Trauma strip every patient?

[Dsmittty911]

The thing I worry about is where AK would carry his penlight. Too SCARY to imagine.

[BEorP]

I believe this is the article here

The neglected art of the physical exam

By MARK ROCK, BA, NREMT-P

"Medic 12, respond Code 3 to an assault victim. PD on scene."

You and your partner arrive to find a young woman under the care of the city police department. An officer has dressed her left hand with a 4×4 dressing and a Kerlix wrap. He explains to you that the woman sustained a laceration to the palm of her left hand while fending off an attacker wielding a knife. The dressing has effectively controlled the bleeding, and the total amount of blood loss is estimated at less than 100 cc.

The patient, who speaks only Spanish, is fully oriented and answers questions quickly and appropriately through a police interpreter. She provides a history of the event consistent with what the officer has given: During an argument with a relative, she was attacked with a large kitchen knife and received the defensive wound.

The patient denies loss of consciousness, weakness, dizziness or shortness of breath. You check her capillary refill, which is less than two seconds. Motor and sensory functions are intact. Her blood pressure is 140/80, radial pulse is 100, strong and regular, respirations are 20 and non-labored with good tidal volume, and the skin is warm and moist with good color. The patient is negative for orthostatic changes. You ask if she was stabbed anywhere else, thrown to the ground or attacked in any other way. Through the interpreter, the answer is negative on all counts.

The patient wears a thick, pullover sweater, which you pull up to inspect the abdomen. Access to the chest is difficult due to the sweater's bulk, and, because you're concerned with the patient's modesty, you palpate the chest through the sweater rather than expose her chest. With the patient's stable presentation, you believe that placing your stethoscope into the collar of the sweater and listening for breath sounds on each side of the anterior chest is adequate.

Confident that no other injuries are present, you transport the patient BLS, code 2, to the nearest hospital, calling en route to let them know that you have a patient with a minor laceration to the palmar surface of the left hand with minimal blood loss secondary to the event and that all other findings are negative.

On arrival, hospital staff immediately remove all of the patient's clothing. With the sweater now off, a quick assessment reveals three separate quarter- to half-inch lacerations to the mid-thoracic region of the patient's back on either side of the spine. The emergency department (ED) physician conducts a thorough pulmonary assessment, inserts a swab to ascertain the depth of the punctures and orders an X-ray.

Discussion

The physical exam is both one of the most important and one of the most neglected elements of patient assessment. Long recognized as an integral part of the secondary survey for trauma patients, a physical exam allows us to identify and treat conditions that were not apparent during the initial assessment, which is concerned only with ascertaining and correcting immediate threats to the patient's airway, breathing or circulation.

Although the opening scenario involved a trauma patient, a complete physical exam is just as important when treating a medical patient in order to provide proper care and ensure that pertinent findings are not overlooked. We should approach a physical exam in the same way that we do vital signs: something that is performed on each and every patient we make contact with, regardless of complaint or apparent condition.

The missing link

Along with a baseline set of vital signs and a patient history, the comprehensive physical examination, particularly on trauma patients, completes what has historically been referred to as the secondary survey. Also known as the "head-to-toe survey" (or "detailed exam" in current curricula), the physical exam is now taught in some circles as an optional component of trauma assessment, and as something that is unnecessary altogether for most medical patients.1,2

This is a questionable position, given the potential for treatment errors and omissions that may arise from not performing this important step of the assessment. The physical exam is of benefit to the patient in several important ways:

1. The physical exam assists us in determining and correcting potential threats to life and well-being that were not apparent during the initial assessment. A patent airway and a carotid pulse may be present in a patient with a pneumothorax or severe abdominal bleeding — or, as in our opening scenario, potential penetrating wounds to the posterior thoracic cavity. These conditions may not manifest via initial changes to the ABCs but typically present with classic signs and/or physical findings that would be readily identified with a physical exam. Unrecognized and untreated, they can result in compromise of a patient's condition. (e.g., One patient who had become hypotensive as a result of pericardial tamponade was treated for dehydration instead.3 It was determined that failure to expose the patient and notice a penetrating wound to the chest was a crucial factor in the misdiagnosis. Further, the therapy based on this misdiagnosis — aggressive fluid resuscitation — hurt, rather than helped, the patient.)

2. The physical exam establishes a baseline of findings in the field. Over time, a patient's condition may improve, remain the same or deteriorate. An emergency physician will be helped immeasurably by a properly performed, thorough physical exam in the field that yields a baseline of findings. Together with an accurate time frame, any changes can give the physician a good idea as to the severity of an acute event.

3. The physical exam is an excellent way to uncover clues to a patient's overall health and general medical history. Even an alert, fully oriented patient might be a poor historian, may not recall or have on hand their prescription medications or even know if they've had a condition diagnosed. Peripheral edema, impaired sensation in the extremities, amputations, hemiparesis or flaccidity: All of these findings should raise our index of suspicion for certain conditions. So, too, should pacemakers, surgical scars, indwelling catheters and shunts or fistulas. The physical exam can alert us to possible etiologies of a patient's complaint.

4. The physical exam allows us to discover elements tangential to a patient's complaint or injury. Although not all problems revealed by a physical exam are life threatening, or even immediately relevant to a patient's complaint, good, thorough care requires that anything of potential medical significance be identified and taken into consideration. Examples might include impaired distal circulation, chronic abdominal distension, jaundice, wheezes or rhonchi/rales without shortness of breath. These findings may warrant field intervention, depending on the patient's clinical severity, level of distress or other indications that the sign or symptom requires immediate treatment.

