OB's - Paramedics Checking Dilation

[Dustdevil]

I have crunched this for several minutes and the only thing I come up with is a better estimate of where the patient is in the delivery process (time to delivery). Does this determine whether you stay on-scene or drive with reckless abandon?

In your crunching, have you been able to come up with a transport time of an hour or more, yet? If so, then this should be pretty self-explanitory, considering all that has already been said. If not, then please continue crunching. Many medical questions cannot be answered in "several minutes," once you begin to think above the DOT level.

To lead you in the right direction, ask yourself this; how could this information be so absolutely vital to the hospital staff, yet worthess to us? What are they getting from it that we would not, and why would it not benefit us?

If you are thoroughly educated and experienced in the L&D process, and aware of the significance of all that is learned from vaginal checks in both the full-term and pre-term pregnancy, but still don't think this is appropriate for EMS on any level, then we have a legitimate discussion on our hands. But if this is simply your way of saying, "I don't need to know all that" without even knowing what it is that you do not know, then we're wasting our time here.

[captainstandup]

I never say never and we do have a legitimate discussion. I am waiting on you to tell me what crucial information can be gained from a digital inspection of the patients vagina that will change your care of this patient in the field?

I have, in over 16 years, never said the words "we don't need to know that" nor will I EVER. There is simply no instance where I have led colleagues or students to belive there are limits as to what they "need to know"

I'll start the discussion by guessing the answers. As I have already said perhaps you are trying to determine how soon delivery will occur based on dilation. 2) You are trying to determine if the membranes remain intact or not 3) Perhaps you are trying to gain early warning of an abnormal presentation, presenting part or prolapsed cord requiring emergency surgical intervention. What information are you going to gain that offsets the risk of digital examination and justifies delayed scene time? Like I said this is a discussion about a medical topic, no need for veiled cynicism or to impugn the knowledge of each other. I am really interested in learning from your perspective on this subject.

[DwayneEMTP]

I've thought through the A&P as well, and I guess I'm in the same boat as Captain...(if I understand him correctly)

I can't see, even on a long transport, what information can be gleened from a digital inspection...but not a visual one..that is going to cause you to stop the ambulance and wait for an empending delivery.

I'm not saying you couldn't gain anything...I just can't think of anything that tips the Cost/benefit scale in the 'digital' direction.

As to the value in the hospital? I don't know, I'm sure there's plenty, but the only thing I've seen it used for? CYA when having to defend yourself against the Dr. who's pissed that you got him to the hospital before the head was crowning...

I look forward to this discussion!!

Have a great day all...

Dwayne

[tniuqs]

Good Grief, sometimes I wonder why I even try, NOT every Paramedic in the world has a hospital just around the freaking corner..... it's not a matter of a "delay of transport" or is it subjecting a patient to a higher risk in means of transport, it IS a matter of using all the tools available and NOT to jepordize the patient(s).

The attitude of rushing the patient to the hospital HAS to change first too: Responding quickly to a scene and stabilizing the patient ON Scene.

Kapish?

That said now don't go off on me about practicing beyond scope as scope does and will change, education, training and proven reliability in making that call will make a big difference.

IF and I say again IF "WE" are to progress as a serious entity as a Proffession in the provision of health care one MUST look to all the senarios that one may encounter .... GLOBALLY. SO dare to think OUTSIDE the BOX / or your own backyard, and understand clearly the very serious differences we all must face in logistics.

cheers

end of rant I hope.

[Dustdevil]

What information are you going to gain that offsets the risk of digital examination and justifies delayed scene time?

Simple; if and when this patient is going to deliver. Both are extremely, extremely important factors. In fact, they are the only reason you are transporting in the first place. If you are going to commit to two hours with this patient, don't you think it would be the least bit beneficial to know those two things? Is there not a medically significant difference between true and false labour that makes that knowledge important to the medical professional caring for them for the next two hours? You bet your arse there is! It makes all the difference in the world, especially in a pre-term mother. If this is a normal, primip in early labour who has not even begun to efface yet, you're in for a leisurely ride. If this is a full-term multiparous mom who is dilating, then you can bust the OB kit open with confidence. But if this is a thirty-two weeker in true labour, you damn sure want to know that as soon as possible, because you have some major preparations to start making. I can guarantee you that the hospital wants to know that too, because they are going to want to have an airborne neonatal team to meet you at the door, and that takes time to to assemble.

