To Expose or Not To Expose, That is the Question.

[spenac]

Patients vital signs can be normal when they are in fact in shock. As they compensate and as they began to decompensate.

My point is that if we do not do a focused exam on any area of complaint we have not done a proper exam. If they say their ear hurts. You are going to visualize it. You are even going to examine it with the otoscope hopefully. Yet your findings will not change the care given by the medic in most cases. So why do we look at the ear even if only externally view it and not internally viewed? So we can report redness, swelling, discharge etc. That is the same thing we should do when a patient complains of rectal, vaginal, penile pain discharge etc. We need to see it to properly report it and to properly document it.

Can we force the assessment on the patient? No. But if you are acting professional they will allow it. In my many years in EMS I have exposed many a patient and never have I gotten a complaint. I explain what and why as I am doing a proper exam. I have never had a patient refuse to allow an exam. I have had patients refuse backboards, IV's, certain meds etc. So yes patients can refuse any and all exams and treatments.

We all have a role to play in medical care, and we need to understand our place in the process. To me, this is like some ER doc attempting a procedure usually handled by a specialist. Yes, he is a doctor, but is it really appropriate to do something that may have minimal benefit, just because he/she CAN? Doctors call in specialists all day long for something beyond their area of expertise. Why should we be any different?

The ER doctor will still examine the patient. Say it's a cardiac patient. The ER doctor will still run EKG's, labs, etc even though he can not fix the problem. Why? So he can properly report to the cardiologist what is going on and help the cardiologist determine the urgency of care the patient needs.

We may not fix the problems we see and in fact most patients we do not fix but because of our exams findings we either change hospitals for a more appropriate one, or we notify the doctor that we are coming in with a patient with urgent needs. If you have a reputation with the doctors of doing proper detailed exams when you call and say urgent they will be ready.

So we need to do a proper exam so we can call in the proper expert. So we are no different than the ER doc.

[fakingpatience]

OK, I am going to throw a female opinion in here. I would not under any (or at least any I can think of now) circumstances allow any provider who did not absolutely 100% necessarily need to to examine ANY of my privates. Even if the pt is in severe pain, there is nothing we can do by examining her that we can't do without the detailed exam. If she is bleeding, it will show through clothes and onto the sheets if it is heavy. Ask the pt if anything is stuck/ impaled, and if they say no, just trust what they say! Yes, some pt's will lie to you, but as someone else mentioned, pts lie and there is nothing we can do about it. Get a detailed history of the pt, when the pain started, type of pain, last menstrual cycle...

Oh, and uglyEMT, " I do believe if the patient called us for pain in their genitalia then it would have to be pretty bad and I dont foresee them holding back information" You would be surprised some of the calls I have taken... let me just say that yes, I have taken a vaginal pain call where the pt was not in severe distress, just 3 am and mild discomfort...

Again, as others have said, I think it is situational. If a woman is pregnant, and birth is imminent, than by all means, expose and do what you need to. Unless the call is very critical (and I mean, severe bleeding, pt unconscious... ) I would not expose.

Sorry if this is disjoined, I went on a call in the middle of typing it...

[Mateo_1387]

Good ol’ classic Spenac post, pose a question that seems to ask for opinion, yet he already knows what the correct answer is (at least by his viewpoint). If you’re answer agrees even halfway with his, then you are still completely wrong… and furthermore are deemed scared, unprofessional, bashful, and therefore must obviously be incapable of saying penis and vagina without giggling, so you must surely call them private parts and no no’s… I digress…

So, what was the point of this post Spenac? Did you’re post from the past covering this topic get deleted or something? Felt enough time went by that you could duplicate it without many noticing?

I take it you also expose and palpate the vagina and anus of all the rape victims you encounter? How do they feel about your ‘professional exam’? I guess you do the same for the child victims too? Do you also prefer to do prostate exams on all males over 40? I bet that one goes over real well...

[DwayneEMTP]

So following your logic then spenac, when the 70 y/o male calls with bleeding hemorhoids then you must bend him over, ask him to spread his cheeks widely apart and examin his ass? I mean you must, as he called 911 which in your mind seems to imply that he is incapable of any type of reasonable thought without your intervention. Of course his 20 year history, list of meds and cases of Tucks pads is irrelevant?