The all-important first step: Expose the patient

The physical exam requires that we both visualize and palpate a patient. All too often, patients with trauma or significant medical complaints (including chest pain, shortness of breath, altered level of consciousness, or neurological signs/symptoms) are wheeled into the ED fully clothed. The techniques of the physical exam — inspection, palpation, auscultation and percussion — simply cannot be performed through clothing. We should remember that the patient care acronym, ABCDE, stands for airway, breathing, circulation, disability, expose the patient.4,5

It's truly disheartening to watch paramedics start IV lines on patients wearing shirts. Not only is the ED staff going to remove the clothing anyway (and untangle that IV line), delivering a patient in this manner indicates that the providers have not performed a proper physical exam.

Case wrap-up

In this case, the patient's injuries were covered by the sweater, which was penetrated by the knife blade but, due to its thickness and elasticity, showed no rips, tears or other damage. The language barrier prevented the providers from getting a reliable history of the event, despite the availability of a translator. Had the sweater been removed and a proper anterior/posterior physical exam performed, the injuries would have been identified.

Not being able to ascertain the depth of the wounds in the field, proper assessment and treatment for this patient would have included continuous pulmonary reassessment, pulse oximetry, an IV line, cardiac monitoring and, depending on local protocols, perhaps even spinal immobilization.

In the ED, the patient's wounds were cleansed and a topical antibiotic ointment applied. Dressings were placed over the injury sites, and the patient was given a tetanus shot. The patient was discharged from the ED three hours after being brought in and enjoyed a quick recovery with no complications.

The ED physician consulted with the providers who brought in the young woman who had been stabbed. He reported to them that the most serious of the three wounds to the back had penetrated the dermis into the fat layer, with no thoracic cavity compromise. Although the injuries in this case turned out to be relatively minor, he reminded them of the importance of performing a thorough physical exam.

Conclusion

Always perform a physical exam on every patient. The physical exam provides us with valuable information, which will guide our course of treatment and assist the ED team, thereby providing a much better service to our patients. Neglecting to do a proper exam can lead to inadequate or inappropriate care. A thorough and complete physical exam is vital to your patient's well-being and your reputation: Don't compromise either one.

[Asysin2leads]

Assessments are a vital skill for any EMS provider. That being said, getting the person to the hospital in a timely manner where people with many more letters after their name can do a much better assessment than us should take priority over playing House M.D. on scene. I mean, after all, there's only one House M.D. and no one else can be him, so don't try. Oh, and if you have one of those young guys who are a little too eager to get to a car wreck so they can strip some young woman of her dignity I mean, er, clothing, kick them in the ass for and give them a 20 spot for a lap dance or something.

[Scaramedic]

I mean, after all, there's only one House M.D. and no one else can be him, so don't try.

So true, my favorite Houseism's....

Dr. Wilson: That smugness of yours really is an attractive quality.

Dr. Gregory House: Thank you. It was either that or get my hair highlighted. Smugness is easier to maintain.

Dr. Gregory House: Sorry, I missed that. White count's been down since the Ricky Martin concert. Some cholo kicked me in the head.

Dr. Lisa Cuddy: I need you to wear your lab coat.

Dr. Gregory House: I need two days of outrageous sex with someone obscenely younger than you. Like half your age.

Dr. Lisa Cuddy: People talk.

Dr. Gregory House: About how big your ass is getting? I've been defending you- you got back!

Peace,

Marty

:joker:

[PRPGfirerescuetech]

I mean, after all, there's only one House M.D. and no one else can be him, so don't try.

this saddens me...

[AZCEP]

I mean, after all, there's only one House M.D. and no one else can be him, so don't try.

But if we don't try, can we ever hope to be as good?

[JPINFV]

Of coruse House MD is based off the little known TV series, Walker, Texas Ranger Doctor. Chuck Norris doesn't do pericardial thump with his fist. He does it with a round house kick to the chest. This makes his ROSC surprisingly high/

Chuck Norris can shock asystole patients back to life.

[Dustdevil]

LMAO!

It's actually a bit disturbing how often it all comes back to Chuck Norris on this board! :?

[fireflymedic]

Stripping patients should be done with modesty and discretion. I agree with the comments others have made in that isolated traumas (ie minor ankle or arm fractures, etc or basic medical patients) do NOT need to be stripped. As far as starting an IV with a patient who has a shirt on, come on, that's ridiculous. Now IF a patient is intoxicated with possible trauma, has altered mental status which is not corrected (ie diabetic), then some degree of undressing may be required. However, I am always sure to maintain as much of the patient's modesty as I can, even if it just involves covering them with a sheet. It is true you cannot treat what you cannot see, and in major traumas, or something in which you have a high index of suspicion, sorry, you are gonna get stripped. I promise not to take you in the hospital like that. We carry gowns on our trucks for that reason to preserve pt modesty as best we can. Having been on both sides of the fence (being an EMS worker and having been through a major trauma) I learned to appreciate that. Though I admit it was totally bizarre having my coworkers being the ones stripping me. I was like uh yeah...was awkward going back in a station full of guys after that. But I know they were just doing their job and under the circumstances, I would have done the same thing had it been one of them. Bottom line, expose the patient as necessary, but keep covered what you can and make use of those sheets and blankets on your trucks. Your patients will thank you !

[Asysin2leads]

When Chuck Norris works the ambulance, telemetry calls HIM.

Okay, I'll stop...