# "Why are we baring this patient?".



## mycrofft (Dec 24, 2012)

We've discussed the drawbacks of cookbook care, how the magic juju of "LSB/ C Collar" or "IV NS bolus" or "NRB everyone" are actually just tools in the kit, neither explicitly harmful nor harmless, depending upon their use.

How about totally "baring the patient"? I understand why a surgeon does, or an obstetrician, but why in the field?

The majority of cases are not a "whole body" incident, most traumas are extremities, most torso complaints are above or below the belt (not both), head injuries have no relation _per se_ to the rest of the body. Now how about cases where pt is unable to give a hx or coherent complaint BUT it is very cold outside (other than emergent rewarming)? Cases where the definitive treatment facility is closer in response time than time needed to SAFELY strip the pt? And what are you going to to with all that goosefleshed territory either in assessment or treatment?* 

I think that wholesale stripping of patients, as some people here have cited are their protocols, is, like any wholesale practice, often a time-wasting, undignified and unnecessary procedure.


*aka "The Dog Caught The Car Conundrum": OK, Ben, you caught it. Now what?".


----------



## NomadicMedic (Dec 24, 2012)

Stripping someone for the sake of stripping someone is pointless. Stripping someone when you're unsure of the extent of their injuries is vital.

Does everyone in a motor vehicle crash get stripped? No. Does everyone in a motor vehicle crash who is ejected from the vehicle and has multisystem trauma get stripped? Absolutely.

We can go round and round about "cookbook care" but it's really designed for the lowest common denominator. It's designed for the EMT or medic who has no critical thinking skills. For that person who has no idea what to do next, a simple B follows A type of instruction manual will work wonders. For the rest of us, we just do what's prudent.


----------



## mycrofft (Dec 24, 2012)

Well said.


----------



## ffemt8978 (Dec 24, 2012)

n7lxi said:


> Stripping someone for the sake of stripping someone is pointless. Stripping someone when you're unsure of the extent of their injuries is vital.
> 
> Does everyone in a motor vehicle crash get stripped? No. Does everyone in a motor vehicle crash who is ejected from the vehicle and has multisystem trauma get stripped? Absolutely.
> 
> We can go round and round about "cookbook care" but it's really designed for the lowest common denominator. It's designed for the EMT or medic who has no critical thinking skills. For that person who has no idea what to do next, a simple B follows A type of instruction manual will work wonders. For the rest of us, we just do what's prudent.



Agreed, but there is a time and a place for everything.  There is very rarely a need to strip a patient on the scene in full view of bystanders.  Why not wait until they are in the ambulance and out of view of the gawking public?


----------



## NomadicMedic (Dec 24, 2012)

Sure, I would assume that would go without saying. As well as having plenty of blankets nearby to cover the patient up with once you get them stripped. We bring patients to the hospital that are borderline hypothermic anyway… No need to make it worse by getting them naked and putting them on an ice cold slab of plastic.


----------



## ffemt8978 (Dec 24, 2012)

n7lxi said:


> Sure, I would assume that would go without saying. As well as having plenty of blankets nearby to cover the patient up with once you get them stripped. We bring patients to the hospital that are borderline hypothermic anyway… No need to make it worse by getting them naked and putting them on an ice cold slab of plastic.



Unfortunately, it can't go without saying.  Too many people forget stuff like that and actually strip patients in public


----------



## NomadicMedic (Dec 24, 2012)

Refer to my above comment, some of us practice with critical thinking skills.
Perhaps that should be added to the protocols."Expose patient, using great care to maintain patient decency and warmth."


----------



## mycrofft (Dec 24, 2012)

Newbies, you reading this!?


----------



## NYMedic828 (Dec 24, 2012)

I almost never strip anyone...

If the patient can tell me what's wrong and where it hurts without suspicion of distraction then why on earth would I cut all of their clothing off...

I believe a lot of it has to do with the mindset of putting oxygen on trauma patients before walking in the ER. People think someone is going to question whether or not they did their job properly on the basis of not doing it... 

If we do everything no one can gig us for not providing the "standar of care."


