# Cutting Clothes



## micsaver (Jan 28, 2009)

Yes, before you mention it I did look it up and read some old posts on the subject. The posts I found mostly talked about cutting clothes on major trauma pts.

We didn't cover this well at all in my training. Actually it was just mentioned. 
How do you cut a persons clothes off? Is there a particular way you find easier with minimal pt movement and privacy? 

My next question is if a pt has a fractured arm/leg or a cut and is fully conscious they can refuse anything at any point right. So If they are upset and don't want you to cut their new pants what do you do?


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## medic417 (Jan 28, 2009)

They say don't cut, don't cut.  You can explain the need to expose and the risks involved if they refuse.  But if you cut after they say no you just bought them new clothes and could be charged with a crime.  

As to clothes cutting techniques, you will see many.  Some are faster, some allow patients more privacy.  But on a major trauma every inch of skin is exposed so you miss nothing.  Anyone tells you otherwise is setting you up to miss something.  But again a patient that is alert can still refuse to allow you to cut clothes just as they can refuse any and all treatments.


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## Scout (Jan 28, 2009)

Along seams so they can be re sown if wanted is what we usualy say. I tend to just cut as much as i need, say if i need to look at the lower leg i cut up to the knee, if i want a collar on i'll just cut off the collar/hood.

And yes they can tell you to sod off. Did you try to remove the cloths? Alot of the time you can remove cloths with minimal movement. As fun as cutting is you dont always need to do it.


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## micsaver (Jan 28, 2009)

I havn't come across this situation yet. I do mostly dialysis transports. Maybe I can get my girlfriend to put on some old cloths so I can practice


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## medic417 (Jan 28, 2009)

micsaver said:


> I havn't come across this situation yet. I do mostly dialysis transports. Maybe I can get my girlfriend to put on some old cloths so I can practice



Just be careful not to cut any vital body parts.


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## RESQ_5_1 (Jan 28, 2009)

If my pt is councious and A/Ox4, I leave it up to them generally. Unless major trauma is involved. I have found that 99% of the people I have to cut clothes off of usually throw those clothes out afterwards even though I cut along the seam.

However, up here in Canada, there are many more layers to deal with during the winter. And, if you have ever tried to remove a pair of $500 snowmobile boots from a fractured ankle, you will find the pt is much more willing to let you cut them without getting mad once you start making the attempt.


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## vquintessence (Jan 28, 2009)

Consent for evaluation and treatment aside, just cut up the middle of the legs until you get to the hip area, otherwise leave the pants around the genitals alone.
For men:  Unless Lorena Bobbit was on scene, his nuts are in a padlock (Jay Leno headline segment anyone?) or there is localized or penetrating injury, you could forgo the exposure.  Also for spinal insults, ya usually don't need to expose the genitals to look for a priaprism.
For women: (assuming you're a male), ya probably don't want to be peeking unless it's OB/GYN or again, there is high likelihood of localized injury.  It's too much of an easy target to sue the male attendant who is alone in the back of a moving vehicle for molestation.   The criminal suit will probably not stick... but the civil suit... the one with the $$ compensation could be much easier to win.  The lawyers only have to prove % liability, not beyond a shadow of a doubt.



medic417 said:


> Just be careful not to cut any vital body parts.



Are toes ok?


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## motownems (Jan 28, 2009)

I routinely ask the pt if I can help them remove their jacket/sweatshirt/hoody.  Once I explain that it would make it easier for me to obtain an accurate bp I have never had a pt refuse. 

As far as the high speed cutting clothing of a trauma pt, I have only done that twice. Both times the pts were unresponsive. As for the technique, strait up the middle of the shirt (if it’s a button down it can be ripped) than straight up the sleeve to the collar; same thing with the pants straight up the leg to the waist.  However for the sake of the privacy of the pt I am of the opinion that this should only be done in the back of the rig, either that or get a wall of FF to stand facing out around you and the pt.

completely aggree with vquintessence about how this makes the provider an easy target...


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## PapaBear434 (Jan 28, 2009)

I had a guy that didn't want me to cut off his boots even though he had a fractured ankle and his boot was full of blood.  I couldn't just cut the laces, as he had some weird wire laces that I had never seen before or since, and my sheers (big ones that look like poultry sheers) couldn't cut through them.  His foot was swelled to the point that I couldn't get the boot off without him screaming.  

So I finally told him that I could cut off the boot, or the OR was going to cut off his foot.  He finally relented and I cut down the side.  Big honkin' sheers came in handy for that.

People need perspective.  Yeah, it sucks that your clothing is going to get cut.  No, I don't care how much you paid for it.  Yes, it's likely ruined by blood or road rash anyway.  Just let me cut and do what I need to do.

Most of the time, you can just remove the article of course.  But when you have a knee dislocation, you can't realistically do that.


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## medic417 (Jan 28, 2009)

vquintessence said:


> Consent for evaluation and treatment aside, just cut up the middle of the legs until you get to the hip area, otherwise leave the pants around the genitals alone.
> For men:  Unless Lorena Bobbit was on scene, his nuts are in a padlock (Jay Leno headline segment anyone?) or there is localized or penetrating injury, you could forgo the exposure.  Also for spinal insults, ya usually don't need to expose the genitals to look for a priaprism.
> For women: (assuming you're a male), ya probably don't want to be peeking unless it's OB/GYN or again, there is high likelihood of localized injury.  It's too much of an easy target to sue the male attendant who is alone in the back of a moving vehicle for molestation.   The criminal suit will probably not stick... but the civil suit... the one with the $$ compensation could be much easier to win.  The lawyers only have to prove % liability, not beyond a shadow of a doubt.
> 
> ...



I would disagree.  On major trauma total exposure is required or you may miss indications of other injurys.  You can not go through life in fear of law suits.  Be consistent in how you treat.   If you cut off all the hot girls clothes cut off all the fat mans clothes too.  

Toes aren't critical to his needs unless he has a weird fetish.:unsure:


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## BossyCow (Jan 28, 2009)

Trauma shears are wonderful! I generally go for the seams if the clothing looks like a favorite and can be saved. Otherwise it's the shortest most direct route to full visualization of the pt. Up the center, down the sleeves. I've bunched up the fabric and cut chunks instead of working my way slowly up a sleeve, depends on the pt's status.


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## medic417 (Jan 28, 2009)

BossyCow said:


> Trauma shears are wonderful! I generally go for the seams if the clothing looks like a favorite and can be saved. Otherwise it's the shortest most direct route to full visualization of the pt. Up the center, down the sleeves. I've bunched up the fabric and cut chunks instead of working my way slowly up a sleeve, depends on the pt's status.



I like that point.  Most never teach that to the new guy.  This is also an important reason to either replace cheap shears pretty much after each complete exposure or buy a good pair that stays sharp.  Limit the amount of times you have to actually open and close the shears.  Work smarter not harder.


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## firecoins (Jan 28, 2009)

I cut everything but I have a blanket set up for privacy once I have checked for injuries.


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## Sasha (Jan 28, 2009)

medic417 said:


> I like that point.  Most never teach that to the new guy.  This is also an important reason to either replace cheap shears pretty much after each complete exposure or buy a good pair that stays sharp.  Limit the amount of times you have to actually open and close the shears.  Work smarter not harder.



And don't use them to cut wrapping paper at Christmas. I figured out that dulls the blade pretty quick too.


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## rescuepoppy (Jan 28, 2009)

About the only thing I wont cut is a motorcycle club jacket. Had to treat a member of a well known motorcycle club once for a possible d/l shoulder. We were able to get his jacket off. I had already told one of his buddies that if we had to cut it that I would give him my shears.


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## BossyCow (Jan 28, 2009)

Sasha said:


> And don't use them to cut wrapping paper at Christmas. I figured out that dulls the blade pretty quick too.



Besides, makes the edges of the wrapping paper all jagged... ask me how I know that!


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## medic417 (Jan 28, 2009)

BossyCow said:


> Besides, makes the edges of the wrapping paper all jagged... ask me how I know that!




Did your Paramedic give you a gift with rough edges?


