Abdominal Exam

[chbare]

Robbins Pathologic Basis of Disease defines that an aneurysm is a localized abnormal dilation, while a dissecting aneurysm is created once the tunica intima is breached. (pg 526-8). I

Yes; however, I still stay away from utilising the term. There exists major differences between dissections and aneurysms and utilising the term dissecting AAA only adds to the confusion. There is even more confusion as dissections are not typical of the abdominal aorta, but we call a AAA a dissecting AAA when the intima is breached? Clearly, this becomes quite confusing very quickly.

Take care,

chbare.

[Dustdevil]

From Dwayne I am getting that experience is the key. From Dust I am getting dont even touch anyone untill you have had X amount of education. So, maybe I read something wrong, or only read what I wanted to read..lol

Nah, we were saying the very same thing. He noted that experience is often used as an excuse for not needing education by those who don't have education. And you may notice that you never hear those with the education saying it is useless or "ridiculous". The only ones who knock it are those who do not have it, and are thus not qualified to judge its usefulness.

Take a year of prerequisite courses, including the two full A&P courses, and then go to EMT school. From there, go directly to paramedic school. Be sure it's a Nationally Accredited school (most are not), and one that results in a degree, not just a certificate.

[spenac]

1. A complete examination requires looking, listening, and touching. Sorry fail for not doing this and for passing the bad habits on to your student. Perhaps you could have said as we visualize the pulsing just as a precaution do not probe but gently place your hand to feel the pulsations.

2. If a student doesn't get in there and do a proper assessment to their level and just try and sit there they fail, might as well not show up as I will not give them credit.

3. The argument it will not change care in the ambulance if done does not fly. Your assessment, description may trigger a higher educated person (i.e. Doctor ) to get busy quicker. It is a lazy lame excuse to not perform proper assessment just because it does not change what you will do in the ambulance.

4. As to the education hijack. Get your education. Do not stop at the basic level. Anything you learn in basic class can be practiced once you are a Paramedic.

[1EMT-P]

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. While in route to the hospital my EMT "ride along" placed him on oxygen, moves down and begins to palpate the abdomen? I yanked his hands up telling him not touch the any of my patients abdomens, ever!

Regardless of what anyone thinks is wrong with this patient, could someone please tell me why we still teach EMTs to palpate the abdomen!

The reason that we teach EMT's to palpate is because we want them to assess their patients. As the senior provider on the truck you have an obligation to mentor the EMT. Yanking his hands away in front of the patient served no purpose!

[Dustdevil]

The reason that we teach EMT's to palpate is because we want them to assess their patients.

Thing is, this all came about back in the early 70s, when EMS personnel were supposed to be "the eyes and hands of the doctor". We were to do an exam, report the findings to the base physician, then follow his orders, a la "EMERGENCY!" We don't do that anymore. We've outgrown that delivery model. Consequently, there is no longer a need to teach people to perform tests they are incapable of interpreting. Whether the guy's belly hurts to palpation or not, an EMT is going to do the exact same thing: Transport. It's high time to quit doing things just because it's the way we've always done them. If there is no benefit to the patient, there is no medical indication.

[spenac]

Thing is, this all came about back in the early 70s, when EMS personnel were supposed to be "the eyes and hands of the doctor". We were to do an exam, report the findings to the base physician, then follow his orders, a la "EMERGENCY!" We don't do that anymore. We've outgrown that delivery model. Consequently, there is no longer a need to teach people to perform tests they are incapable of interpreting. Whether the guy's belly hurts to palpation or not, an EMT is going to do the exact same thing: Transport. It's high time to quit doing things just because it's the way we've always done them. If there is no benefit to the patient, there is no medical indication.

Dust this is where I have to disagree with you. Again even if it changes no care in my ambulance it allows me to notify the hospital and perhaps even an uneducated description may trigger the doctor to be ready for more than the normal. Visualizing, palpating, and auscultating should be done even when it changes nothing in the ambulance. This is not tradition this is patient care.

[Tom B.]

Dust this is where I have to disagree with you. Again even if it changes no care in my ambulance it allows me to notify the hospital and perhaps even an uneducated description may trigger the doctor to be ready for more than the normal. Visualizing, palpating, and auscultating should be done even when it changes nothing in the ambulance. This is not tradition this is patient care.

If the patient is complaining of abdominal pain, the physician is going to do his own assessment whether you needlessly provoke additional pain in the prehospital setting or not.

I vote for leaving the patient's abdomen alone unless it's going to influence your transport decision or destination.

Tom

[VentMedic]

Dust this is where I have to disagree with you. Again even if it changes no care in my ambulance it allows me to notify the hospital and perhaps even an uneducated description may trigger the doctor to be ready for more than the normal. Visualizing, palpating, and auscultating should be done even when it changes nothing in the ambulance. This is not tradition this is patient care.

But only if you have the education to back up the skill.

Imagine a pt involved in an MVC on a cold Winter night in the north. The EMT decides to undress the patient in the cold with cold hands and palpate. He/She finds the abdomen rigid and tender. Calls this data into the ED where they may actually take that data and activate a Trauma Alert which adds several thousand dollars to the patient's bill. Upon arrival the patient states he/she had his clothes removed by someone in a wrinkled T-Shirt and bed head with cold hands. Also, the patient states the MVC had made him want to move his pee and bowels really bad especially while the EMT was poking his belly. The patient also states he/she had no pain and the EMT replies, "it's in our protocols".

No, a skill should not be done just because. There should be education to support why you are doing such skill even if and especially if you are to do it each time. EMT-Bs also use a NRBM for many things just because and often it is due to lack of education to where it is easier to just say do it this way rather then try to justify otherwise with only 110 hours of training.

[spenac]

Vent, Dust, Tom I am going to have to disagree. No offense intended and perhaps it is because of the environment that I started my EMS journey in but I feel not doing a complete examination which includes touching the patient is failure to render proper care, examination. And even if the EMT does because of cold hands trigger an occasional false alert it is better than no alert when they do get it right. As to pain you can assess rigid vs soft w/o pushing hard. I agree if you do not know what the organs feel/sound like when healthy no point in pushing, probing, percussing when sick, injured but they can still gently feel. And again my thought process is probably clouded because I was required to do more as a basic than many Paramedics do, but was required to know the hows and whys. I guess that is why I firmly believe we should require people to get at least Paramedic education before getting into EMS.

Personally I still think patients would be better assessed if we started requiring all patients put on hospital gown and we actually visualize, touch, and auscultate skin. If people are afraid to touch perhaps they need to not join a health profession.

[VentMedic]

If people are afraid to touch perhaps they need to not join a health profession.

This doesn't have anything to do with all the "eewwww!" threads you see on some of the EMS forums where EMT(P)s are afraid to touch patients. Rather is has to do with understanding why you touch rather than just because you can. The fire chief article you posted could also have be defended that he as a medical person could have examined the woman's breasts for injuries and by your stance, clearly justified his actions.

If all initial training and education was equal as well as competent and involved medical directors, then yes, things might be different. However when you have more services that are more like Collier County or Washington DC rather than Seattle and more mills mass producing warm bodies wearing EMT(P)s patches just for the sake of filling slots or having every FF be an EMT or Paramedic, then what is allowed by scope and what should be done are two very different issues.

But, these same statements can be applied to just about any "skill". To many learn too little about intubation or giving medications and soon those become a problem. The whole group or even state may then be penalized for the actions of those who were not properly trained and educated. Collier county can again be used as an example as can some counties in California. Look at the recent epinephrine issue in Massachusetts.

Edited January 5, 2010 by VentMedic