Abdominal Exam

[daedalus]

To those stating that you can poke an abdomen without fear of rupturing an AAA, and referring articles to cite this, you may want to review some pathology of aortic aneurysm. Many people have asymptomatic AAAs that may require surgical repair in the future, but are for the present, stable. It seems reasonable based on the posted citations that abdominal exams may be preformed without fear in these patients, when it is justified. However, in a patient with a dissecting AAA (different ballgame), I find it unreasonable to preform unnecessary palpation of the abdomen for teaching purposes.

-daed

[daedalus]

Maybe it's just a terminology gap, but that's plain weird.

I would hope and expect that any field or clinical placement would be to develop a competent provider while under the supervision of a preceptor. During my five months of preceptorship I was expected to take on more and more responsibility such that by the end of my placement my preceptor would be comfortable leaving me to run the call completely. My clinical placements were more restricted as we were operating in the Hospital environment and had to be careful not to interfere with their plans, but I was still expected to perform full pt. assessments, come up with my own differential for the clinical instructor and do things such as state a tx. plan, or explain the patho, etc. We would then follow the pt.'s care as much as possible and when practical ask questions of the staff there. In my program we did do half a dozen "observation" ride-outs, but those were done at the very beginning of the course to provide exposure and context for students; who since they hadn't learned very much yet, couldn't be expected to do more than practice a few skills under supervision.

Some excellent medics make awful preceptors because they are completely incapable of backing off and letting a student fumble through waiting only to intervene when necessary.

I agree with you in theory, however the american EMT student is poorly educated* and the (only) one or two ride alongs they do are often in the middle of the 4 month program, so they are not even ready to do the few basic skills that they are taught.

*Individuals should not get offended. EMTs as a whole under educated. That includes me.

[cosgrojo]

Now I cringe to think of the people I could have harmed and may have.

Even now the hospitals don't always contact every ambulance agency for every screw up although it may be documented. You may never know how bad you mucked up until you are called before your company's attorneys.

How many have gone back to see the result of some of those difficult intubations? Ever go back to see if the patient got a trach? Maybe it is all written off as part of "saving a life" but does that mean messing up the cords because you didn't really know what you were doing is okay? Let's say you are an EMT-B and have very little manikin time or a decent instruction on the Combitube. You are allowed to "practice" on a real patient and do serious damage to the cords to where a trach is necessary or rip the esophagus to where the patient would need urgent surgery. Do you feel the patient's complications were warranted just so you could "try it out" on a real person?

Working in the hospital has also given me an opportunity to "attempt to fix" the mistakes made either by myself or by others. Screw up on a ventilator setting and create a pneumo, you get to help decompress but it then really isn't as thrilling as finding a pneumo in the field. Botch an intubation and do many leak tests while corticosteroids are given in hopes the inflammation lessens to where that patient doesn't get a trach and that is on your permanent record. Let an IV infiltrate and do many perfusion checks or maybe Wydase to keep the tissue from becoming necrotic. Screw up an arterial stick and sweat out if the radial nerve or artery will be the same. Screw up doing ETI with suction on a meconium baby and do ECMO for several days until the infant can be weaned off or dies.

Of course, some of these are what we see from the field and many times the Paramedic will never know since they may not be immediately obvious. If you cause a pneumo, we might speculate that it was you in the field but may not be able to prove it. Some of the damage might be from the circumstances surrounding the incident. Some might be part of that "what happens in the truck stays in the truck" mentality which has been a factor that prevents tracking medical errors in EMS so that there can be an improvement. Also, FDs do enjoy have some limits on their liability as a agency of some government entity. Essentially if your patient dies, you can say they may have died anyway. However, occasionally something is caught and it may even make headlines so you do get to enjoy the equal status in medicine with the other health care professionals.

I think for the most part, most of the people I work with try and follow-up with patients that we dropped off at the ER. We do this to both find out what was actually going on with them, as well as to find out what we did right and what we potentially did wrong. We aren't always able to follow-up due to a myriad of variables, but it is not due to lack of want.

We all accept the liability inherent of working in the emergency medical community, and one would be crazy not to expect a "muck-up" or two along the way. I for one love when I get feed back from the hospital... both positive and negative. These are issues that are at every level of medicine, not just EMS. For every level of "education," there is another level of liability and extenuating circumstances. I guess I'm curious how you expect anyone to learn how to perform the skills (that you've seen botched in the field, and in the hospital) without ever practicing or trying them out? I'm with you on the education bit, I've stated that before, but we still need to be able to "physically" perform the *gasp* "skills."

I am a huge basketball fan, it's my favorite sport... I have studied the mechanics and strategy of the sport since I was a young child. I even read books about proper form and technique required to shoot a basketball with high efficiency. I can dissect a guys shot with one glance, and can tell him how to improve it... but I can't shoot myself. Physically unable to do it well. My point is that while I could write a thesis about the form and function of a jump-shot, and could get into a rousing debate on the merits of jump vs. set shots, a 12 year old gifted with a modicum of athletic talent could beat me in a game of HORSE, and never know why. As much as we talk about "education" being more important than those evil "skills," we still need to be able to do the skills. You can't expect someone to be able to perform a skill without ever being able to practice it live, based solely on how many books you read and how many lectures you sat through.

These things we talk about... Education, Experience, Skills... everyone seems to be taking sides and I don't have the ability to understand. They are all important, they all serve a purpose, and a superior provider will have equal parts of all of these attributes. It's like the laminated cards I see on the RN's med cart... ensuring the patient's rights. Right patient, right route etc... It's about the "right" education, the "right" experience, and the "right" skills.

[Siffaliss]

Ok this is getting beat to death but here's another post ...