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## BossyCow (Jan 28, 2009)

medic417 said:


> Did your Paramedic give you a gift with rough edges?



That's a sort of personal question isn't it? But no.. as difficult as this may be for you to accept.. I actually use trauma shears myself.... not all of my EMS experience comes vicariously through my husband.... 

I do recall one Christmas though, when my husband was working a lot of overtime around the holidays and had stashed the kids presents in his room at work. He brought them home Christmas morning wrapped in red biohazard bags and tied with crime scene tape yellow bows and duct tape.


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## micsaver (Jan 28, 2009)

BossyCow said:


> ... Otherwise it's the shortest most direct route to full visualization of the pt. Up the center, down the sleeves.



There is a good point. It's probably not a good idea to go cutting the sleeves with your sheers going towards the pt's face. See lot's of good tips and techniques that I wish I would have been shown (or tried) in class.


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## Tincanfireman (Jan 28, 2009)

And since no one has mentioned it yet, if the pt. absolutely refuses your attempt/advice to remove their garments with scissors, document it thoroughly. You might also let them know that ER personnel tend to cut first and ask second, so they're most likely to end up with a bio bag full of bloody rags anyway. Also, remember that when you remove their clothes, they are gonna lose a good bit of body heat in a hurry, so have those blankets ready to go and keep that ambulance toasty.


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## Grady_emt (Jan 28, 2009)

rescuepoppy said:


> About the only thing I wont cut is a motorcycle club jacket. Had to treat a member of a well known motorcycle club once for a possible d/l shoulder. We were able to get his jacket off. I had already told one of his buddies that if we had to cut it that I would give him my shears.





That is about the only time I try to save something is when cutting a rider's leathers.  Go for the seams, or right next to it so they can be repaired, or if there are laces (like up the sides of pants/chaps) go for those as new lacing is easy to obtain

And if youre cutting a jacket, make sure it's not a down filled one, they make a mess, unless you want to look like you've been tarred and feathered.


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## daedalus (Jan 28, 2009)

What is the taboo with exposing the genitals? Its a part of the body, subject to getting injured, and in major trauma it needs to be exposed. If we are medical professionals than we should act like it. Doctors do not get out of digital rectal exams and pelvics, no matter if they are male or female. It is a vital part of an exam.


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## BossyCow (Jan 28, 2009)

daedalus said:


> What is the taboo with exposing the genitals? Its a part of the body, subject to getting injured, and in major trauma it needs to be exposed. If we are medical professionals than we should act like it. Doctors do not get out of digital rectal exams and pelvics, no matter if they are male or female. It is a vital part of an exam.



With an unconscious or critical pt, or a major trauma absolutely. But with some pt's they feel vulnerable enough being sick or injured and in the back of the rig that the indignity of exposure is difficult. I generally take my cue from the pt. I've seen little old ladies fling their clothing aside without a second thought and a grown man who was absolutely mortified that his injury happened while he was taking a whizz outside and his pants were unzipped. He asked one of the guys on scene to zip him up before we flipped him over onto the backboard. 

I think its possible to walk a middle line here. We remove clothing as necessary, and attempt to preserve the modesty of the patient within their comfort level whenever we can. Those are the only rules I follow.


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## marineman (Jan 28, 2009)

rescuepoppy said:


> About the only thing I wont cut is a motorcycle club jacket. Had to treat a member of a well known motorcycle club once for a possible d/l shoulder. We were able to get his jacket off. I had already told one of his buddies that if we had to cut it that I would give him my shears.



This is a good point and in that case I would agree. There's not much we can do in the field for a dislocated shoulder with a jacket off that we couldn't do with it on and it's generally good not to agitate your patients too much. 

On the other hand there are a few around here that refuse to cut motorcycle leathers period. In the case of a MVC on a motorcycle there's a good probability of major trauma so I won't give that a second thought. If you're involved in a major trauma and get upset when I cut your $200 jacket just wait until you get the ER bill.


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## Sasha (Jan 28, 2009)

daedalus said:


> What is the taboo with exposing the genitals? Its a part of the body, subject to getting injured, and in major trauma it needs to be exposed. If we are medical professionals than we should act like it. Doctors do not get out of digital rectal exams and pelvics, no matter if they are male or female. It is a vital part of an exam.



I agree with you!! I had a partner at my old job who was so shy about this he refused to perform exams on females. Granted we were IFT and the exams were not super vital, but he wouldn't listen to breathe sounds, wouldn't look at the dressing on the woman's upper thigh. Jeez louise!


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## medic417 (Jan 28, 2009)

Sasha said:


> I agree with you!! I had a partner at my old job who was so shy about this he refused to perform exams on females. Granted we were IFT and the exams were not super vital, but he wouldn't listen to breathe sounds, wouldn't look at the dressing on the woman's upper thigh. Jeez louise!



Sounds like he needs out of EMS.  Our job is a touchy, feely, looky at that job.


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## Sasha (Jan 28, 2009)

medic417 said:


> Sounds like he needs out of EMS.  Our job is a touchy, feely, looky at that job.



Well I feel he didn't have a very good EMT class. This is the partner who couldn't take a blood pressure and had to be taught. You don't automatically feel comfortable touching and assesing people in private areas often viewed as "taboo" by general public. It's something you gotta get comfortable with.

At least I wasn't comfortable first off.


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## medic417 (Jan 28, 2009)

Sasha said:


> Well I feel he didn't have a very good EMT class. This is the partner who couldn't take a blood pressure and had to be taught. You don't automatically feel comfortable touching and assesing people in private areas often viewed as "taboo" by general public. It's something you gotta get comfortable with.
> 
> At least I wasn't comfortable first off.



I guess I have been doing it so long I do not even realize I am doing it.  Thinking back to my first EMS course I recall one of the instructors while teaching how to listen to breath sounds getting onto me for improperly doing it.  I went to low to avoid her large breast.  She took my hand made me lift it and listen in proper location.  So ever since I just do what needs being done.


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## daedalus (Jan 29, 2009)

I remember the first time I had to lift a particularly large breast out of the way to do a 12 lead. It was awkward but ever since than I have been fine.


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## firecoins (Jan 29, 2009)

daedalus said:


> I remember the first time I had to lift a particularly large breast out of the way to do a 12 lead. It was awkward but ever since than I have been fine.



I got quite used to doing this in the hospital during clinicals as well.


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## PapaBear434 (Jan 29, 2009)

daedalus said:


> I remember the first time I had to lift a particularly large breast out of the way to do a 12 lead. It was awkward but ever since than I have been fine.



I had a woman lift her own my first time.  She just goes "Oh, there ya go, young man.  The ol' saggin' tits do get in the way from time to time."

That pretty much killed any sense of modesty I had left.


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## vquintessence (Jan 29, 2009)

Heh, never said I was afraid of exposing them completely _when_ necessary.  But really medic417 and Daedalus, you guys advocate exposure to every trauma pt to do a _complete_ assessment?  My refusal to do that goes beyond lawsuits, because if anyone was really that afraid of em, they wouldn't be in health care.  When does privacy or modesty come into consideration?

"Sir, you have an angulated ankle fx after a trench collapse.  You have poor distal CSM (PMS, whatever you all use).  You deny pain other than what's isolated at your ankle, but I need to cut off _all_ your clothing to fully understand what's going on with you."  Hell, might as well go the whole 9 yards and backboard the fella c high flow O2.

"Ma'am, you state severe LLQ abd pain, deny pregnancy, deny intercourse, but since you are in child bearing age (13-60'ish) and I don't believe you, I need to examine your genitalia for fear of bleeding secondary to ectopic pregnancy."

Bossycow put it best with walking the middle line.

Kind of related:  _How does everyone feel with cutting the clothes of a homeless person?  In New England or anywhere north of the Mason-Dixie line._


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## medic417 (Jan 29, 2009)

vquintessence said:


> Heh, never said I was afraid of exposing them completely _when_ necessary.  But really medic417 and Daedalus, you guys advocate exposure to every trauma pt to do a _complete_ assessment?  My refusal to do that goes beyond lawsuits, because if anyone was really that afraid of em, they wouldn't be in health care.  When does privacy or modesty come into consideration?
> 
> "Sir, you have an angulated ankle fx after a trench collapse.  You have poor distal CSM (PMS, whatever you all use).  You deny pain other than what's isolated at your ankle, but I need to cut off _all_ your clothing to fully understand what's going on with you."  Hell, might as well go the whole 9 yards and backboard the fella c high flow O2.
> 
> ...