----------



## NomadicMedic (Dec 24, 2012)

I would guess that most of us "rarely strip patients" as most of us simply don't respond to that many traumatic injuries that would require exposing a patient fully. However, in the instance where you would need to do it… You need to do it.

I can count on one hand the number of times I've had to cut someone's clothes in the last year. And two of those were drownings. So let's be honest, is there really a huge number of EMTs cutting patients clothes off for no good reason? 

As a caveat, I will say this…, Patients brought to Harborview Medical Center in Seattle better be naked.  I brought a guy there who had been hit in the head with a bottle and had a large lac.The trauma nurse asked me why he wasn't stripped. I think I may have given a smart *** answer, "he didn't want to?"

Conversely, I brought a motorcycle wreck patient, who had been ejected from his bike and was found about 40 feet away in a ravine, to another hospital. He had been stripped and immobilized. He was unconscious and had a skull fracture. He also had several other fractures and abrasions all over. The first thing the nurse asked me when I walked in was, "why is he naked?"


----------



## Akulahawk (Dec 24, 2012)

n7lxi said:


> Stripping someone for the sake of stripping someone is pointless. Stripping someone when you're unsure of the extent of their injuries is vital.
> 
> Does everyone in a motor vehicle crash get stripped? No. Does everyone in a motor vehicle crash who is ejected from the vehicle and has multisystem trauma get stripped? Absolutely.
> 
> We can go round and round about "cookbook care" but it's really designed for the lowest common denominator. It's designed for the EMT or medic who has no critical thinking skills. For that person who has no idea what to do next, a simple B follows A type of instruction manual will work wonders. For the rest of us, we just do what's prudent.


Very well said.


ffemt8978 said:


> Agreed, but there is a time and a place for everything. There is very rarely a need to strip a patient on the scene in full view of bystanders. Why not wait until they are in the ambulance and out of view of the gawking public?


I try to do that myself, if possible.


n7lxi said:


> Sure, I would assume that would go without saying. As well as having plenty of blankets nearby to cover the patient up with once you get them stripped. We bring patients to the hospital that are borderline hypothermic anyway… No need to make it worse by getting them naked and putting them on an ice cold slab of plastic.





ffemt8978 said:


> Unfortunately, it can't go without saying. Too many people forget stuff like that and actually strip patients in public


I have seen that done as well, however, sometimes you have to do it in public. As I have said above, my preference is to not do that. I would much rather do my skin exam in the back of the ambulance away from the eyes of the public, to preserve the patient's privacy is much as possible.

I certainly think about the level of exposure that is necessary to determine the extent of the patient's injuries. That could be anything from simply looking under the clothing to complete removal. None of this is done lightly. Over the years, there have been only a few times that I have ever had to completely strip the patient. There are certainly more times that I can remember that I simply had to "take a look" in and around the area where a known injury was to ensure that the injury wasn't a distractor.

As we all know, there is no such thing as privacy in medicine, however I do what I can to preserve as much privacy as possible.

In my current role as a student nurse, I do have to take a look at the patient's skin, not to determine if there is a traumatic injury, rather it is to determine if there is any skin breakdown. This is not something that we normally have to do in EMS. Even then, I still attempt to preserve as much privacy as possible, even among the indignities of medicine.

Do what you have to do, when you have to do it, but no more than you have to do. Your patient should be able to understand the difference between doing your job and taking advantage of the situation.


----------



## DrParasite (Dec 25, 2012)

I'm pretty sure they stressed that every trauma patient gets completely exposed. in fact, I make sure every female trauma patient ages 18 to 30 ends up in the ER completely naked.   I once brought a 25 year old who jammed her finger. I had her remove her clothes, put her on the cot, and took her to the ER.    When the ER asked why, I told them every trauma patient needs to be exposed... it's in the book, which they obviously didn't read.  Of course when i did that on the 80 year old lady who fell, we tried to walk her to the cot, and she kept tripping over her boobs.....

