Abdominal Exam

[Siffaliss]

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!

Wow you're arrogant. What was your reasoning behind yanking your EMT's hands from the patient? Was there an obvious pulsating mass that they didn't recognize? You very likely made that EMT feel like a piece of crap, and for what? What could you possibly have taught them by acting out like that?

Palpation is an important part of an abdo assessment, unless of course that action is contraindicated. Being an EMT is NOT a contraindication.

Edited January 1, 2010 by Siffaliss

[JPINFV]

So if its a student on the truck to gain the clinical experience required ...they still need to 'ask permission'? I thought thats why they were there in the first place...to get 'real life hands on experience'.....

Depending on how the preceptor/student relationship is, yes. It's the preceptor's patient first and foremost. In my mind, ambulance clinicals should work similar to field training with the student starting as more of an observer and progressing to being primarily responsible for the patient. If the student is doing the assessment, then I wouldn't expect him to be asking the preceptor if he can palpate. However, the student shouldn't just jump in because he thinks that something was "missed."

[Lone Star]

In the times I did 'clinical ride alongs', I've NEVER had to 'ask permission' from my preceptors to treat the patient. That IS why I'm there, after all.

Maybe I was one of the 'lucky ones' who's preceptors actually ENCOURAGED more than an 'observational position'.

I can understand the preceptor having the patient 'stand aside' if the patient's condition is more serious than the student can handle, or requires more treatments than the students scope of practice allows.

I've never had a preceptor knock my hands off a patient either, especially when I'm doing a proper assessment...

[DwayneEMTP]

It sounds to me as if the OP is trying to paint the picture of a dissecting AAA. And if so, there is little to be gained and much to be lost by palping by an inexperienced, likely heavy handed, new EMTB.

It also sounded, (playing devils' advocate) the the OP may be asking why we continue to teach abd palpation to students that, most often, won't have the educational background to do anything educated/intelligent with that information.

I can agree to a certain extent on both points actually. Though without giving it some significant thought, which often involves waiting to see what Dust thinks, I can't really argue either way at this point.

I do agree that if you're 'yanking the hands' of anyone off of a patient, most especially those of an already insecure, terrified 3rd ride EMTB then you need to take a chill pill. These folks have gotten into the back of the ambulance, again, most often, without the knowledge/education/training necessary to feel confident and productive, which often causes them to do some pretty dorky things. Making them feel even dumber by reacting to those dorky things in a foolish manner simply sets them back, when our job is to attempt to elevate them to a new level while in our care.

I look at 3rd riders almost exactly the way I do my patients. They are in a place that they've been convinced by books and teachers that they belong, only to find that nothing actually works the way that they were taught. They are insecure, scared, have no control over the events occurring, and will be gone before they have even a tiny chance to remedy that. Chastising them for unprofessional behaviors that are predictable, in fact unavoidable does no good to anyone. In fact the new EMTB that steps up and gets in my way by being overly aggressive immediately gets kudos in my book. EMS is a contact, not spectator sport. It takes balls to put yourself 'out there' when on early rides, timidity should be discouraged even if initial brazenness is at first unproductive.

Why teach it? Because a small percentage of them will stay in the ambulance long enough to learn it's value. Because it's a standard of care regardless of their ability to use that information. Because it forces them to actually put their hands on patients, one of the skills that many have a terribly hard time learning. Because for every DAAA 'near miss' there will be 5000 abds that have exactly nothing wrong with them reinforcing the more important skills stated above.

Though you've taken a bit of a beating here, I think this is a great thread! At least it caused someone with my limited brain power to sit and think for a few hours.

Thanks for the post brother.

Dwayne

[Kiwiology]

Standard of care, duh.

When I went to the hospital with a sore tummy and puking up nasty green stuff the doctor poked and pressed and prodded and percussed my abdo, I would expect the same of any ambo.

Our BLS level officers are taught Ryle's answers, palpation, percussion and asc....oscil....auscul....eh whatever, listeng to the abdo with a stethoscope.

Edited January 1, 2010 by kiwimedic

[DwayneEMTP]

Standard of care, duh.

When I went to the hospital with a sore tummy and puking up nasty green stuff the doctor poked and pressed and prodded and percussed my abdo, I would expect the same of any ambo.

Our BLS level officers are taught Ryle's answers, palpation, percussion and asc....oscil....auscul....eh whatever, listeng to the abdo with a stethoscope.

Why 'duh?'

Do you then feel that the poking, prodding and percussing have an intrinsic value, even when done by those that gain little if any clinical information from it?

I didn't get the feeling that the OP, though he seems to have chosen to no longer participate in his own conversation, felt that these were worthless skill on all levels, only those at the basic cert.

Why then are they valuable? Should the hospital give me all lab values of the pt I'm helping to resuscitate after transfer of care because it's a standard of care, despite the fact that I have almost no knowledge of their significance? What is gained by that?

Dwayne

[Kiwiology]

Do you then feel that the poking, prodding and percussing have an intrinsic value, even when done by those that gain little if any clinical information from it?

I personally believe a few things Ambulance Officers at the BLS level do are of only extrinsic value as they aren't taught very much about them. I know I've examined patients and noted something down but I have no idea what it means or how it might be clinically significant.

The clinical knowledge of the registrar in the emergency department would leave me for dead when assessing somebody with abdo pain because he knows more than I do. Likewise, my clinical knowledge when assessing a cardiac patient would leave one of our BLS AO's for dead because I know more than is taught in the BLS cardiac course.