Guess you did not pay attn to the statement major trauma?  

And actually the female scenario you joke about does require a visual exam.  

Honestly we should start exposing more patients.  To many just want to sit and do nothing rather than actually examine their patients.


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## EeyoreEMT (Jan 29, 2009)

*girls, boys and lawsuits*

When a male has a female pt, especially underage, it is very wise to have your partner have their mirror turned to see you and the pt, if you can, swtich with a female or have an additional person in the back so it's not 1-1. If it's critical, who care, expose, treat-go! I found myself with a partner one time that liked to look at the girls a bit too much, unnecessary cutting and exposing!! What I did was get to them first and if they had to be exposed I would do it with modesty if they were concious or if bystanders and have them covered with blankets and on backboard by the time my partner could say anything, and he knew the mirror was always there, for his protection and hers!!


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## vquintessence (Jan 29, 2009)

*zealous assessment vs right to privacy*



medic417 said:


> Guess you did not pay attn to the statement major trauma?
> 
> And actually the female scenario you joke about does require a visual exam.
> 
> Honestly we should start exposing more patients.  To many just want to sit and do nothing rather than actually examine their patients.



Jeez, disagreement is no reason to be smarmy!  Everyone here has implied that major trauma/illness justifies exposure.  Otherwise it's personally discretionary.  The LLQ pain I was "joking" about could have enough _other_ etiologies for me to not deem a visual examination of the genitalia _immediately_ necessary.  It's all about differential diagnosis.  No need to pretend that a vastly different level of care is being offered through these different viewpoints.  Regardless we won't see eye to eye.


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## medic417 (Jan 29, 2009)

vquintessence said:


> Jeez, disagreement is no reason to be smarmy!  Everyone here has implied that major trauma/illness justifies exposure.  Otherwise it's personally discretionary.  The LLQ pain I was "joking" about could have enough _other_ etiologies for me to not deem a visual examination of the genitalia _immediately_ necessary.  It's all about differential diagnosis.  No need to pretend that a vastly different level of care is being offered through these different viewpoints.  Regardless we won't see eye to eye.



I did not give you a smarty reply.  I politely answered in rebuttal to your statement.  
Just because my answer is from a different view than you you have chosen to act as if I attacked you.  Would you prefer all her just to agree with you?  There is no learning if we are unable to express our educated opinions based on our experience.


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## marineman (Jan 29, 2009)

hmmm... this one could be heading to a lock soon so I'll just throw in if you have to lift the girls to assess breath sounds or apply the monitor make sure that you're using the back of your hand to lift it.


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## medic417 (Jan 29, 2009)

marineman said:


> hmmm... this one could be heading to a lock soon so I'll just throw in if you have to lift the girls to assess breath sounds or apply the monitor make sure that you're using the back of your hand to lift it.



Actually Tim Phalen in 12 lead video lifts by cupping breast.  So education is palm not back of hand.  But I see why most use back of hand.


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## marineman (Jan 29, 2009)

Honest question, is there any reason to use palm? To me by using the back of the hand you accomplish the same thing and it removes any doubt as to what your intentions are.


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## PapaBear434 (Jan 29, 2009)

marineman said:


> Honest question, is there any reason to use palm? To me by using the back of the hand you accomplish the same thing and it removes any doubt as to what your intentions are.



Agreed.  That's why they also taught us to check for sternum fractures with the blade of our hand rather than flat hand or fingers, and why you only do a check on a femoral pulse in the most dire of situations.


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## reaper (Jan 29, 2009)

That is taking it a little to far. This is medicine. Do the job!


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## Sasha (Jan 29, 2009)

medic417 said:


> Actually Tim Phalen in 12 lead video lifts by cupping breast.  So education is palm not back of hand.  But I see why most use back of hand.




Are you kidding? As if EMTs and Medics aren't in enough danger of molestation accusations.

I use the back of the hand AND I'm a woman.


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## Ridryder911 (Jan 29, 2009)

medic417 said:


> Actually Tim Phalen in 12 lead video lifts by cupping breast.  So education is palm not back of hand.  But I see why most use back of hand.



So? Tim is not an authority. He is just another educator as many of videos is full of flaws as well. 




PapaBear434 said:


> Agreed.  That's why they also taught us to check for sternum fractures with the blade of our hand rather than flat hand or fingers, and why you only do a check on a femoral pulse in the most dire of situations.



Actually the reason for side hand is produce direct pressure on the sternum itself to see if rib/cartilage will occur.. nothing r/t sexual groping. As well, I check femoral pulses all the time on serious patients. Location should NEVER prevent assessment techniques. I can place my hand into the pants, etc. to check. Personally I don't care what people think, I am there for the patients sake. My actions will reflect that. If they are concerned I will immediately educate them of such. 

Folks it comes down to this, act professional and as if you are doing your job as you should, and attempt to show some dignity and nothing will occur. If you need to assess, assess, yet use common sense. Real trauma patients get stripped, medical patients get stripped as needed. I can assure you as a Nurse & Paramedic (being male) I have performed thousands of exams and procedures on both sexes. If one acts as it is part of their job and performs such consistent then there should be no problem Be respectful, place a towel, sheet, over as needed and provide dignity. 

R/r 911


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## jester_1269 (Jan 29, 2009)

back of the hand, definately.  You're not helping anyone if you get your cert sued out from under you.


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## enjoynz (Jan 29, 2009)

We had a cyclist that was snuged off her bike by a small truck.
She didn't want her new expensive riding jacket cut off,
so had to deal with the pain of us taking it off the normal way.
Her choice, not ours!
I'm not sure if insurance can cover claims for expensive clothes?
Guess with the excess, it's not really worth it.

Cheers Enjoynz


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## Aidey (Jan 30, 2009)

vquintessence said:


> _How does everyone feel with cutting the clothes of a homeless person?  In New England or anywhere north of the Mason-Dixie line._



Most, if not all of the hospitals I've transported to had clothes bins with random stuff in them that they would give to patients who needed it. Where I volunteered there was only one hospital in the area and I think the stuff there was donated by both the employees and a couple of local charities/church groups. So I generally didn't have any qualms about cutting their clothes. 


I was taught up the center of the legs, down the sleeves if you are cutting the whole sleeve, up if you are only cutting part way up (say to expose a wrist or elbow). For non button up shirts I was taught to cut in a Y or T pattern to get the front of the shirt off. I generally cut depending on the situation and what is going on. Like others have said, I've had patients refuse to have their clothes cut, only to change their mind because of pain. 

On the side subject of 12-leads and breasts, I was always taught to ask the patient to hold their breast out of the way first, if they couldn't, then use the back of your hand. Even though I'm female, that is the way I've always done it.


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## Outbac1 (Jan 30, 2009)

Ridryder911 said:


> Folks it comes down to this, act professional and as if you are doing your job as you should, and attempt to show some dignity and nothing will occur. If you need to assess, assess, yet use common sense. Real trauma patients get stripped, medical patients get stripped as needed. ..... If one acts as it is part of their job and performs such consistent then there should be no problem Be respectful, place a towel, sheet, over as needed and provide dignity.
> 
> R/r 911



I agree. Act professional and provide dignity as required.


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## medic417 (Jan 30, 2009)

Ridryder911 said:


> So? Tim is not an authority. He is just another educator as many of videos is full of flaws as well.
> 
> 
> 
> ...



LOL.  I actually laughed when I saw the video, just thought I would bring it up since he is supposed to be an expert.  It causes another problem you can not use that hand for anything else if you palm the breast.  Using the back of the hand allows use of your fingers to hold, wires, etc.  


Consistency is what will keep you out of trouble.  Be professional.  Do the job.


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## emtidon (Jan 30, 2009)

I agree with you.Usually if you explain to the patient in a nice calm manner,that you need to see whats going on.The patients in my case have been more than willing to let me cut the clothes.


