Expose/don't expose? That is the question.

[medic417]

So when and how much should you expose? Can you do a proper exam w/o exposing? Should you expose when you do your lung and heart sounds? Is skin taboo?

Examples to consider;

Trauma minor and major, expose?

Vaginal bleeding, expose?

Chest pain, expose?

Pediatric patient with broken arm, expose?

Basically when and how much should we expose, obviously in private to protect patient?

 

[Sasha]

Can you do a proper exam w/o exposing? Should you expose when you do your lung and heart sounds?

Can you not simply slip your hand under their shirt to do so?

In all honesty, if the patient's not unconcious, it's up to them how much you expose and for how long, not you.

It's not so much that skin is taboo(hopefully), it's preserving their dignity and comfort level, even if it's just you and them, many people simply don't feel comfortable letting it all hang out for a stranger to see. Major trauma? Expose the heck out of it. Chest pain? Expose as necessary for the 12 lead, examine for indication of trauma, or to pace/shock/whatever the rhythm indicates. Is it necessary to leave their chest exposed for the entire ride?

If, however, an EMT or paramedic is not exposing their patient's due to their own uncomfortableness with it, that's a different story. I've noticed a lot of EMTs, new and old, who are uncomfortable with examining the opposite sex. In hospital clinicals if we have a female to assess, I'm usually the one shoved in there to do it, when I worked BLS IFT, if we had a female patient, I've had male partners who would ask me to go do their physical exam because they were uncomfortable. If something like that is the case, they really need to either get over it or re-evaluate if they should remain in EMS.

 

[BossyCow]

It's not black and white. In each of the examples originally posed I can come up with an instance where I would and wouldn't expose. And exposure is in varying degrees.

The decision has to be based on what are you exposing and why or why not? I expose what I need to see, when I need to see it. Case by case, patient by patient. Hard and fast rules about you 'MUST ALWAYS' are dangerous. We need to consider the patient's ethnicity, age, modesty and incorporate them into our patient care plan.

 

[medic417]

If, however, an EMT or paramedic is not exposing their patient's due to their own uncomfortableness with it, that's a different story. I've noticed a lot of EMTs, new and old, who are uncomfortable with examining the opposite sex. In hospital clinicals if we have a female to assess, I'm usually the one shoved in there to do it, when I worked BLS IFT, if we had a female patient, I've had male partners who would ask me to go do their physical exam because they were uncomfortable. If something like that is the case, they really need to either get over it or re-evaluate if they should remain in EMS.

I agree if you are uncomfortable looking and touching you need out of EMS as we are a eyes and hands on business.

 

[PapaBear434]

If, however, an EMT or paramedic is not exposing their patient's due to their own uncomfortableness with it, that's a different story. I've noticed a lot of EMTs, new and old, who are uncomfortable with examining the opposite sex. In hospital clinicals if we have a female to assess, I'm usually the one shoved in there to do it, when I worked BLS IFT, if we had a female patient, I've had male partners who would ask me to go do their physical exam because they were uncomfortable. If something like that is the case, they really need to either get over it or re-evaluate if they should remain in EMS.

If I'm working, and we have a female we need to strip, I will usually let a female EMT handle it if we have one available. Or at the very least, have one present. It's left over CYA from the police department, maybe. I'll do it if there is no female available, because they need care, but no reason to take the legal risk if you don't have too.

 

[Sasha]

If I'm working, and we have a female we need to strip, I will usually let a female EMT handle it if we have one available. Or at the very least, have one present. It's left over CYA from the police department, maybe. I'll do it if there is no female available, because they need care, but no reason to take the legal risk if you don't have too.

I'm not talking about when a female needs to be completely exposed. I'm talking about a normal physical assesment for... say abdominal pain or even leg pain. If a male is not comfortable with palpating an abdomen or examining the lower leg of a female, perhaps he wont fare well in medicine!

 

[PapaBear434]

I'm not talking about when a female needs to be completely exposed. I'm talking about a normal physical assesment for... say abdominal pain or even leg pain. If a male is not comfortable with palpating an abdomen or examining the lower leg of a female, perhaps he wont fare well in medicine!

Ah, gotcha. Yeah, that would be ridiculous. I heard about a guy getting fired because he was a devout... SOMETHING. I don't know, some super-religious sect. He refused to examine women, and men only above the waist. Needless to say, he was pretty useless except as for a driver.