Yes, I know this is not standard, urban firemonkey, ten minute transport, 90 day medic school, DOT minimum curriculum fare we are talking about. Nobody ever implied that it was. But the fact is that the human body follows no protocols. It does it's own thing, and only on a semi-predictable basis. If there is one thing that is predictable in medicine, it is unpredictability. Expect the unexpected. The only to do that is to be aware of the potential of the unexpected, and to actively rule it out. You don't do that by waiting for crowning. How would you handle this transport anyhow? Sit at the foot of the cot and stare at your patient's vagina for two to three hours? I'd like to see that! But, if you have no idea what is going on behind door number 1, then that's really about your only choice. Not me. I have better, more professional options. It's just extremely sad that we are not educating our people to even consider those options, much less understand them.

The very best thing about EMT City is that medics from so many different backgrounds come together to discuss a common theme. Therefore, we are exposed to so many different, and potentially great ideas that we would have never thought of while secluded in our own little system, where nothing ever changes. But to benefit from this, we simply must have the ability to think progressively and open-mindedly, considering the diversity of our patients and the diversity of our systems. We can't get stuck on this nonsense about, "well, we don't have to worry about that in downtown Los Angeles," or "my protocols don't allow that," or "that's out of my scope of practice," or worst of all, "I don't need to know that." That mentality is the reason that EMS is still living in 1972. Think outside the box, people! EMS is not about your personal protocols. It's about medicine! Get an EDUCATION, not just more "training" and cards for your wallet. Despite what your school taught you, it is not enough to know that there are 206 bones in the body, yet not be taught the names of even ten percent of them. You need to know all of them! You need to know about the physical properties and chemical functions of those bones, the names of their parts, and the names of the parts that connect to them. The best paramedic school in this country still barely scratches the surface of what anybody who calls themselves a "medical professional" should know. If your school was less than two years long, and required no scientific prerequisites, then you're screwed from the beginning. You start off way behind the 8-ball. And, unfortunately, the vast majority of you will never go any farther than that. I'm no super-medic. And the only significant OB training I even have is in medic and nursing school clinicals. But instead of just standing around and watching during those clinicals, I engaged my brain and soaked up some medically significant knowledge that applies to my paramedic practice. You can too!

As to the value in the hospital? I don't know, I'm sure there's plenty, but the only thing I've seen it used for? CYA when having to defend yourself against the Dr. who's pissed that you got him to the hospital before the head was crowning...

... he was just a couple of linear thoughts away from seeing the light. Pretty impressive for a student who has yet to spent his first paid day on an ambulance.

So, no offence or impugning intended, Bro. We just have a tradition here of subtly pointing people towards the answers to their own questions without force feeding them to them, because the knowledge acquired that way lasts longer.

[croaker260]

(FYI- I use the term "medics" very generally....)

There are some cases that knowing cervical dilation is beneficial, predominantly in frontier/rural settings where the medic is both trained and prepared to deliver the baby THERE, complications and all. Those settings, and those medics properly trained, much less those medics properly trained in those settings...are rare indeed....

Truthfully, 90% of the medics/EMTs I have met have only a rudimentary knowledge of OB issues, especially difficult deliveries.

This "skill" (if it can even be called that) requires repeated practice to perfect, something that 99% of medics wont get at all, much less in volume.

What we need is NOT a new technique/task that will expose the medic to increased liability (and yes there is increased liability, I have seen at least one case where an EMT came very close to losing his job and his department sued over this very issue)

What we DO need is a crap load more OB rotations, and OB training, especially difficult deliveries....just like we need more difficult airway training, and difficult vascular access training, and hell, difficult everything training.....

(or EDUCATION, if that word pleases you more Dust )

Address that BEFORE you talk about every Tom, Dick and Scary Hairy Larry sticking his scary , hairy, hands elbow deep in some patients hoo hoo to check for something he has only read about once and tried on a plastic topographic sheet twice.....

Only once we are trained in OB in general to a REAL degree.....then we can discuss how to do it reliably, constantly, for every provider, for this not-so-risk-free task....then we can discuss if it is a useful data tool..which by the way with the advent of more accurate measurements of contractions through toc... ultrasound, and most important.....simple thorough physical and subjective assessment

BTW , my opinion on the topic is that it doesn't add (IMHO ) much to the information base, beyond a good thorough assessment (something many have yet to master). Remember that 10 CM can be 5 hours away, even days away in some rare cases...., or five minutes away. While I understand your perception of a GAP in our information gathering skills, I think that this will not solve that gap, I think it will do something worse. Instead of providing us with information, it will provide us with MIS INFORMATION..can you see the new saying??? Treat the Patient , not the hoo hoo!