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## emtidon (Jan 30, 2009)

Down filled jackets are best cut somewhere other then the back of your rig.let someone else clean the mess.


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## medicdan (Jan 30, 2009)

emtidon said:


> Down filled jackets are best cut somewhere other then the back of your rig.let someone else clean the mess.



Down-filled jackets are best NEVER cut, hasn't AD taught you anything*?



* Think Kelly Grayson.


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## emtidon (Jan 30, 2009)

emt-student said:


> Down-filled jackets are best NEVER cut, hasn't AD taught you anything*?
> 
> 
> 
> * Think Kelly Grayson.



but if you have to expose to see why your skier who landed on their torso after coming off a jump can't breath and you need to C-Collar.I'm just saying the jacket needs to come off and if it needs to be cut,cut it.It just would be nice to do it where its someone elses clean up responsibility.


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## Airwaygoddess (Jan 30, 2009)

*Got to see how it went in and if it came out.......*

Gun shot wounds and stabbings are strip and flip but remember if cutting clothes and it is a crime scene TRY not to cut through places where bullet holes and knife cuts are.  These are now evidence.  As folks have said here already, blankets for warmth and patient modesty, have the back of the ambulance warmed up for the patient to help with slow down the progression of shock.  Remember to keep yourself and your partner safe also!!


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## PapaBear434 (Jan 30, 2009)

Ridryder911 said:


> Actually the reason for side hand is produce direct pressure on the sternum itself to see if rib/cartilage will occur.. nothing r/t sexual groping. As well, I check femoral pulses all the time on serious patients. Location should NEVER prevent assessment techniques. I can place my hand into the pants, etc. to check. Personally I don't care what people think, I am there for the patients sake. My actions will reflect that. If they are concerned I will immediately educate them of such.



I know why we do the sternum the way we do, but it used to be that you could just reach down and poke around with your fingers.  Now they want you to use the blade, so I was told, so that it erases the "groping" motion.  It's also why the sternum rub to check for responsiveness has fallen out of favor.  Well, in addition to the fact that it could cause even more damage should that person have a chest trauma.  

As far as the femoral goes, they had to specifically tell us not to check that pulse point unless the patient is completely unresponsive.  Sure, seems like common sense.  But one of my fellow classmates got into the field and went for a femoral on a conscious and somewhat alert stroke patient (apparently she was completely there mentally, just no ability to verbalize) and the woman freaked the hell out.  Investigation conducted, and it was concluded that he was doing the right thing and the wrong time, and the woman (who actually recovered almost completely, surprisingly) and her family shrugged it off as good intentions from a noobie.  So of course they had to go and issue to the entire department to be careful and not do a femoral unless someone is completely unconscious/crashed, as the coherent patient you do this to may not be so forgiving as this woman was.

It's just another layer of CYA on the part of the department.


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## micsaver (Jan 30, 2009)

PapaBear434 said:


> ... It's also why the sternum rub to check for responsiveness has fallen out of favor.



That's the first I have heard of that. I took class less than a year ago and we were taught to do the sternum rub to check responsiveness. When did this change come about and what is recommended instead of it?


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## exodus (Jan 30, 2009)

micsaver said:


> That's the first I have heard of that. I took class less than a year ago and we were taught to do the sternum rub to check responsiveness. When did this change come about and what is recommended instead of it?



We were taught sternum rub so we wouldn't be surprised if we saw it in the field, but they said it's no longer used, and now we should use a clavical area pinch.


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## medic417 (Jan 30, 2009)

medic417 said:


> Actually Tim Phalen in 12 lead video lifts by cupping breast.  So education is palm not back of hand.  But I see why most use back of hand.




Here is the video for your consideration:

http://www.youtube.com/watch?v=TFcyiCKyaZ4&feature=related


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## Juxel (Jan 30, 2009)

exodus said:


> We were taught sternum rub so we wouldn't be surprised if we saw it in the field, but they said it's no longer used, and now we should use a clavical area pinch.



Maybe I'm a little old school, but I'm particularly fond of a good sternal rub, especially if I suspect the person is faking.  The alternatives are more useful to assess for localization of pain.  You should be familiar with a trapezius muscle squeeze, supraorbital pressure, and mandibular pressure.  Just remember not to use the latter two on a patient with facial injuries.


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## medic417 (Jan 30, 2009)

Juxel said:


> Maybe I'm a little old school, but I'm particularly fond of a good sternal rub, especially if I suspect the person is faking.  The alternatives are more useful to assess for localization of pain.  You should be familiar with a trapezius muscle squeeze, supraorbital pressure, and mandibular pressure.  Just remember not to use the latter two on a patient with facial injuries.



What if you are wrong and they are not faking?  Now you have done harm.  First rule is do no harm.


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## PapaBear434 (Jan 30, 2009)

micsaver said:


> That's the first I have heard of that. I took class less than a year ago and we were taught to do the sternum rub to check responsiveness. When did this change come about and what is recommended instead of it?



Pretty much what Exodus said.  We were taught it so we wouldn't freak out when we saw someone giving someone's chest a good noogie, but we were told to use a pinch to the shoulder/clavicle,  a pinch to the earlobe, and a pen between the fingers and a gentle squeeze.  All of these will cause pain but won't cause any serious damage or bruising.  

But then, if they ARE unresponsive and you have to do CPR anyway, you are gonna end up with far more trauma than a sternum rub coudl do.  Even still, I stick to a earlobe or shoulder pinch.  Does the trick usually.  If I have doubts to their faking, I do the hand drop to the face, though that's probably not really approved either.


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## BossyCow (Jan 30, 2009)

PapaBear434 said:


> Pretty much what Exodus said.  We were taught it so we wouldn't freak out when we saw someone giving someone's chest a good noogie, but we were told to use a pinch to the shoulder/clavicle,  a pinch to the earlobe, and a pen between the fingers and a gentle squeeze.  All of these will cause pain but won't cause any serious damage or bruising.
> 
> But then, if they ARE unresponsive and you have to do CPR anyway, you are gonna end up with far more trauma than a sternum rub coudl do.  Even still, I stick to a earlobe or shoulder pinch.  Does the trick usually.  If I have doubts to their faking, I do the hand drop to the face, though that's probably not really approved either.



There's a whole thread devoted to the facial trauma supposedly resulting from the hand drop. I've never seen it in the field and can't imagine it without first taping a brick to the pt's hand... but then... I don't know it all.


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## medic417 (Jan 30, 2009)

BossyCow said:


> There's a whole thread devoted to the facial trauma supposedly resulting from the hand drop. I've never seen it in the field and can't imagine it without first taping a brick to the pt's hand... but then... I don't know it all.



:unsure::huh:


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## triemal04 (Jan 30, 2009)

medic417 said:


> What if you are wrong and they are not faking?  Now you have done harm.  First rule is do no harm.


I suppose...if they allready had traumatic injuries to that area.  Which hopefully you where considering before you tried that move.  Seriously, if you are causing damage to an otherwise uninjured individual by doing a sternal rub, you are doing something very wrong.


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## marineman (Jan 30, 2009)

We were told to give up on the sternal rub since it's assessing for response to pain and it's really not all that painful (at least the way most people do it, yes I know you can make it hurt). I like the shoulder pinch but honestly it's not that big of a deal, just do something that hurts but doesn't cause harm and see if they react.

If you think your patient is faking real lightly move your pen or finger across their eyelashes, if their eyelids twitch they're with you.


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## medic417 (Jan 30, 2009)

triemal04 said:


> I suppose...if they allready had traumatic injuries to that area.  Which hopefully you where considering before you tried that move.  Seriously, if you are causing damage to an otherwise uninjured individual by doing a sternal rub, you are doing something very wrong.



But how are you sure they are faking.  Some patients with CVA's and other problems appear to be faking but they really can not respond.  How would you like it if I caused your mother extra pain because I was going to prove she was faking?