Do we expose a trauma pt? Of course? Do I expose the vaginal area of the female that claims to have fallen off of a ladder and landed spread eagle on the edge of her wheelbarrow causing blood to soak through her pants and undergarments? (real pt) No question. In both of those cases there is the near certainty that I will have some knowledge and expertise that can be of benefit to my patient, warranting the exposure. Do I expose the female that complains of spotting and some vaginal burning x 5 days? Of course not. She is the expert in that case. Good vitals, (And come on, you're not talking to children here when you describe compesated shock, as much as you'd like to believe that you are), good history is all that I'm likely to need to properly care for this pt.

The female pt that complains of lower flank pain radiating to her pelvis and groin...Do you truly expose the genitalia of all of your kidney stone pts as they writh on the bed puking? I have to assign a meat gazer label if that were the case.

I have examined many penis', vaginas and rectums overseas where longer term pain management, wound care and antibiotic therapy was within my scope of practice. In the U.S? Only if my intelligence, history, and index of suspicion would lead me to believe that it was a prudent medical intervention. How do you know if she's lying when she says she's spotting but is actually flowing heavily? You, as a medical professional should not only notice the change in vitals, but the giant blood stain at her crotch should cause some suspicion.

As Matty said, your entire argument was predicted by the way you phrased the question. I've not been around much for a bit, but I'm guessing that the City has a bunch of new, eager, curious young minds, as that seems to be the time that you throw this type of silliness out there.

Always properly assess your pts kids. We don't put a splint on for chest pain, we don't use CPAP for a twisted ankle, and we don't put pts in compromising, possibly humiliating situations without first developing an index of suspicion. Besides, if a good set of vitals, good physical exam (non traumatic, clothes on), and a rockstar history isn't enough to tell you that you're pt isn't bleeding to death through her vagina, than it's back to Basic class for you....

Of course, having said that, there are more than a few providers at the City that I would gladly allow to do a genital exam, regardless of my physical complaints... :-)

Just sayin'...

Dwayne

[uglyEMT]

No problem fakingpatients. I know there are always exceptions to the rules. I havent had many female in distress patients so my knowlege base is limited, I digress. Thankfully most of my squad is female and the crew I ride with I am the only male so usually in those situations I am a gopher anyways.

I think Dwayne said it the best about recognizing the S&S and treating from there.

As a professional courtesy while on duty yesterday I asked my Captain, an ER Doc, and a Medic friend and all said the same thing. HECK NO! Unless its absolutly vital (ie pregnancy, miscariage, hemmorage, ect) by NO MEANS should we expose a patient's genitalia.

Thanks for the thinking question even though it now seems like a loaded one. I am glad you got me thinking about this and what would happen if i come across this situation. I will use sound judgment, assess the S&S, take good vitals and if all lead me to believe its not life threatening the cloths stay on, I document clearly the pain and radiation, give a good assessment to the ER and hand over to definitive care.

[spenac]

Thanks for the thinking question even though it now seems like a loaded one. I am glad you got me thinking about this and what would happen if i come across this situation. I will use sound judgment, assess the S&S, take good vitals and if all lead me to believe its not life threatening the cloths stay on, I document clearly the pain and radiation, give a good assessment to the ER and hand over to definitive care.

Not a loaded question as a couple of people that don't like me implied. This is a question designed to get people talking and thinking. And wow it has gotten people thinking and talking.

I agree we do often rely on just what we are told by the patient, take a set or two of vitals, and drop off patients with a report that states what patient said and what vitals were. But is that a proper exam? No it is not. If the patient claims their arm hurts yet I do not expose it or palpate it if not in this scenario the ones that made the rude comments about me would be saying I did not do a proper exam. It is the same principle.

So lets say a healthy looking 16 year old female calls 911 for chest pain. Are we going to do proper lung and heart sounds which means touching the skin? Are we going to expose to make sure we have equal expansion? Are we going to palpate to see if pain reproduced by palpation? Are we going to expose to properly place 12 lead? Or are we going to just tell the hospital patient complains of chest pain, denies trauma, here are her vitals, good bye?

You can not rule in or rule out anything if you fail to do a proper exam.

Oh and thanks to the jerk that gave me a negative.

Edited October 7, 2010 by spenac

[Just Plain Ruff]

I'm going to chime in here.

I see where you were going Spenac, this is a good subject to bring up but it also scares a lot of people. Males looking at female parts. That goes against the grain of how we are brought up, as we aren't supposed to see the privates of the opposite sex, except in movies and magazines(ha ha)

But I don't think I'm going to do much more than look to assess if there is bleeding or trauma.

