Should all patients have clothing removed?

[spenac]

This subject was brought up on another smaller site and wanted to see your thoughts. It spun from a scenario of 2 medics being fired and facing legal issues for failing first to find the signs of child abuse and then by default failing to report it. Child died as result. They had listened to mothers explanation of arm injury and did not examine any other skin area, thus missed all the bruises of different ages on the child.

Then idea was mentioned should we consider placing all patients in hospital gowns to avoid missing anything. At hospital it seems pretty much all patients are placed in gowns and Doctors then actually see all skin when examining patient. It was brought up that if patient doesn't complain about an area we could miss edema (to the low back, thighs, or buttocks which could be sign of heart failure), miss less obvious bed sores, miss bruising, etc. It appears that only severe trauma and OB patients have clothing removed.

So whats your thoughts, should all patients have clothing removed and put in hospital gown or under sheet to avoid missing the less obvious? Do any services require something like this?

[AZCEP]

I answered no, because of the word "all". There are just too many situations that don't need managed this way.

Yes, a thorough exam is important. Exposing and examining is critical to finding a good many things. Patient modesty, is also a consideration. Particularly in the public arenas that we often find ourselves. A focused examination should be able to find most things without necessarily removing all the clothing.

Is it easier to do when the patient is in the buff? Definitely, but this does not mean they all should be forced to achieve it.

[dahlio]

As great as it would be, I don't believe it is appropriate. Patient's privacy is just as important. I'd like to know what kind of c/c the child was having where the two medics got fired. If it was a simple broken leg from roller skating or what not, then there would be no reason to preform a detailed physical exam. On the otherhand, if the kid was unconcious, then it would be necessary to preform a detailed pys exam. It's hard to determine whether the medics were at fault or not from just the information you provided, but then again, that's not what this topic is about

Yes, removing all their clothing, and taking a look at all parts of their body would rule out a lot of things, but once again, it's about patient privacy. Putting them in a hospital gown, or under a sheet would be keeping them easily exposed, and might take away some of their dignity. I don't believe clothing needs to be removed, unless it's sever trauma, a c/c in an area that is clothed, or is a Ob/Gyn call. Removing some clothes might be necessary, but removing all of it is not.

[spenac]

Part of arm that was broken was the humerus.

Also if this was done would imagine most would not have clothes removed until in the ambulance to protect privacy. Even trauma where you strip them and flip them you should still try to protect right to privacy.

[katbemeEMT-B]

One thing we have to remember is that we are a culturally diversified country. We have to be very careful when it comes to other cultures when we are caring for a patient. From personal experience, those from the Middle East and African cultures do not allow the females to be exposed under any circumstance. We had a Somalian patient with severe abdominal pain. She was 26 years old, married, and had two children. We were able to examine her but she could have no skin exposed. Her mother stood by to ensure this. It does make the examination more difficult but it is workable. I think that we as EMS need to be very careful when dealing with patients that is why getting a good hx is so important. This will give you any medical information you need and will also help if there are any cultural requirements you need to know. When we have a patient whether white, hispanic, somalian, or any other nationality we ask if there are any religious or cultural beliefs that we should be aware of. Many we already know because of cultural diversity training.

Question: Was this kid transported to the hospital? The hospital staff or x-ray tech should have noticed the bruises.

[Ridryder 911]

You don't expose, you can't see, you can't see you can't document, you can't document you did not assess.

R/r 911

[AZCEP]

Not every patient requires the same assessment. You do not need to remove the clothing from EVERY patient you see.

No protocol can fit every patient, so why would we think that an assessment would. Tailor the need to expose with the presentation of the patient.

[Chief1C]

Was the only injury a humerus fracture?

The child died because of a humerus fracture? Did it go untreated, was the child left at home? Was there an artery lacerated, or a compound fracture that caused sepsis, or from a pulmonary embolism?

Just to immobilize a humerus injury, would require the shirt to be cut away from the body. I've seen quite a few odd ball, and mid-shaft humerus fractures, the better part of the number were easily spotted with out much effort put forth.

A more detailed account of the situation would be excellent!

[spenac]

Was the only injury a humerus fracture?

The child died because of a humerus fracture? Did it go untreated, was the child left at home? Was there an artery lacerated, or a compound fracture that caused sepsis, or from a pulmonary embolism?

Just to immobilize a humerus injury, would require the shirt to be cut away from the body. I've seen quite a few odd ball, and mid-shaft humerus fractures, the better part of the number were easily spotted with out much effort put forth.

A more detailed account of the situation would be excellent!

Ok you made a statement that would require shirt cut away to be splinted actually can be done with shirt on, should it no. The humerus is a strong bone and would require force to cause. Should trigger suspicion that more thoracic injurys were possible and shirt would be removed to investigate. At this point bruises of various ages would have been visible and therefore the medics are required to report it as possible abuse, reporting it to just the ER doc is not enough needs direct report to child protective services. The standard of care for this injury would require at least shirt removal, in court you have to meet or exceed what is considered standard of care or your screwed. These medics splinted shirt on, therefore saw no other injurys, therefore made no report. As far as hospital in this scenario they screwed up and failed to report but thats their legal problem not EMS's. But had the medics seen it, reported and reported it child would have been possibly protected instead returned from hospital with parents and died of more abuse 3 days later.

If the practice was to always remove clothing would not even have to rely on medics to think about whether the circumstances dictate it.

[Just Plain Ruff]

well I believe that the hotter the patient the more clothes have to come off.

NO I dont' believe the above OK

But there are situations where the clothes have to come off.

If you are transporting a 40 year old woman complaining of a headache are you gonna take all her clothes off?

If you are transporting a 14 year old female or male with nausea and vomiting do the clothes need to come off?

I vote no on the two above but someone will disagree with me I am sure but we have to use common sense here. There are many situations that require the clothes off but generic medical complaints are in my opininon not one of them. But there are times where the clothes should come off.

Are you going to take off the clothes of a patient whose only complaint is abdominal pain or a headache?

Hospital gowns are good if you have them but not every ambulance has access to them.

I do believe that if an IV Is needed then at least take off the shirt and if there is one, the bra but make sure you cover them back up.