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## Ridryder911 (Jan 30, 2009)

Use commons sense! Sternal rub is an acceptable painful response and technically so is twisting of the nipple (but I would not suggest that one). One is only inflecting a noxious stimulus, not inflecting danger to the patient. If you are doing danger, your not performing a sternal rub properly. Noxious stimulus is noxious stimulus, I have even seen physicians flip their fingers on the eye. Again, use professionalism and common sense. You are not there to harm them, but I know of many patients that are past the trapezius pinch, and can tolerate most so called "painful response". 

You don't check for femoral pulses on a abdominal/back pain, as a Supv. I would be chewing your arse out for doing a poor assessment. There is *NO* contraindication of assessing pulses femoral, popliteal, pedal, etc on a patient where it might be needed to be assessed. Quit being a fraidy cat if the procedure is warranted, and is part of an assessment then do it. I have never had any complaints even from 80 year old Sunday School teachers. Show me the literature that describes one should not assess central pulses or that it has "fallen out of favor" and I will show you where one should assess pulsating, and quality of circulation; which can only be done by assessing pulses.


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## medic417 (Jan 30, 2009)

Ridryder911 said:


> You don't check for femoral pulses on a abdominal/back pain, as a Supv. I would be chewing your arse out for doing a poor assessment. There is *NO* contraindication of assessing pulses femoral, popliteal, pedal, etc on a patient where it might be needed to be assessed. Quit being a fraidy cat if the procedure is warranted, and is part of an assessment then do it. I have never had any complaints even from 80 year old Sunday School teachers. Show me the literature that describes one should not assess central pulses or that it has "fallen out of favor" and I will show you where one should assess pulsating, and quality of circulation; which can only be done by assessing pulses.



People that are not willing to touch, look, and listen really need to get out of EMS.  If your going to claim to be an EMS Professional do a proper exam.  Rid is spot on.


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## triemal04 (Jan 30, 2009)

medic417 said:


> But how are you sure they are faking.  Some patients with CVA's and other problems appear to be faking but they really can not respond.  How would you like it if I caused your mother extra pain because I was going to prove she was faking?


Uh...well...I'm not sure they are faking.  That's why I'm doing it.  For :censored::censored::censored::censored:'s sake, what kind of question is that?  If you KNOW they are faking then you allready have your answer; leave them alone, or TELL them you know they are faking.  If you find someone who is not responsive knowing if they really are and how unresponsive they are is one of the most basic pieces of info we get!  And if my mother was found unresponsive on the floor the only way I'd have a problem with you doing a sternal rub was if you didn't do it.


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## Ridryder911 (Jan 30, 2009)

medic417 said:


> But how are you sure they are faking.  Some patients with CVA's and other problems appear to be faking but they really can not respond.  How would you like it if I caused your mother extra pain because I was going to prove she was faking?



Trust me, the sternal rub is nothing in comparison to the, deep painful reflex, use of a  pin (Wartenberg) wheel (sharp pointed steel pins on a wheel), multiple IV's, finger stick, nasopharyngeal airway, foley catheter, hemoccult and rectal tone check that will be shortly performed. 

So in comparison, a sternal rub is nothing. Unfortunately that is the consequence of being ill. 

R/r 9


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## medic417 (Jan 30, 2009)

triemal04 said:


> Uh...well...I'm not sure they are faking.  That's why I'm doing it.  For :censored::censored::censored::censored:'s sake, what kind of question is that?  If you KNOW they are faking then you allready have your answer; leave them alone, or TELL them you know they are faking.  If you find someone who is not responsive knowing if they really are and how unresponsive they are is one of the most basic pieces of info we get!  And if my mother was found unresponsive on the floor the only way I'd have a problem with you doing a sternal rub was if you didn't do it.



I agree checking for response is appropriate.  But if you know someones faking I see no reason to torture them.  If they are faking then they probably have a mental issue so are still in need of medical care.  Just transport and let the docs tort......... um treat.


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## medic417 (Jan 30, 2009)

Ridryder911 said:


> Trust me, the sternal rub is nothing in comparison to the, deep painful reflex, use of a  pin (Wartenberg) wheel (sharp pointed steel pins on a wheel), multiple IV's, finger stick, nasopharyngeal airway, foley catheter, hemoccult and rectal tone check that will be shortly performed.
> 
> So in comparison, a sternal rub is nothing. Unfortunately that is the consequence of being ill.
> 
> R/r 9



Thats the truth.  Whoever designed many of Medicines practices was a sadist.


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## marineman (Jan 30, 2009)

medic417 said:


> I agree checking for response is appropriate.  But if you know someones faking I see no reason to torture them.  If they are faking then they probably have a mental issue so are still in need of medical care.  Just transport and let the docs tort......... um treat.



That's my take on it. I like to find out if their faking or not using the eyelash thing but in the hospital an unresponsive patient getting the full work up is much worse than any painful stimuli so I let them be in their happy little I fooled the EMT world for a while.


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## triemal04 (Jan 30, 2009)

medic417 said:


> I agree checking for response is appropriate.  But if you know someones faking I see no reason to torture them.  If they are faking then they probably have a mental issue so are still in need of medical care.  Just transport and let the docs tort......... um treat.


Ok, I don't have any problem with that.  But you always need to determine if they are faking or not; your post came across as not doing a sternal rub because it was painful and the person might be able to feel it.  Continuing to cause someone pn when you know flat out that they are faking is wrong.  Telling them that you know what is going on and what the end result will be if they continue with their behavior...much more effective.


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## medic417 (Jan 30, 2009)

triemal04 said:


> Ok, I don't have any problem with that.  But you always need to determine if they are faking or not; your post came across as not doing a sternal rub because it was painful and the person might be able to feel it.  Continuing to cause someone pn when you know flat out that they are faking is wrong.  Telling them that you know what is going on and what the end result will be if they continue with their behavior...much more effective.



Describe in detail the procedures that Rid listed and if that doesn't scare them into a quick recovery they really do have mental issues that need addressed.


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## Jon (Jan 30, 2009)

Grady_emt said:


> That is about the only time I try to save something is when cutting a rider's leathers.  Go for the seams, or right next to it so they can be repaired, or if there are laces (like up the sides of pants/chaps) go for those as new lacing is easy to obtain
> 
> And if youre cutting a jacket, make sure it's not a down filled one, they make a mess, unless you want to look like you've been tarred and feathered.


Leathers and riding gear are expensive.

Biker Gang "Colors" are even more valuable, to those that worry about them. It is something to be conscious of.., good point.



As for "Fully" naked. Although I understand why - I challenge you to explain what injuries that "traditional" undergarments would hide in such a way that you couldn't move them slightly to visualize.

**TRADITIONAL - If it is a college kid wearing boxers that are longer than my gym shorts... yeah - they have to go**

If the patient is conscious - leaving them with some shred of dignity might be a good thing. Yes - there is a fear of lawsuits... and it may be overstated... but I really don't want to have to go to court to deal with a false claim.


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## Jon (Jan 30, 2009)

medic417 said:


> What if you are wrong and they are not faking?  Now you have done harm.  First rule is do no harm.


Really?

Standard of care is to document A.V.P.U.

How can you assess P vs. U in an apparently unresponsive patient without painful stimuli?


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## medic417 (Jan 30, 2009)

Jon said:


> Leathers and riding gear are expensive.
> 
> Biker Gang "Colors" are even more valuable, to those that worry about them. It is something to be conscious of.., good point.
> 
> ...



Had one trauma many years ago that appeared OK as in no blood on underwear.  The medic left underwear on her.  Got to hospital with her vitals dropping.  When hospital cut away her under wear they found her vagina packed.  She was bleeding out internally with no outward show of blood because of the packing.  Had he removed the underwear he would have seen that and could have at least been more aware of her possible injurys.


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## medic417 (Jan 30, 2009)

Jon said:


> Really?
> 
> Standard of care is to document A.V.P.U.
> 
> How can you assess P vs. U in an apparently unresponsive patient without painful stimuli?



Your correct you do need a test for stimuli response.  I mispoke because I get so tired of those that keep trying to prove someones faking.  Perform one  stimuli test and quit trying to out play the fakers.  Now with longer transports you will have to get AVPU score again, but it is not continuous torture of the faker.