The risk is too high to the male provider.

Case in point, had a medic friend of mine a long time ago run a call on a woman with vaginal bleeding. She wasn't on her period she said. The medic looked down there for bleeding and that was it, a visual exam and nothing else.

My friend also explained what he was doing and why he needed to do it and the patient allowed him to look.

Got to the hospital and handed the patient off. The patient then told the nurse that the medic looked and the nurse convinced her to file a sexual battery complaint against my friend. He was charged but not convicted. He lost his job and eventually lost his house and family due to being unemployed and I lost a good friend when he just up and walked away from town and never came back.

To look is a valid thing but to do anything more is not a good thing in this day and age. If like Dwayne said about his patient (ladder girl) yes you do a more thorough exam but there are times for that.

This topic is a tough one to tackle and many people have strong feelings on this subject. It is a good subject to discuss but maybe we aren't ready to have this discussion.

[uglyEMT]

spenac I agreed with this question I guess at 6am reading other comments I had to wonder. I did give you a plus 1 for it so i really do agree.

I understand what you are saying about proper exams and such. As for your example of the minor with chest pains. I wouldnt be removing her bra to do it. I can get all the things you stated but not have to expose the breast bear (I dont do 12 lead as I am only a basic) Plus at 16 I will be having a parental consent and witness during the whole thing anyways (including transport). The genital exam borders on over stepping unless as has been stated numerous times it is vital.

Ruff brings up a good point. Just because it quote a proper exam doesnt mean the patient, nurse, social worker, ect will see it that way and then your headign for the lawyers office fighting for your liscense. Now before jumping the gun I am not saying I wouldnt do something because I would worry about my liscense if it was absolutly necessary.

Dwayne did have a good male example, bloody hemroids, I am not going to ask the guy if i can see them. I will however ask him to stand up, if possible, and as I do a quick palpation of the pelvic region for associated pains I will definatly look at his clothing, if I see any hint of blood coming through the clothing I would be cutting lickity split. But if nothing is there and he has no other pain I will take his word its hemroids and get him to definative care to see a protologist.

Here is my final conclusion, Yes technically it is a proper exam as defined by the term. Thats where the problem is, thats where I treat. Now for the real world, it would border on sexual misconduct or assult or battery depending on the lawyer if there is no other reason other than pain to be down there. This goes for male or females including the responder (female with female, male with male)

It is a very slippery slope for no other fact then perception. Yes we are professionals, we dont look at it that way, its part of the exam, yada yada yada. Public perception is what the real world is based on.

Thank you again for a very provacative question but one that needs to be discussed openly.

[HERBIE1]

Patients vital signs can be normal when they are in fact in shock. As they compensate and as they began to decompensate.

Thanks. I had no idea. (sarcasm)

My point is that if we do not do a focused exam on any area of complaint we have not done a proper exam. If they say their ear hurts. You are going to visualize it. You are even going to examine it with the otoscope hopefully. Yet your findings will not change the care given by the medic in most cases. So why do we look at the ear even if only externally view it and not internally viewed? So we can report redness, swelling, discharge etc. That is the same thing we should do when a patient complains of rectal, vaginal, penile pain discharge etc. We need to see it to properly report it and to properly document it.

Otoscope? I would love to know how many prehospital providers use those. Anyway...

We report what we see. Let's pretend we did use an otoscope and see an inflamed tympanic membrane,and the person seems to have a case of otitis. We don't carry antibiotics, so what exactly do we do? We report this to the doc, and will he simply write a script, based on our findings, or will he also take a look? We could tell him we think- or a patient suspects- she is pregnant and is having abdominal pain, so will he order an ultrasound simply based on our word, or do you think he might confirm that pregnancy with a beta-HCG test?

Can we force the assessment on the patient? No. But if you are acting professional they will allow it. In my many years in EMS I have exposed many a patient and never have I gotten a complaint. I explain what and why as I am doing a proper exam. I have never had a patient refuse to allow an exam. I have had patients refuse backboards, IV's, certain meds etc. So yes patients can refuse any and all exams and treatments.