Came to a head when he decided to lecture one pregnant woman who was having some issues (vaginal bleeding, extremely scared) because she was pregnant and not married. I would have LOVED to been on that truck with him to tear him up, but apparently a Chief handled it for me.

This wasn't in our city, mind you, it was in an adjacent city. We talk to our neighbors quite a bit since we share a couple hospitals, and they couldn't WAIT to share this one...

 

[zacdav89]

I was told when I was in training by one of our E.R. doctors and by my instructor, that we should be visibly assessing those areas that have a complaint of pain or discomfort it could show important clues to what is going on, just if the patient isn’t going to die because of there clothing or the time to work around the clothing, the shears should stay away. And like any procedure ask and explain will help with the cya.

 

[daedalus]

Only a provider who does not know the value of a solid assessment would argue to keep a patient covered. Ever wonder why hospital and doctor office patients take off their shirt and pants and wear a gown? Could it be that the physician that has 8 years of medical education knows the value of a PE?

 

[daedalus]

Ah, gotcha. Yeah, that would be ridiculous. I heard about a guy getting fired because he was a devout... SOMETHING. I don't know, some super-religious sect. He refused to examine women, and men only above the waist. Needless to say, he was pretty useless except as for a driver.

Came to a head when he decided to lecture one pregnant woman who was having some issues (vaginal bleeding, extremely scared) because she was pregnant and not married. I would have LOVED to been on that truck with him to tear him up, but apparently a Chief handled it for me.

This wasn't in our city, mind you, it was in an adjacent city. We talk to our neighbors quite a bit since we share a couple hospitals, and they couldn't WAIT to share this one...

And that is why providers should not have a right to incorporate religion into their practice of medicine/nursing/paramedicine. (I am not speaking of refusing to participate in abortions, etc, but if you cannot do simple exams because of your beliefs, your outta here, it just goes back to common sense. Your right to practice religion does not give you a right not to uphold the standard of care).

 

[AJ Hidell]

A few years ago, a patient came to me complaining of just feeling generally bad. Earache, headache, fever, nausea. I quickly found raging bilateral ear infections. His symptoms were a little over the top for otitis media in an adult, but there's a large range of variation, so I diagnosed it as OM, wrote him a script for antibiotics, and sent him on his way. The next day, he came back to follow up and asked for something for pain in his leg. "What pain in your leg?", I asked. He pulled up his pant leg, and there on his calf was a bright red and hot cellulitis. He was headed towards sepsis from it, and that is what was causing his symptoms! He said nothing about it on the original visit, and I had not bothered to look anywhere below his chest, so I missed it. And the results of missing that could well have been catastrophic.

I don't think I have to really explain the relevance of that story. Learn from my mistake. You think that baring a patients chest or genitals is embarrassing? There is nothing more embarrassing than walking into an ER and telling the staff what you think your patient has, only to have them quickly point out to you the very obvious signs you missed.

You don't have to strip every patient down on every run. But you do have to make sure that all potentially relevant bases are covered. And, just as in my example, not all relevant bases are immediately obvious. For example, would you bare the chest of a patient complaining of a headache? You had better. Because if there is a rash on that chest, that is an ominous sign that should not be missed. What about a dyspnea patient? Is it enough to simply auscultate? No. You need to be looking for retractions and accessory muscle usage, as well as general skin appearance. Vag bleed? It is bleeding, regardless of location. Bleeding needs to be qualified and quantified in every patient.

All that said, there's not much reason for an EMT to be exposing a lot, since an EMT generally lacks the ability to interpret or do anything with the information gathered from such exposure. If your examination is simply for the purpose of going through the motions of an exam that you can't really do anything with, then there is no clear indication for it.

Medical indication is the key term here. If you have the education to do something with the information gathered, and are in a system that allows you to provide interventions, then go for it. But there is little justification for delaying a patient's transportation, or even making them undergo the same examination twice, simply to go through the motions for no medical indication.

As with every other issue in EMS, education is the answer. Without a lot more education than is given in the average EMT or paramedic course, you start out with a terribly inadequate foundation of knowledge for determining what is necessary and appropriate and what is not. Consequently, there simply is no simple cookbook formula that can be implemented to tell you how to do a competent physical exam. It's not a checklist skill. It is a critical thinking skill that can only be developed with education and experience.