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## Jon (Jan 30, 2009)

medic417 said:


> Had one trauma many years ago that appeared OK as in no blood on underwear.  The medic left underwear on her.  Got to hospital with her vitals dropping.  When hospital cut away her under wear they found her vagina packed.  She was bleeding out internally with no outward show of blood because of the packing.  Had he removed the underwear he would have seen that and could have at least been more aware of her possible injurys.



Ok. Could they have lifted up the underwear to look... without having to cut it off?




medic417 said:


> Your correct you do need a test for stimuli response.  I mispoke because I get so tired of those that keep trying to prove someones faking.  Perform one  stimuli test and quit trying to out play the fakers.  Now with longer transports you will have to get AVPU score again, but it is not continuous torture of the faker.


I concur with you - but I'm not sure that was what the OP was implying he was doing.


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## micsaver (Jan 30, 2009)

My girlfriend is a vet student and we often get into great medical discussions. Her contribution is this: "My patients don't wear clothes (unless they are poodles) and don't fake anything.  If they hurt, they hurt, and if they are nearly dead, they are nearly dead, period.  They can, of course, bite you, kick you, and step on you.  Then again, humans can too.  I think I have the better deal." -_-


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## medic417 (Jan 30, 2009)

Jon said:


> Ok. Could they have lifted up the underwear to look... without having to cut it off?



Honestly moving underwear around would probably make a patient feel like you were trying to get a peek at their privates more than if you were to cut off or slide off underwear.  Expose then cover with a sheet or blanket.  Put them in a hospital gown.  Be consistent and do the job.  If fear of lawsuits affects patient care at some point that is more likely to get you sued where you will lose than just doing the job as needed and consistently.


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## Ridryder911 (Jan 30, 2009)

Don't want to receive painful response to be checked or have a nasopharyngeal airway placed, then quit faking it. Sorry, I will not be mean but I have no tolerance for fakers as well. I will be place them privately and be VERY blunt & whisper to them; if I am medically educated enough to treat them, I am medically educated to tell B.S. from the real deal. So for time sake, you can continue your performance or awaken and discuss the problems. If you wish to continue the charade, then you must surfer the consequences of those with that symptoms and I can assure it is not nice. 

Usually, they will usually make a remarkable recovery. The option is theirs. It is not torture, they have a choice. 

R/r 911


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## downunderwunda (Jan 30, 2009)

There is no reason why an initial assesment cannot be mad on the raodside with minimal cutting. If you find something then certainly explore it further. My principal is Primary assessment, collar, KED, into wagon then cut, cut, cut.

Patient modesty is always a primary concern. You can do a proper assessment in your car, & yours are bigger than ours. You can do a good seconday with notes on where to explore on a tertiary, prior to transport. The only time i will deviate from that is if there is too much claret & I need to determine the cause there & then.


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## Fir Na Au Saol (Feb 1, 2009)

After reading this entire thread, it seems pretty simple really, if you have your brain switched on and are using it. Do what medically needs to be done for each patient. If they're talking to you, talk to them. Tell them what is going on and why you need to do this or that examination or procedure. If they're not talking to you, do what medically needs to be done for each patient. If the family is standing there watching you, tell THEM what is going on and why you need to do this or that examination or procedure. Now granted, that isn't always that easy with a critical patient, but do what you can. 

Think. Communicate. Document.

That's my $0.02 of free opinion, YMMV.


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## medic417 (Feb 1, 2009)

Fir Na Au Saol said:


> After reading this entire thread, it seems pretty simple really, if you have your brain switched on and are using it. Do what medically needs to be done for each patient. If they're talking to you, talk to them. Tell them what is going on and why you need to do this or that examination or procedure. If they're not talking to you, do what medically needs to be done for each patient. If the family is standing there watching you, tell THEM what is going on and why you need to do this or that examination or procedure. Now granted, that isn't always that easy with a critical patient, but do what you can.
> 
> Think. Communicate. Document.
> 
> That's my $0.02 of free opinion, YMMV.



Actually even if you are sure patient has no ability to know what is happening you should tell them what you are doing.  You might be surprised when they recall the rude comments you made about them once they wake up.  Plus that keeps you in the habit of talking to your patient as well as you may hear yourself and decide no I should do this different.


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## Sasha (Feb 1, 2009)

> What if you are wrong and they are not faking? Now you have done harm. First rule is do no harm.



Be realistic. Sometimes you HAVE to do harm, and a sternal rub is very low on the "harm" scale. It hurts, two seconds later, it still kinda aches, and then you're done with it.

Sternal rubs are needed to asses the "P" in "AVPU". I'm not gonna use my pen on their nail, or go around pinching people. Sternal rub is my "P" assesment of choice

Would the same apply to those who start saline locks "just in case"? They don't need it at that point, IVs hurt, so they're doing harm. Should they all have their licenses pulled?


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## medic417 (Feb 1, 2009)

Sasha said:


> Be realistic. Sometimes you HAVE to do harm, and a sternal rub is very low on the "harm" scale. It hurts, two seconds later, it still kinda aches, and then you're done with it.
> 
> Sternal rubs are needed to asses the "P" in "AVPU". I'm not gonna use my pen on their nail, or go around pinching people. Sternal rub is my "P" assesment of choice
> 
> Would the same apply to those who start saline locks "just in case"? They don't need it at that point, IVs hurt, so they're doing harm. Should they all have their licenses pulled?



Actually starting IV's just to start them is bad medicine.  If you have no reason to suspect any possible need of meds or fluid and that the ER is just going to release them you have no business starting an IV.  Honestly doing it w/o need is either an attempt to punish the person wasting your time or it is a way to bump the bill to ALS grade, which is fraud.  

Oh and I already admitted to need of stimuli for the "P" in AVPU.  Please don't beat me no more.


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## Shishkabob (Feb 1, 2009)

Can't forget traction in traction splints... causes pain for the better good.


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## medic417 (Feb 1, 2009)

Linuss said:


> Can't forget traction in traction splints... causes pain for the better good.



Yes but once in place and bones realigned by traction most patients even w/o pain meds say it hurts less than it did before traction applied.  Of course now I do not do it w/o pain meds but when as a basic I just had to tell them this will hurt like heck.


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## Sasha (Feb 1, 2009)

> Actually starting IV's just to start them is bad medicine. If you have no reason to suspect any possible need of meds or fluid and that the ER is just going to release them you have no business starting an IV. Honestly doing it w/o need is either an attempt to punish the person wasting your time or it is a way to bump the bill to ALS grade, which is fraud.



Or, they're started because hm... Last time I checked we weren't doctors, we couldn't diagnose what's REALLY going on with the patient, and no one is every really "stable" but "potentially unstable" and you want to have that line in case they need meds, but at this point you have no plan for meds or fluids.

The last ride time I had, I started a saline locked IV just because the patient didn't feel right, but there was nothing outwardly wrong with him. I felt better with one just in case his condition changed. Not because I was "punishing him" and I don't really care what the cost of transport is billed as, neither did my preceptor due to the fact it wasn't private.

In the middle of transport patient had a seizure which we easily treated because of previously established IV access.

Still call it bad medicine?


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## medic417 (Feb 1, 2009)

Sasha said:


> Or, they're started because hm... Last time I checked we weren't doctors, we couldn't diagnose what's REALLY going on with the patient, and no one is every really "stable" but "potentially unstable" and you want to have that line in case they need meds, but at this point you have no plan for meds or fluids.
> 
> The last ride time I had, I started a saline locked IV just because the patient didn't feel right, but there was nothing outwardly wrong with him. I felt better with one just in case his condition changed. Not because I was "punishing him" and I don't really care what the cost of transport is billed as, neither did my preceptor due to the fact it wasn't private.
> 
> ...




You didn't do it just because, you did it because based on what the patient said made you feel more comfortable in case.  That was justified.  But the caller with a stubbed toe that doesn't even hurt anymore has no bruising or swelling, no other complaints, just decided he wanted to go let a doctor see it does not need an IV.  

And regardless of what they teach you in school you do make a field diagnosis.  If you did not you would not have any needs for any medicine or equipment.  You would just sit beside them for the ride and do nothing.  So don't start the I don't diagnose crap you know better than that.