I've never had a complaint either, but I also do not go beyond beyond my scope of practice. I do not pretend I spent 4 years in medical school plus a residency, plus having a whole tool box full of diagnostics.tests, procedures to confirm my diagnosis, nor do I have a definitive way to treat something like an ear infection, hemorrhoids, an STD, or PID. I can SUSPECT- and am usually correct- what may be going on with a patient, but unless I can definitively treat a condition- based on my training and available resources and protocols, I also stay within my well defined boundaries.

The ER doctor will still examine the patient. Say it's a cardiac patient. The ER doctor will still run EKG's, labs, etc even though he can not fix the problem. Why? So he can properly report to the cardiologist what is going on and help the cardiologist determine the urgency of care the patient needs.

Actually, an ER doctor CAN "fix", or at least begin to mitigate many "cardiac" problems. If he runs his tests he may see no reason to immediately activate the cardiac cath team because the patient is suffering from a muscle strain, angina, or indigestion. He will probably call for a consult in such cases, but the person will also not be immediately rushed to the cath lab for an angiogram.

We may not fix the problems we see and in fact most patients we do not fix but because of our exams findings we either change hospitals for a more appropriate one, or we notify the doctor that we are coming in with a patient with urgent needs. If you have a reputation with the doctors of doing proper detailed exams when you call and say urgent they will be ready.

Again, we use our powers of observation, any tools we have, a detailed history, and an APPROPRIATE exam, and we can paint a very good picture of what we think may be going on. It's up to the doctor to confirm or shoot down our suspicions. I am very good at what I do, but I also do not expect ANY doctor- even ones that I have known and worked with for years- to simply accept what I say at face value.

God forbid- if anyone I know is sexually assaulted(barring a massive bleed), and I find out someone in EMS wanted to do a vaginal exam just because they want to prove they are a professional- I will be doing business with that provider.

First, we are not trained as ob/gyne's, we are not trained to look for, evaluate, or collect evidence, and we may very well even compromise a criminal case- and the benefit is only to the ego of the provider, not the patient. Good luck convincing an attorney that you are a "professional" while trying to justify why you did an internal or even cursory visual exam on a rape victim who is not in any way medically unstable or having massive trauma. Just be sure to provide the documentation of your rape advocate training, of your evidence technician background, and the protocols that allow you to do all this.

If someone is complaining of penile discharge, tell me exactly WHY I need to expose and evaluate that discharge? What benefit would that be to the patient? Will I be inserting a swab to obtain a C&S?

Will I be confirming a case of syphilis, chlamydia, or gonorhhea, while prescribing a course of antibiotics? I have no protocols for STD's in my system. Describe what the patient says with as many details as possible, evaluate their vitals, add any pertinent subjective data(appearance, demeanor, scene information, etc), and report your findings to the doctor. THAT is our job.

So we need to do a proper exam so we can call in the proper expert. So we are no different than the ER doc.

We are VERY different than the ER doc. In every way. In terms of training, skills, experience, available resources at our disposal, responsibility, and liability. The proper expert in our case is medical control- the person who wrote your protocols, the person on the other end of the radio, or the ER doc where you deliver your patient. He/she is the EXPERT in their field, and has far more training and tools at their disposal than we do. Would you simply take the word of some bystander who claims they are a medic, and tells you that the trauma patient you are called is not really injured? Would you walk away, would you base your care/treatment/transport based on their statements, or would you provide the care and treatment you are trained to do?

EMERGENCY medical services. That means we are trained to mitigate, fix, or maybe only transport- someone within very specific guidelines, in very specific situations, to obtain very specific- and generally temporary- outcomes.

[Just Plain Ruff]

I agree with Herbies last statement on his long thread.

We are different from the doc.

We also don't take the word of a bystander claiming to be a medic.

I was flying monday morning.

About 10 minutes into this 30 minute flight they announced that they needed medical help.

I waited for a short time for a doctor or nurse to push their call button but none were forthwith.

I then pushed my call button and told them who I was.

I was ushered back to a woman who more than likely was having a heart attack and started to talk to her.

Told her who I was and all that.

She looked crappy so I had the crew put Oxygen on her, gave her some aspirin out of the flight bag, put the AED patches on her and also started an IV. We landed what seemed like moments later and met the responding ground medics arrived and entered the plane.

I gave them a report and we helped her off the plane.

That medic took my report, assessed my IV and began his assessment.

The EMS supervisor came up to me and asked for a copy of my license which I had no problem providing.

Remember Trust but verify