In all seriousness, multi system traumas get full exposed.  usually in the back of the truck, bit if you have a life threat that need to be mitigated on the scene (major bleeding is the big one that needs exposure), than do what you can, but treat the patient.  I'd rather have a patient embarrassed that something is flopping in the wind and alive than covered up and dead because I decided to respect their privacy.  If you need to examine something, either have them remove it, or you remove it from around them.    if not, no need to remove their clothes.

If i'm activating a trauma team, they are going to be fully exposed in the trauma bay, so I am going to remove their clothes in the ambulance to check for injuries.  Then they get covered in a sheet or blanket when we wheel them in.  I am going to still do my job.  If the hospital doesn't like it, they are more than welcome to ask my supervisor why i did something, and he will gladly explain it to them.


----------



## NomadicMedic (Dec 25, 2012)

I think this is a good discussion. I also believe that a good portion of these "Doing it for the sake of doing it" decisions may come down to provider attitude. There is a HUGE difference between telling a nurse, "patients get stripped, cause they're going to get stripped in the trauma bay anyway and if you don't like it, you can call my boss" and "this patient was ejected from a motor vehicle at a high rate of speed. I was unable to ascertain the extent of her injuries without exposing her fully."

Remember, it all comes down to critical thinking. If you can justify your actions and they are prudent and always in the best interest of the patient you will seldom run into those issues where anyone "has to talk to your boss". 

For example, "this appeared to be a minor motor vehicle accident. The temperature was 18° and it was snowing. The patient was already cold. I didn't feel it was prudent to strip the patient of her clothing until we arrived at the hospital." Make sense?

All of those needless protocol items can be superseded if you can justify your actions. Backboards, 15 L per minute of oxygen on a non-rebreather, exposing the patient fully… Be smart, understand why you're doing what you're doing and be able to explain and justify your decision.


----------



## abckidsmom (Dec 25, 2012)

n7lxi said:


> I think this is a good discussion. I also believe that a good portion of these "Doing it for the sake of doing it" decisions may come down to provider attitude. There is a HUGE difference between telling a nurse, "patients get stripped, cause they're going to get stripped in the trauma bay anyway and if you don't like it, you can call my boss" and "this patient was ejected from a motor vehicle at a high rate of speed. I was unable to ascertain the extent of her injuries without exposing her fully."
> 
> Remember, it all comes down to critical thinking. If you can justify your actions and they are prudent and always in the best interest of the patient you will seldom run into those issues where anyone "has to talk to your boss".
> 
> ...



Absolutely.


----------



## medic417 (Dec 25, 2012)

Come on man. Second rule of EMS is a trauma patient is a naked patient.  Strip 'em and flip 'em.  :rofl:

I agree use some judgment of when and what to expose.  But do not give the crap that checking would not change your patient care in the field.  You are patient advocate, you can not advocate for your patient if you do not properly examine the area of complaint.


----------



## NYMedic828 (Dec 25, 2012)

n7lxi said:


> I think this is a good discussion. I also believe that a good portion of these "Doing it for the sake of doing it" decisions may come down to provider attitude. There is a HUGE difference between telling a nurse, "patients get stripped, cause they're going to get stripped in the trauma bay anyway and if you don't like it, you can call my boss" and "this patient was ejected from a motor vehicle at a high rate of speed. I was unable to ascertain the extent of her injuries without exposing her fully."
> 
> Remember, it all comes down to critical thinking. If you can justify your actions and they are prudent and always in the best interest of the patient you will seldom run into those issues where anyone "has to talk to your boss".
> 
> ...



Statement of the year.


----------



## medic417 (Dec 25, 2012)

NYMedic828 said:


> Statement of the year.



Seriously in the past 360 days there has not been a better statement?:unsure:


----------



## NYMedic828 (Dec 25, 2012)

medic417 said:


> Seriously in the past 360 days there has not been a better statement?:unsure:



In relation to my past work week, I particularly like that one.

Its been a week of "put him on O2 before we go into the ER" and "well the protocol says" etc etc.