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## Fir Na Au Saol (Feb 1, 2009)

medic417 said:


> Actually even if you are sure patient has no ability to know what is happening you should tell them what you are doing.  You might be surprised when they recall the rude comments you made about them once they wake up.  Plus that keeps you in the habit of talking to your patient as well as you may hear yourself and decide no I should do this different.


Good point. I do make a habit of talking to all patients. CVA and seizure Pts often can hear and remember even if they can't respond.  This has earned me copious thanks from a couple of seizure Pts.


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## Sasha (Feb 1, 2009)

medic417 said:


> You didn't do it just because, you did it because based on what the patient said made you feel more comfortable in case.  That was justified.  But the caller with a stubbed toe that doesn't even hurt anymore has no bruising or swelling, no other complaints, just decided he wanted to go let a doctor see it does not need an IV.
> 
> And regardless of what they teach you in school you do make a field diagnosis.  If you did not you would not have any needs for any medicine or equipment.  You would just sit beside them for the ride and do nothing.  So don't start the I don't diagnose crap you know better than that.



Oh of course you speculate what you THINK it is, I do it all the time on rides and if I'm in the same ER later that day, ask the doctor what was going on with the patient to see if I was right or way off base. 

However if you start giving your patients a dx or tell the doctor there's nothing wrong with that patient, you BETTER be 100% right or you make yourself look like a butt.


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## medic417 (Feb 1, 2009)

Sasha said:


> Oh of course you speculate what you THINK it is, I do it all the time on rides and if I'm in the same ER later that day, ask the doctor what was going on with the patient to see if I was right or way off base.
> 
> However if you start giving your patients a dx or tell the doctor there's nothing wrong with that patient, you BETTER be 100% right or you make yourself look like a butt.




I guess I must be just better than the average medic as doctors do ask what my diagnosis is.


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## Sasha (Feb 1, 2009)

medic417 said:


> I guess I must be just better than the average medic



So you keep telling everyone.


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## medic417 (Feb 1, 2009)

Sasha said:


> So you keep telling everyone.



Yes I do.  Your welcome.  B)


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## Aidey (Feb 1, 2009)

The only hospital I ever transported to was also the hospital where I did my clinicals, giving me an advantage because most of the doctors at least recognized me. 

The doctors who liked EMS would ask for a diagnosis, the doctors who didn't wouldn't. I've had doctors say "Ok we've got the patient, see ya, bye" and I've had others stand there with me and we've thrown DDs back and forth House style. (Those are usually the "I don't know what the heck is going on, someone else figure it out" calls). 

Either way, whether doctors like it or not we are forming at least a working diagnosis. I think it's a sign of a good relationship when they listen to what we are saying. It may have nothing to do with the caliber of the medic, and more to do with the ego/attitude of the doctor.


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## BossyCow (Feb 2, 2009)

medic417 said:


> I guess I must be just better than the average medic as doctors do ask what my diagnosis is.



Only doctors diagnose. Period. While an ER doc may ask you for what you think might be going on, he is only really asking for your rule out.


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## PapaBear434 (Feb 2, 2009)

BossyCow said:


> Only doctors diagnose. Period. While an ER doc may ask you for what you think might be going on, he is only really asking for your rule out.



The way it was described to me is this:  We don't have medical opinions or diagnosis, we have medical assessments.  It's up to the doctor to do the former.


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## medic417 (Feb 2, 2009)

BossyCow said:


> Only doctors diagnose. Period. While an ER doc may ask you for what you think might be going on, he is only really asking for your rule out.



Then all meds including Oxygen must be removed from the ambulance.  W/o at least a field or working diagnosis we can do nothing.  Deciding which protocol to follow requires you to examine and diagnose.  It may not be a definitive diagnosis but it is a working diagnosis.  Honestly if we can not diagnose anything you could not even put a bandage on a laceration because you could not diagnose that the patient is bleeding.  Its just ridiculous to say we do not diagnose.


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## Sasha (Feb 2, 2009)

medic417 said:


> Then all meds including Oxygen must be removed from the ambulance.  W/o at least a field or working diagnosis we can do nothing.  Deciding which protocol to follow requires you to examine and diagnose.  It may not be a definitive diagnosis but it is a working diagnosis.  Honestly if we can not diagnose anything you could not even put a bandage on a laceration because you could not diagnose that the patient is bleeding.  Its just ridiculous to say we do not diagnose.



You don't give meds on your speculated diagnosis, you give meds based on the presentation and signs and symptoms of a patient. You don't treat CHF. You treat the fluid filling up in their lungs and the s.o.b.


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## medic417 (Feb 2, 2009)

Sasha said:


> You don't give meds on your speculated diagnosis, you give meds based on the presentation and signs and symptoms of a patient. You don't treat CHF. You treat the fluid filling up in their lungs and the s.o.b.



Nope fluid in the lungs is a diagnosis.  So can't treat it as per you we can not diagnose.  Heck I can't even splint the angulated leg because I can't even diagnos that it just aint right.  Actually my protocols state for CHF do XXXX.  So if I can't determine CHF I can't do XXXX.  So yes I field diagnose CHF.  For a fractured femur I do XXXXX, so guess what I field diagnose fractued femur and do XXXXX.  For a STEMI I do XXXX, XXXX. and XXXXXXXXX.   So I field diagnose STEMI and do XXXX, XXXX, and XXXXXXXXX.  

Again maybe I'm just better than all other medics and allowed to diagnose but somehow I feel there are others out there that might even be better than me that diagnose also.


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## Aidey (Feb 2, 2009)

I'm with Medic417 on this one. A diagnosis is a decision as to what is wrong with the patient. In order to treat the patient we have to make a decision, and thus we are making a diagnosis.


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## JPINFV (Feb 2, 2009)

You have a patient that is hot, flush, dry, and altered, what do you do?

I can think of at least two DDXs where patients can have those symptoms and, strangely enough, have essentially opposite treatments. Tell me how I can differentiate between, say CO poisoning (move to fresh air) and heat stroke (seek shelter), without choosing a DDX? 

Debating if we call something a DDX or a 'working dx' or an impression or an assessment is just semantics.


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## BossyCow (Feb 2, 2009)

medic417 said:


> Then all meds including Oxygen must be removed from the ambulance.  W/o at least a field or working diagnosis we can do nothing.  Deciding which protocol to follow requires you to examine and diagnose.  It may not be a definitive diagnosis but it is a working diagnosis.  Honestly if we can not diagnose anything you could not even put a bandage on a laceration because you could not diagnose that the patient is bleeding.  Its just ridiculous to say we do not diagnose.



Read your scope of practice, we do not diagnose, we are not allowed to diagnose. Yes we may treat signs and symptoms, but we cannot legally diagnose, that's why it says Rule Out on your PCR. 

You can treat a symptom without diagnosing the cause. Don't be silly.


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## medic417 (Feb 2, 2009)

BossyCow said:


> Read your scope of practice, we do not diagnose, we are not allowed to diagnose. Yes we may treat signs and symptoms, but we cannot legally diagnose, that's why it says Rule Out on your PCR.
> 
> You can treat a symptom without diagnosing the cause. Don't be silly.



My PCR does not say rule out.  My scope of practice requires me to diagnose.  I have to diagnose what type of cardiac problem so I can treat it.  I have diagnose which respiratory problem so I can detremine whice one to treat.  Sorry but we diagnose other wise all we would be is "ambulance drivers".


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## Sasha (Feb 2, 2009)

> Nope fluid in the lungs is a diagnosis.



Symptom.

10chars.


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## BossyCow (Feb 2, 2009)

medic417 said:


> Nope fluid in the lungs is a diagnosis.  So can't treat it as per you we can not diagnose.  Heck I can't even splint the angulated leg because I can't even diagnos that it just aint right.  Actually my protocols state for CHF do XXXX.  So if I can't determine CHF I can't do XXXX.  So yes I field diagnose CHF.  For a fractured femur I do XXXXX, so guess what I field diagnose fractued femur and do XXXXX.  For a STEMI I do XXXX, XXXX. and XXXXXXXXX.   So I field diagnose STEMI and do XXXX, XXXX, and XXXXXXXXX.
> 
> Again maybe I'm just better than all other medics and allowed to diagnose but somehow I feel there are others out there that might even be better than me that diagnose also.