 

[medic417]

Only a provider who does not know the value of a solid assessment would argue to keep a patient covered. Ever wonder why hospital and doctor office patients take off their shirt and pants and wear a gown? Could it be that the physician that has 8 years of medical education knows the value of a PE?

Now that is a good point to think about.

Take the pediatric with the broken arm, if we exposed by at least raising shirt to do breath sounds perhaps we would see the signs of abuse and be able to alert the proper help.

The vaginal bleeding we need to see how steady a flow, how much, is there lumps in it, bright or dark red, etc. Plus by seeing her stomach we might see marks where she has been hit even if she denied being assualted.

 

[Aidey]

I'm with Bossy on this one. I generally expose, but I can't say always because sometimes it just doesn't happen. There might not be time, or the patient might refuse.

I also don't think it's necessary to expose the whole patient every single time. If someone is complaining of an isolated ankle injury I'm not going to cut their shirt off. If I need to access under the shirt I'll lift it up. I am also a firm believer in a through verbal exam. Something as simple as asking "Aside from this, is anything else bothering you?" is a really good way of finding out about additional problems that the patient may not feel is the primary issue.

I've found with some patients they are also more comfortable being exposed if it's done in stages. Remove the shirt, do the exam, put the shirt back on. Then remove the pants, do the exam, and put the pants back on, etc. When I worked in a clinical setting the Doctors didn't make everyone strip all the time. If they were just doing a focused exam they often didn't make the patient wear a gown unless it was a pelvic issue or they were going to do a procedure that could get messy, like a I&D.

 

[medic417]

Keep in mind exposing does not equal cutting clothes off. Even in trauma there are times we can remove rather than cut. You can also expose just by shifting clothes up or down but at times this aggrevates patients more than if you just had them undress, put a hopital gown on, and put a sheet over them.

 

[Aidey]

I know, but I always differentiate because I've met a couple of people who a little trauma shear happy and if they expose something they cut the clothes.

 

[daedalus]

There are no guarantees in life and no one said it was supposed to be fair. Go out in public with clothes, expect them to be cut off if you are injured severely enough to require paramedics. That said, I do not cut when I can remove.

 

[karaya]

And that is why providers should not have a right to incorporate religion into their practice of medicine/nursing/paramedicine. (I am not speaking of refusing to participate in abortions, etc, but if you cannot do simple exams because of your beliefs, your outta here, it just goes back to common sense. Your right to practice religion does not give you a right not to uphold the standard of care).

Hear, hear!!

 

[BossyCow]

And that is why providers should not have a right to incorporate religion into their practice of medicine/nursing/paramedicine

Sure they do, they have the right to practice their religion as they choose. Of course employers then have the right not to hire them because they can't do the job. There was a thread a while back about an orthodox jewish ambulance service.

I believe that anyone can choose what they like as their religious practice. Where I draw the line is when that practice is supposed to dictate the policies of a workplace. Aside of course from reasonable accomodations like allowing the jewish worker to shift trade with the catholic in order to have Yom Kippur off.

I see a lot of examples of people making mountains out of molehills. We assume that those who disagree with us do so with evil intentions. We also assume often that our 'rightness' automatically makes the other guy 'wrong' instead of just holding a different opinion.

A workplace has certain requirements... some physical, some on appearance, others on ability. I couldn't say that my religious practice forbids attending institutes of higher learning because the only true text is the bible (I actually heard that one from a patient) and then insist that the local hospital hire me as a neurosurgeon. We have to be able to do the job we are hired to do. If we can't we are free to seek employment elsewhere.

Sometimes those moral choices come with a price tag. Sometimes those moral choices make us such a PITA that no one wants to work with us. Then there are those who go quietly among the noise and haste, living their lives, doing their jobs and still, somehow following their spiritual path as well.

This doesn't infringe on anyone's right to practice their religion. It simply means that in the real world, we sometimes have to adjust. As I said in another thread.. I can't think of a single religion that stated that following a strict moral code should be easy and pain free.

 

[medic417]

I know, but I always differentiate because I've met a couple of people who a little trauma shear happy and if they expose something they cut the clothes.

Knew a medic that cut all the clothes and even an expensive coat off a lady when all she had done was step in a hole and break her ankle. Even the hospital threw a fit about that one.

 

[firecoins]

I agree if you are uncomfortable looking and touching you need out of EMS as we are a eyes and hands on business.

and the rest of the body business.