----------



## TheLocalMedic (Dec 26, 2012)

I'm a big supporter of not unnecessarily stripping people, but if it's a trauma that the hospital will activate their trauma team for you can be darn sure that they'll be showing up in the buff!  If it's cold then I'll put a blanket on the board so they don't conduct as much heat through the plastic and then burrito wrap them and use warm saline, but I really don't know that you can justify bringing in a trauma that's still clothed.  If you're smart you'll have the heater running the minute you go responding so that by the time you bring them into your vehicle it'll be nice and toasty.  

Granted, the minor neck pain from a rear-ender doesn't warrant removing anything besides bulky jackets and whatnot, but if it's a legit trauma we're fully expected to have these patients stripped.  I can see the look the trauma doc would give me if I showed up with an activation still dressed...  "Oh, so you didn't actually think it was important to see if they had any injuries then?"


----------



## mycrofft (Dec 26, 2012)

TheLocalMedic said:


> I'm a big supporter of not unnecessarily stripping people, but if it's a trauma that the hospital will activate their trauma team for you can be darn sure that they'll be showing up in the buff!  If it's cold then I'll put a blanket on the board so they don't conduct as much heat through the plastic and then burrito wrap them and use warm saline, but I really don't know that you can justify bringing in a trauma that's still clothed.  If you're smart you'll have the heater running the minute you go responding so that by the time you bring them into your vehicle it'll be nice and toasty.
> 
> Granted, the minor neck pain from a rear-ender doesn't warrant removing anything besides bulky jackets and whatnot, but if it's a legit trauma we're fully expected to have these patients stripped.  I can see the look the trauma doc would give me if I showed up with an activation still dressed...  "Oh, so you didn't actually think it was important to see if they had any injuries then?"




How about a broken arm?


----------



## Tigger (Dec 26, 2012)

I might add that if you need to expose someone (or just remove clothing layers), ask them if they can help you get it off before you just cut it right off. I put myself in a great deal of pain getting my nice ski jacket off in the back of a rig rather than having it destroyed. 




mycrofft said:


> How about a broken arm?



I would imagine that most hospitals do not activate their trauma team for a broken arm unless it is _really_ broken.


----------



## TheLocalMedic (Dec 26, 2012)

mycrofft said:


> How about a broken arm?



Isolated injury?  Then the sleeve goes.  In the presence of significant mechanism where I'm going to board them, then they're getting stripped.  I didn't think that "distracting injuries" were even a real thing until I saw a guy who didn't even notice his busted tib fib because of his mangled hand.


----------



## DrParasite (Dec 27, 2012)

mycrofft said:


> How about a broken arm?


just one?  than they might lose the sleeve, but that's about it.   than again, an isolated extremity injury isn't criteria for a trauma team activation.  Even if it's really really broken, it's an ortho issue, not a trauma team criteria.

now if they fell 40 feet off a roof, and their only complaint is their arm hurts, I might end up exposing the entire body, to ensure there isn't any other injury (the whole distracting injuries concept).


----------



## Bullets (Dec 27, 2012)

Just like every other thing we do, based on the presentation and cause of injury


----------



## mycrofft (Dec 27, 2012)

................oops


----------



## mycrofft (Dec 27, 2012)

Can't even goad most of you into irrationality.  No one has mentioned goosedown vests....


----------



## medic417 (Dec 27, 2012)

mycrofft said:


> Can't even goad most of you into irrationality.  No one has mentioned goosedown vests....



Must cut the goose down.  Pretty feathers everywhere.  Must cut.:rofl:


----------



## mycrofft (Dec 27, 2012)

medic417 said:


> Must cut the goose down.  Pretty feathers everywhere.  Must cut.:rofl:


----------



## TheLocalMedic (Dec 27, 2012)

http://regionstraumapro.com/post/34759617837

Thought it was interesting


----------



## mycrofft (Dec 27, 2012)

TheLocalMedic said:


> http://regionstraumapro.com/post/34759617837
> 
> Thought it was interesting



Thanks, I do too. Being a contrarian:
1. He had to think back that far?
2. Preserving evidence is secondary to pt well-being.Just don't reduce it to chaff.


----------