Fluid in the lungs is a sign/symptom.. CHF is a diagnosis. But the diagnosis of CHF was not made by you, but made by the pt's doctor and reported to you. 

What about those greenstick fxs that aren't visibly angulated? Can you 'diagnose' that one? You can say you see signs of what might be a STEMI and treat what you see, but the dianosis of STEMI happens with the doc. Not even R.N.s diagnose.. look it up. Sorry, this isn't a judgement call, you are just plain wrong here.


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## JPINFV (Feb 2, 2009)

Could be both actually. Hearing rales would be a sign while the congestion felt by the patient would be a symptom.


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## daedalus (Feb 2, 2009)

Ay, I disagree. We do "diagnose". For example, a de-compensating CHF patient with bilateral rales and obvious pitting edema in dependent areas. With a Hx of CHF we can create a working diagnosis of pulmonary edema, which we must do if we are to treat for it. Giving Lasix and Nirtro for purely for treating "primary rales" would show a great lack of critical thinking and would be cookbook medicine. Besides, pathophysiology of heart failure is learned at the medic level, why so if we cannot recognize and treat it (hence diagnose).

We Diagnosis Acute MI all the time. Based on Hx, FamHx, signs and symptoms, and a EKG, we remotely activate the cath lab and bypass all hospitals without one.


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## vquintessence (Feb 2, 2009)

*apologies to the OP for my tangents!*



daedalus said:


> Ay, I disagree. We do "diagnose". For example, a de-compensating CHF patient with bilateral rales and obvious pitting edema in dependent areas. With a Hx of CHF we can create a working diagnosis of pulmonary edema, which we must do if we are to treat for it. Giving Lasix and Nirtro for purely for treating "primary rales" would show a great lack of critical thinking and would be cookbook medicine. Besides, pathophysiology of heart failure is learned at the medic level, why so if we cannot recognize and treat it (hence diagnose).
> 
> We Diagnosis Acute MI all the time. Based on Hx, FamHx, signs and symptoms, and a EKG, we remotely activate the cath lab and bypass all hospitals without one.



I like your phrase "working diagnosis".  Fits the bill nicely for either debating side.  Guess the only debate is whether or not our working diagnosis should be official, except of course for all the field interpretations performed by Doctor Ambulance..

Officially speaking, it's possibly good habit to NOT tell pts any definitive answer as to an exact etiology of their illness.  Sure, that is a bit of hypocrisy with that, because times I've had someone who is/has been febrile, has rhonchi present and a productive cough, and said to the pt "Looks like ya might have pneumonia."  And I've been wrong.

As far as us (EMS) diagnosing AMI, we should make it our business to never be the ones to inform the pt with CP that they're not having an AMI.  Offer treatment and reassurance, give them honest answers, but probably best to avoid definitive statements like "you're not having a heart attack".
Unless you have a means to obtain lab values and your service is licensed to diagnose said labs, we have no right to tell the pt they aren't having an AMI based solely on our field/working diagnosis and ecg findings. Even services with licensed Istat use/diagnosis/whatever, will NOT have the transport time to recheck troponin to _completely_ rule out an AMI.


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## marineman (Feb 2, 2009)

I agree with the working diagnosis bit. I will never tell a patient definitively what is wrong with them and generally try to avoid the subject as a whole but I do come up with something in my head based on their presentation that I use to treat. 

If a patient does ask me I will generalize as much as possible and make certain that they understand I cannot officially diagnose them and the doctor will require more information before he can.


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## daedalus (Feb 3, 2009)

vquintessence said:


> I like your phrase "working diagnosis".  Fits the bill nicely for either debating side.  Guess the only debate is whether or not our working diagnosis should be official, except of course for all the field interpretations performed by Doctor Ambulance..
> 
> Officially speaking, it's possibly good habit to NOT tell pts any definitive answer as to an exact etiology of their illness.  Sure, that is a bit of hypocrisy with that, because times I've had someone who is/has been febrile, has rhonchi present and a productive cough, and said to the pt "Looks like ya might have pneumonia."  And I've been wrong.
> 
> ...


In Ventura County in California, if we find ST elevation with s/s of MI we are to tell he patient " According to the EKG, you may be having a heart attack. We are going to bring you to Los Robles Hospital in another city for emergency heart treatment"

Of course, a field EKG cannot rule out an MI. That is what serial cardiac enzymes and EKGs at the hospital are for. We absolutely cannot tell them they are not having an MI.


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## daedalus (Feb 3, 2009)

> I've had someone who is/has been febrile, has rhonchi present and a productive cough, and said to the pt "Looks like ya might have pneumonia." And I've been wrong.



Aint it cool how many different things can cause the same set of symptoms? I have great respect for the clinicians in the hospital who sort out everything.


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## vquintessence (Feb 3, 2009)

daedalus said:


> Aint it cool how many different things can cause the same set of symptoms? I have great respect for the clinicians in the hospital who sort out everything.



Yeah definately.  See horses, expect horses, treat them as horses, you can be right much of the time, but then crap, it was a zebra.


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## RESQ_5_1 (Feb 3, 2009)

On the PCR forms we fill out here, I have a box that says "Assessment". This is my opportunity to state what my differential Diagnosis is. Even with an angulated fracture, the Dr will take an x-ray (not available on my rig). Like Sasha said, we treat the symptoms presented to us. We don't officially diagnose a particular illness. If it's something I can see, it's a sign. If it's something the pt feels, it's a symptom.


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## JPINFV (Feb 3, 2009)

vquintessence said:


> Yeah definately.  See horses, expect horses, treat them as horses, you can be right much of the time, but then crap, it was a zebra.





...but how often do you see sea horses?


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## PapaBear434 (Feb 3, 2009)

JPINFV said:


> ...but how often do you see sea horses?




```
http://www.instantrimshot.com
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## NEMed2 (Feb 3, 2009)

If you must, cut a down coat outside, if you didn't think they would be pissed for cutting it in the first place, enjoy that ride in.

Cut what you must, but try to keep the pt's dignity intact if possible.  If they refuse, document document document.


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## CAOX3 (Feb 13, 2009)

If I cut your clothes off, rest assured they needed to come off.  It probably wont be along the seams either for that I apologise, but im sure you can understand my haste in accessing your possibly life-threatning injury.

Having a multi-system trauma pt disrobe is probably not a good idea, it will usually compromise the integrity of your immobilization.

If a pt can physically disrobe themselves  then their injury is usually not signifigant enough to warrent it.


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## PapaBear434 (Feb 13, 2009)

CAOX3 said:


> If I cut your clothes off, rest assured they needed to come off.  It probably wont be along the seams either for that I apologise, but im sure you can understand my haste in accessing your possibly life-threatning injury.
> 
> Having a multi-system trauma pt disrobe is probably not a good idea, it will usually compromise the integrity of your immobilization.
> 
> If a pt can physically disrobe themselves  then their injury is usually not signifigant enough to warrent it.



I have never once cut along the seams.  The material is typically harder to cut there, and I'm out to fix you, not your clothes.


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## TransportJockey (Feb 13, 2009)

Grady_emt said:


> That is about the only time I try to save something is when cutting a rider's leathers.  Go for the seams, or right next to it so they can be repaired, or if there are laces (like up the sides of pants/chaps) go for those as new lacing is easy to obtain
> 
> And if youre cutting a jacket, make sure it's not a down filled one, they make a mess, unless you want to look like you've been tarred and feathered.



I thank you on that one. As someone who has had his leathers cut off when there was no major injury, I always try to make cuts on those as neat and easy to repair as possible. Especially since my race set cost me over $800...


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## BossyCow (Feb 13, 2009)

PapaBear434 said:


> I have never once cut along the seams.  The material is typically harder to cut there, and I'm out to fix you, not your clothes.



Cutting right next to a seam is generally easier, the fabric is more stable from the seam and you can cut the single layer side of the seam. Also, what holds a garment together also is where it best comes apart.


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