If you're a medic doing an assessment with a newer practitioner that has lower registration than you, perhaps explain what you're doing (if there's time). Then, if it's ok with the patient, allow your EMT to do the same and explain what he finds.

[VentMedic]

I guess I'm curious how you expect anyone to learn how to perform the skills (that you've seen botched in the field, and in the hospital) without ever practicing or trying them out? I'm with you on the education bit, I've stated that before, but we still need to be able to "physically" perform the *gasp* "skills."

***************************************

These things we talk about... Education, Experience, Skills... everyone seems to be taking sides and I don't have the ability to understand. They are all important, they all serve a purpose, and a superior provider will have equal parts of all of these attributes. It's like the laminated cards I see on the RN's med cart... ensuring the patient's rights. Right patient, right route etc... It's about the "right" education, the "right" experience, and the "right" skills.

Some are making much more of this than what it is. What has been stated over and over is that if you have the education, you may be able to obtain more skills. However, if your "training" lacks education about A&P to even give you the bare essentials to understand why you are doing a skill, don't expect everyone to just allow you to mess with their patient just for the sake of a "skill".

Those laminated cards on nursing carts are required by certain certifying agencies and not because the nurses have never been educated about the basics of giving a medication. If they did not have the education to begin with, they would not be allowed to touch a medication cart and they would not have the "expectancy" that someone should allow them to touch medications until they have be properly educated first. In this situation and as it should be in many that involve patient care, education should come before just allowing someone to attempt to do something that might cause discomfort or even harm to a patient. Maybe the intubation failure rate for some EMS providers would not be as high or the medical directors might actually put more trust in those they have oversight of.

Edited January 3, 2010 by VentMedic

[CBEMT]

Also, FDs do enjoy have some limits on their liability as a agency of some government entity. Essentially if your patient dies, you can say they may have died anyway.

Ugh, don't remind me. My state has several different laws giving specific immunity to firefighters (and specifically not naming other "brands" of providers) for medical care provided in the field.

Fire owns EMS, the IAFF owns the state legislature, the legislature makes the laws, and the public suffers.

Edited January 3, 2010 by CBEMT

[Lisa O]

BTW: Out of curiosity, how do you believe that Dustdevil and Dwayne differ in opinions..maybe I am the one reading things wrong...(now that this thread is hijacked beyond recovery....LOL)

From Dwayne I am getting that experience is the key. From Dust I am getting dont even touch anyone untill you have had X amount of education. So, maybe I read something wrong, or only read what I wanted to read..lol

And OMG yes, I need to apologize to the OP. I am sorry about jacking (up) your thread and drawing any attention away from what it should have been about.

Hey Lisa.

As chbare mentioned, EMS is the only medical field where many believe it is best to gain experience before knowledge. All others do it the other, and seemingly more logical, way around. If you choose to go straight to medic you WILL catch some shit from those that don't have a significant education (which is why they need the 'experience' scaffold to support their self esteem)...but f*ck em...this is about you, not them, right?

Best of luck to you in whatever you decide.

Dwayne

This

Fixed that for ya.

Lisa, you can go many places in the US and become a "paramedic" in three months with nothing more than a GED and an EMT card (and a buttload of money). So no, you do not 'have to' have all those courses to buy a patch. But you said you wanted to be a "damn good" paramedic. To do that, it takes a LOT more education than most shake 'n bake schools will give you or require of you.

.

Edited January 3, 2010 by Lisa O

[chbare]

However, in a patient with a dissecting AAA (different ballgame), I find it unreasonable to preform unnecessary palpation of the abdomen for teaching purposes.

-daed

Sorry bro, but I am compelled to point this out because many people fail to make the proper determination. While it is possible to have a concomitant dissection and aneurism. It is not generally proper to say "dissecting AAA" IMHO.

The pathology of a dissection versus aneurysm is different:

In a dissection, there is somewhat of a tear of the intima within the vessel. This leads to dissection of the layers and the creation of a false passage between the layers. With time, this dissection continues until the false passage communicates with the external environment of the vessel. This is generally not good. The location of your bad dissections are commonly around areas of a vessel where you have high pressures and a turn of the vessel. Many originate in or around the aortic arch in the thoracic aorta. You can research the late Dr. DeBakey as he actually created a classification system for dissections and survived a dissection himself.

An aneurism, however, is in essence a weak ballooning of a section of the vessel. Of course, many histological and pathological changes occur, but we can agree the basic mechanism differs from a dissection to an aneurism.

Take care,

chbare.

Edited January 3, 2010 by chbare

[daedalus]

Sorry bro, but I am compelled to point this out because many people fail to make the proper determination. While it is possible to have a concomitant dissection and aneurism. It is not generally proper to say "dissecting AAA" IMHO.

The pathology of a dissection versus aneurysm is different:

In a dissection, there is somewhat of a tear of the intima within the vessel. This leads to dissection of the layers and the creation of a false passage between the layers. With time, this dissection continues until the false passage communicates with the external environment of the vessel. This is generally not good. The location of your bad dissections are commonly around areas of a vessel where you have high pressures and a turn of the vessel. Many originate in or around the aortic arch in the thoracic aorta. You can research the late Dr. DeBakey as he actually created a classification system for dissections and survived a dissection himself.

An aneurism, however, is in essence a weak ballooning of a section of the vessel. Of course, many histological and pathological changes occur, but we can agree the basic mechanism differs from a dissection to an aneurism.

Take care,

chbare.

Robbins Pathologic Basis of Disease defines that an aneurysm is a localized abnormal dilation, while a dissecting aneurysm is created once the tunica intima is breached. (pg 526-8). I

[medichopeful]

Not being able to properly assess the patient takes us in to whether they should even be allowed on the ambulance in the first place

Simple answer: no. Unless they are with somebody with more training (read: paramedic).