All I can tell the registrar is "this patient has pain upon palpation over the RUQ and hasn't pee'd in a day"; to me it means very little and I might be able fumble my way through whatever diagnosis they give; an ambo who hands me a rhythm strip and says "it doesn't look normal Ben, this guy has some pretty bad chest pain" might not know what the rhythm is, I can look at and go 'aaaaaaah T wave changes with PVCs".

Even if the ambo who is poking and prodding me doesn't know all the endocrinology in the world, they can at least pass it on at handover. Might mean nothing, might mean something ....

Probably makes the patient feel better too!

Edited January 1, 2010 by kiwimedic

[kohlerrf]

Ok,All good replies, however things like "The standard of care" and "Ive always been taught to" don't really address the issue address. Yes I agree we have to present a good picture the the ER staff as part of the transference of care. As far as listening for lung sounds thats a different topic so I would like to remain on point and discuss the abdomen. Our local "protocols" do not specifically address things such as how to do a physical exam although it is in the state curriculum and the national registry. That being said I am not satisfied that the state or the national registry have all the answerers. There are many procedures we do that are contradictory to the curriculum. For example compression only CPR with no BVM or advanced airway or permissive hypothermia wich is not even addressed in the classroom and over drive pacing just to name a few. This forum should be read thinking out of the box and nothing read here is law however is may be the stuff law is made from.

An EMT should be able to take a proper history(including recent bowel movements number and quality, urination frequency color and oder, nausea vomiting, fever,etc...) vital signs, visualize the abdomen for discoloration or deformity and yes even gently touch abdomen to feel for temperature or pulsation. However the additional information gained by invasively poking your fingers into the four quadrants of an acute abdomen in the pre-hospital setting can spark major problems can dramatically contribute to a poor prognosis and that can only be handled surgically. I feel the risk of the EMT pushing on a hot appendix and rupturing it, perforating an diseased bowel, bursting an abdominal aneuyrsm or causing the patient to vomit and compromise the airway to name a few, however minimal, are too great for the new information that could be potentially gained. Remember that because patients can be ticklish, rigidity, lumps or mases could easily be a reaction caused by the patients own embarrassment, or your cold hands, and as such palpation is low on the list of objectivity even in the hospital setting.

Regarding auscultation and percussing the abdomen. These are probably the top 2 most objective techniques. Even if you were an expert at interpreting bowel sounds and the percussive sounds or "fluid waves" across the abdomen, these techniques cannot be done in a moving ambulance. Regardless of the findings nothing here would change your treatment in the field and delaying transport to perform these properly would only delay definitive patient care.

Students are taught to palpate the abdomen to have the skill and pass the test bla bla bla. We also educate using a objective body of evidence rather than just teach chapter 6 pages 132-158 from the manual?

[P_Instructor]

Our local "protocols" do not specifically address things such as how to do a physical exam although it is in the state curriculum and the national registry. That being said I am not satisfied that the state or the national registry have all the answerers. There are many procedures we do that are contradictory to the curriculum.

However the additional information gained by invasively poking your fingers into the four quadrants of an acute abdomen in the pre-hospital setting can spark major problems can dramatically contribute to a poor prognosis and that can only be handled surgically. I feel the risk of the EMT pushing on a hot appendix and rupturing it, perforating an diseased bowel, bursting an abdominal aneuyrsm or causing the patient to vomit and compromise the airway to name a few, however minimal, are too great for the new information that could be potentially gained. Remember that because patients can be ticklish, rigidity, lumps or mases could easily be a reaction caused by the patients own embarrassment, or your cold hands, and as such palpation is low on the list of objectivity even in the hospital setting.

Students are taught to palpate the abdomen to have the skill and pass the test bla bla bla. We also educate using a objective body of evidence rather than just teach chapter 6 pages 132-158 from the manual?

1. Abdominal exam not addressed in protocols? This is a standard. How can you potentially treat a patient without a complete and thorough assessment?

2. Do the exam, and if taught properly (non 'poking', but gentle palpation) you could find out much good information that can be disseminated to the ER to prepare them for whatever event. You need to assess for lumps, bumps, masses, palpations, etc. Who knows, it might only be a 'diastasis recti', but without exam, you could hinder the idea of rapid transport of a dissection.

3. We don't teach what is in the chapter per say.....teach the curriculum which includes a good thorough abdominal exam along with history of the event. Teaching the newby Basics any other way could compromise good assessment tools in the future. Don't jump down their throats, teach them the proper way and what to look for, whether they or you can do anything for the complaint or not. Complacency can be a killer.

This is only the opinion of this poster.

[kohlerrf]

On scene the patient was outwardly stable. From the history, visualization of the abdomen and vital signs this pt was potentially unstable 2 large bore were started in route, and run kvo, on arrival I advised the ER staff I was treating a rule out AAA and they confirmed it by a sono. Patient was taken to the O.R. he burst on the table but was saved. I did not palpate , auscultate or percuss in the pre-hospital setting did I harm the patient? What was a the very real possibility here had I delayed transport and started "gently manipulate, palpate, percuss and auscultate" this abdomen while the patient was sitting in his office chair? More importantly would your full abdominal exam rule out a AAA in the field?

And just to set the record straight. While I did yank his hand away I did not reprimand him in front of the patient and to be more specific after the pt had been handed off it was during our debeif I asked him not to palpate the abdomen of my patients and gave him the above mentioned reasons.