Until we hit that point in education, Dust my friend, discussion of this task is much akin to discussing intubation and RSI for providers with out intense education of the anatomy of the airway and physiology of cellular respiration, another thing pre-hospital education is lacking at all levels.

BTW TNIUGS... let me share my experience if I may....

Interesting PP missed by an OB.... they do routine Ultrasounds. I really have a hard time swallowing that one, C sections are the bread and butter of OB specialists.... SO if the Mom has a low implanted Placenta (unrecognized or undiagnosed)and infringing upon internal oz then during a normal progression of labor. The mom and child are both in a life threatening situation.... any dilation of will result in serious bleeding, AND prior to any rupture of membranes, seriously if one is doing a pelvic with this amount of force.....and lack of knowledge I must agree they should NOT be even attempting to judge station or cervical dilation, bottom line education is the key.

Let me share my experiance....

My wife had a severe abrupted placenta missed by not one hospital but two , including the "High Risk OB hospital", missed by two separate ultrasounds.... that was not confirmed until the emergent c-section (indicated by Babies HR and failure to respond to terb.... not by the "normal ultrasound" or the toco). There was a near complete lack of external bleeding...anatomy can be a tricky thing.....and the ultrasound, like the ECG, only shows us a few select views and it is ultimately read by a human being with preconceptions, bias, and even simple exhaustion.

[Dustdevil]

That's what I'm talkin about, right there! =D>

Thank you, Steve! That is what I mean by evaluating all of the relevant factors, and then -- only after doing so -- discussing the implications of the issue intelligently. Excellent job. And I have come to expect nothing less from you.

I'm not asking anybody to make the quantum leap to believing that this is something that is appropriate for their system, or for EMS in general. Steve didn't. And, as he made clear, our current educational system is decades (if not forever) away from even coming close to being even minimally adequate to start pushing this kind of practice to the masses. But simple common sense should be enough for anybody who calls themselves a medical professional to conclude that this is indeed very useful information, and that in a system vastly different than your own, there is that possibility that it transforms from more than just "nice to know," to a necessity for prudent and intelligent medical practice.

[tniuqs]

If you will allow swaying a bit off topic:

What we need is NOT a new technique/task that will expose the medic to increased liability (and yes there is increased liability, I have seen at least one case where an EMT came very close to losing his job and his department sued over this very issue)

Why is FEAR of litigation an excuse in so many situations for EMS providers ?

I will never understand this I guess, but when this type of blank senario is used as an example of why we should not explore or prove a need to promote improved education, just blow it off and say I saw/ I heard this once. Not attacking your credibility at all just the concept as far as debate. Just think about the first Paramedic to shoot a tube, start an IV or discharge a defib, in civilian practice.....if He/ She did not push these previously expected norms then we would still be "RUSHING THE PATIENT TO THE HOSPITAL"

Just a little sidebar as well if you don't mind, the first time I put in a femoral line the RNs absolutly freaked out .... "you can't do that"!!!!!! your just an Abulance Attendant!

The MD checked the line for patency then stated "please hang 2 units of O neg stat, now that patient survived, and she didn't sue me in fact I got cookies and peanut butter too, my fave .... funny thing.

[spenac]

Well I can't add much. Thank you Dust and tniuqs you made the argument better than I would have for those of us here in frontier medicine to have that option. And I applaud those that did some research and based on that argued against it. I do agree that all should be educated to do this. But in the field those within 15 minutes of the hospital would not change care based on it so really probably never be placed in your protocols. I have always maintained that EMS is not a one size fits all business. I hope that this as well as some of my other topics helps a few of you to get out of your box. Of course some of my other topics have caused some to get mad just because it made you uncomfortable since you would not even try and open your mind.

I am a firm believer that we can become real healthcare professionals. But to do it we are all going to have to get out of our comfort zones.

One last argument for those in areas like mine. As I have mentioned before many of my OB's are illegal. They have been told all kinds of horror stories including that their baby will be taken from them. They get on the ambulance and they will say they have no pain. They stay quit and still. Honestly when I first started I thought most of them were faking labor. There is no outward indication that they are about to deliver. To check dilation could at least help us stay up on if there is a real chance of delivery. Yes I know a lady can go from 1 to 10 in minutes or days, but any extra information is helpful. And as Dust has mentioned a pre-term is really one that you need to stay on top of. When your by yourself and deliver a pre-term you are stuck in the back trying to keep the premie alive and manage the mother, because your partner is driving.

