However, again, it is never acceptable for someone to call another a F**ing moron in the workplace. But this should not be confused with a stern lecture which the weak may perceive as be a horrific thing.

Edited January 14, 2010 by VentMedic

[Kiwiology]

...If I am given 30 minutes to teach CPAP to Paramedics who have no clue about hemodynamics but I am told by their employer to just show them how to hook it up, am I a bad instructor?

No

...If they were through a spoon fed program, they may expect the same spoon feeding and coddling in the work place. They will soon have to realize their own responsibilities.

It seems the children of today expect to be spoon fed and have education at least, if not most things, handed to them in broken down, nice, bite sized managable pieces so that nobody fails or ends up looking stupid or "left behind"; much to the deteriment of higher level cognitive learning.

One of the presenters at the International Roundtable on Paramedicine speakers here in NZ last October mentioned the "trophy children" generation who expect some form of reward for just doing what is expected of them; the two are maybe not hand-in-hand concepts but are closely related IMO

[spenac]

http://www.emsresponder.com/print/EMS-Magazine/CE-Article---Abdominal-Pain/1$11559

EXAMINATION

The patient exam will include observing the patient while conducting the physical assessment and incorporating their history. As patient assessment begins, observe (inspect) the abdomen for any bruising, asymmetry or other abnormality. The exam may include auscultation, palpation and tapping. Review your local protocols for abdominal assessment details, such as recommended technique and which components of the exam should be included. Table IV provides examples of assessment demonstrations that can be found on the Internet.

Depending on a variety of factors, such as the patient's level of distress, distance to the hospital and presence of potentially life-threatening conditions, auscultation may be considered. Auscultation can help to assess the activity of bowel sounds, which may be described as clicks and gurgles. If auscultation is going to be done, consider performing it prior to palpation.

Begin palpation with gentle and shallow pressure, then progress to deeper assessment. Gentle palpation is recommended first in an effort to reduce the chance that the patient will tighten his abdominal muscles. Palpate each quadrant while keeping possible organ and system involvement in mind. As palpation occurs, observe the patient for abdominal guarding, resistance or rebound tenderness.

To assess for rebound tenderness, palpate the abdomen deeply and then quickly release the pressure. If the patient reports increased pain when pressure is released, he has rebound tenderness, which represents aggravation of the peritoneum and may indicate peritonitis.

Obtain a complete set of vital signs early during the patient assessment. Vitals should include heart rate, respirations, blood pressure and temperature, when possible, and should be reassessed every 10 minutes, or more frequently as needed.

Assessing for orthostatic vital sign changes, also referred to as postural changes, may be considered, especially if volume loss is suspected. To perform this, obtain an initial set of vital signs while the patient is either supine or sitting, then ask the patient to stand and retake his vital signs. Orthostatic changes can be noted by an increase in heart rate of approximately 20 beats or a decrease in blood pressure by up to 20 millimeters of mercury or more. Positive orthostatic changes may indicate volume depletion. A 20-10-20 rule may also be considered: a decrease in systolic blood pressure by 20, a rise in diastolic by 10, or an increase in heart rate by 20 beats per minute.23-25 Assessing for orthostatic vital signs is not recommended if the patient's initial vital signs reveal tachycardia and/or hypotension when sitting or supine.

Distal circulation and perfusion may be assessed to compare the color, texture and temperature of the legs. Check pedal or popliteal pulses for the presence of peripheral pulses.

[VentMedic]

spenac,

Since that CE course discusses IVs, isn't it found in the ALS section on RapidCE?

Of course that is not to say that your state won't recognize it for EMT.

Edited January 16, 2010 by VentMedic