Somebody mentioned bust out the OB kit and just get ready. Well if I opened an OB kit and used the gowns and gloves every patient my entire supply budget would be gone just on OB kits.

Now the legal side in the USA more and more doctors are refusing to deliver because of all the lawsuits and I feel that means it is even more important for us to do a complete exam to cover ourself. Yes itniuqs, in the USA everything sadly is about the possible lawsuit rather than the patient.

So I say we all need more education so we can all have the option of expanded scopes of practice based on the needs of our area.

[katbemeEMT-B]

Spenac, I agree with you that in your scenario, the ability to check for dilation may be helpful. But if you are using it to determine if a woman is in labor is not a quantifiable reason. A woman can dilate and not be in labor. A better way to do this is to rest your hands on the womans abdomen and feel for consistent hardening of the entire abdomen. There should be no soft spots. When you feel this, you begin timing these "contractions". I have used this on two non-English speaking patients. This avoids the risk of introducing any type of bacteria into the vagina and cervix. If after monitoring the patient for contractions you note that they are two minutes or less apart, then yes, a more internal check should be performed. You are absolutely right when you say Hispanic women tend to internalize, especially if they are illegals. I see this with legals too.

I also agree that as EMS providers there definitely needs to be more OB education. I believe that education should begin at the EMT-B level not just medics. If as a medic, you are on a truck with a basic, wouldn't you feel more comfortable knowing that your partner is just as educated in OBs so he/she can assist you? What is taught at the Basic level is ridiculous. I don't know what is taught at the medic level as I have not gotten that far in my education yet, (doing generals right now), but I am looking forward to learning it. I think the education should consist of general OB knowledge, OB complications (signs and symptoms, and what to do or not to do), assisting mom in proper breathing and relaxing (this helps oxygen intake for the baby), intensive OB rotations (at a general hospital and a hospital that specializes in neonatal emergency care), and maybe even a section on keeping the provider cool, calm, and collected. I'm sure there are things I missed that some one else can add.

I would also like to respond to tniuqs. You asked how an OB can miss placenta previa. As has already been stated, they depend on ultrasound for an internal picture of the uterus. I do not know the exact details, as I did not ask the OB when it happened, but I do know that ultrasounds don't always show a clear picture of what is going on. Often times, the placenta is initially attached low in the uterus and as the baby and uterus grow, the placenta rises to it's normal position. It is the failure of the placenta to do so that causes placenta previa. I also know that this OB does not do constant ultrasounds on his patients unless he has reason to believe there is something amiss. This patient was progressing normally during her pregnancy and subsequent labor. She did not exhibit the normal excessive bleeding associated with placenta previa. If anything, she bled less than normal. Maybe that should have been the tipoff. When she came in for delivery, her contractions were three minutes apart and the OB happened to be on the floor as he had just delivered another baby. He went in to check for dilation and that's when all hell broke loose. She ended up having an emergency cesarian. It does not take much force to rupture a placenta enough to excessively bleed. You have to remember, OBs are human, they are not machines that never make mistakes and they aren't going to catch everything.

As far as my comment about inexperience, that was directed towards something spenac stated (not you as I don't know enough about your experience or area of service), about not knowing what it's like to be in a rural setting and having long transports. In a city or urban setting when you are looking at a transport time of less then fifteen minutes, checking for dilation is not going to assist the provider or change their direction of care. Seriously, by the time you take baseline vitals and monitor the abdomen to ensure mom us truly in labor, you would be at the hospital. Experience tells us as providers that these are our main concerns, not how dilated she is. Now if a provider is placed in a rural setting with long transport times, yes, maybe checking for dilation can be of benefit. But I still feel other things take precedence and checking for dilation should be a last resort. Dilation is not the only determining factor when it comes to timing of a delivery. A provider must also take into account gestationally how far along mom is and how big is the baby. A pre-term mom or small baby due to inadequate prenatal care does not require mom to completely dilate. This is where provider experience comes in. I think you would have to agree with me that just because a person's EMT class touched on OB emergencies, or a medic did an OB rotation, it is not enough for either one to gain the type of knowledge or experience needed to be truly educated in Obstetrics, emergent or otherwise.