Prehospital Abdominal Assessment

[Craig Alan Evans]

I think prehospital education does a horrible job of teaching a thorough abdominal assessment. Keeping this discussion outside of trauma and obstetrics as I feel we do pretty well in those areas; if you were to concentrate on only conditions which would require immediate surgical intervention or are life threatening what do you think we should be teaching paramedics to be looking for?

I propose:
Cholecystitis
Ascending Cholangitis
Abdominal Aortic Aneurism
Appendicitis
Necrotic Bowel Syndrome

Which means we need to include Murphy's Sign, McBurney's Point, and
Obturator sign to our assessment skills and teach the symptoms and signs of Charcot's triad and Reynold's pentad to name a few.

Thoughts?

 

[Veneficus]

Any abdominal assessment needs to start with the differentials per quad, including gynecological problems.

Probably followed with visceral vs peritoneal pain.

after that you can add in all the other stuff you mentioned.

 

[Craig Alan Evans]

Agree. Along that line of thought we need to teach that rebound tenderness is a sign of peritonitis, not appendicitis. Peritonitis can be found in an acute appendicitis, early bleeding, as well as any other condition that irritates the peritoneum.

 

[RocketMedic]

I strongly disagree with the current "quad =4" method. Palpate the entire abdomen and flanks, not four cursory random stabs. We also need training on obese abdominal findings.

 

[Veneficus]

I strongly disagree with the current "quad =4" method. Palpate the entire abdomen and flanks, not four cursory random stabs. We also need training on obese abdominal findings.

4 quads are not random stabs, there are specific things to look for in each. It is much different from the current EMS teaching of "look for something by palpating 4 places."

The trouble is you have to know what you are looking for, which is a rather extensive list. (including ascitis) It is most easily broken down to medical or surgical pathology. Which means you would also have to add considerable education for both.

Along the same lines, you would also have to add considerable gyn pathology. Some of which would necessitate a bimanual exam. (You are going to have a hard time convincing a med director to permit that)

Aside from a renal stone, a mass, or perhaps kidney inflammation,(which are usually assessed for with a strike) i would be curious as to what you expect to find with palpation of a flank?

 

[DrParasite]

quite honestly, as a dumb EMT, while I think the abdominal assessment isn't the greatest, based on what a paramedic can treat, it's adequate.

for all the other stuff, while the initial suspicion can be done prehospitally, how much of the definitive diagnosis requires more tests and equipment in hospital? ultrasounds, CAT scans, exploratory surgery, lab work, these are all needed to confirm the initial diagnosis.

otherwise, ERs nationwide would have patients walk in with abd pain, the doc would poke and prod them for 10 minutes, and 5 minutes later they would be discharged with a diagnosis and either a prescription or an appointment with a surgeon to repair/remove the problem.

 

[Craig Alan Evans]

quite honestly, as a dumb EMT, while I think the abdominal assessment isn't the greatest, based on what a paramedic can treat, it's adequate.

for all the other stuff, while the initial suspicion can be done prehospitally, how much of the definitive diagnosis requires more tests and equipment in hospital? ultrasounds, CAT scans, exploratory surgery, lab work, these are all needed to confirm the initial diagnosis.

otherwise, ERs nationwide would have patients walk in with abd pain, the doc would poke and prod them for 10 minutes, and 5 minutes later they would be discharged with a diagnosis and either a prescription or an appointment with a surgeon to repair/remove the problem.

One of the most important things EMTs can do is set the stage for the receiving ER. What we tell them based on our assessment many times will dictate the ERs initial resources, or where they will place the patient in their matrix (triage, waiting room, straight to a physician, etc). You can come in with abd pain in the RUQ which is very vague or you paint an entirely different picture when you say you have a patient with URQ abd pain, - Murphy's sign, a fever of 102, with jaundice, and altered mental status. This gives the receiving ER a much better picture of what may be occurring and thereby triage the patient properly. The patient's hospital visit should begin when you walk into their home. Essentially EMS is the initial triage and therefore we need to use good assessment techniques so we do not mislead the hospital. With the large volume of patients being seen in ERs today sometimes just a little misdirection can cause a misdiagnosis and poor patient outcome.

 

[mycrofft]

That in mind, we run into EMS systems issues.

If I have X minutes to intervene, do I spend it on testing for M, N, or P first?
What process do I follow to rule in what I can help now versus what they can do later, then apportion subsequent time and effort to what makes the most sense?
How far into "zebraville" do I swerve, weighing potential acuity of something like a dissecting aortal aneurysm versus it's likelihood and is it something I can do something about before getting to the hospital?
I suspect coordination with the receiving parties is a good thing here.

For most EMT-B's and lower, learning the basic abdominal exam including auscultation is in order, then when to do it and what to record. Refinement is predicated upon some sort of at least rudimentary knowledge. This would help stave off the "four jabs and done" syndrome.

 

[Veneficus]

What can I do?

Everytime a new idea or technology comes out in EMS, one of the first things the "nay-sayers" always ask is "What will it change?"

In the case of the abdominal examination, it could change a lot.

For example, there are some old school docs out there who actually think you need to leave a patient with abd pain in pain in order to properly assess it.

In their defense, that was once a legit exam technique, but hasn't been in more than a decade. Ultrasound and CT have made "diagnostic pain" absolutely obsolete.

IN the US, ultrasound is not used as often or as proficently as in Europe. One of the main reasons is because it is operator dependant. Here in Europe, the doctor performs the ultrasound. In the US, often a tech looking for a specific pathology. The positive or negative finding is then relayed to the doctor in most instances. Only in a FAST exam or a very few other conditions is ultrasound the adjunct of first resort in the US for the acute patient.

You can use ultrasound in EMS. It can be used to document changes over time. One of its benefits, especially since it costs so little, is the ability to enter exams into the patient record. You can literally see abdominal ultrasound exams like a flip book on any given patient.

But back to the matter at hand.

Perhaps one of the most medically useful contributions of EMS is to correlate physical findings with patient environment. That is simply not effectively done in an ivory tower. Especially by providers who haven't seen first hand all the wonderful things patients do to themselves.

There is also the ability to actually be part of the continuum of care and note changes in the physical exam over time. We have all heard stories about witnessing STEMIs in patients, begining treatment, and at the hospital no evidence of ST elevation was found. (If you haven't heard a story, you just did)

Some things that may change EMS treatment?

No fluid bolusing an aneurysm or ascitis.
Pain management.
Not giving morphine (opioid) to an already constipated patient or a patient having a miscarriage or in labor.
Going to the right destination facility. (contrary to EMS belief, the ER is not the definitive care destination)

Afterall, if trauma is taken to a specific destination because it is a surgical emergency, why wouldn't you take all of your surgical emergencies to a trauma center? (afterall, there is a surgeon there.)

In the hospital one of the favorite things the EDs seem to like is to get a surgical consult on abd pain. If you went to a place that couldn't do that, wouldn't that delay or even stop the pt from getting appropriate diagnosis and care?

In a female would you not be inclined to go to a facility that had ob/gyn services on staff is you suspected such pathology?

Personally, I think it is a great stain on the professionalism and ability of EMS providers that they have to be told to take trauma patients to a trauma center.

Why would you have to be told to take a patient suffering from any specific illness to a place that could serve them?

Seems almost intuitive to me.

We often speak of alternative destinations for EMS patients instead of the ED. But let's face it, if you have to be told to take a gyn patient to a gyn facility, trauma to a trauma facility, or MI to a PCI lab, you are just not smart enough to be anything more than an ambulance driver. Because all you are doing is taking every patient to whatever facility suits you, not them. Even a taxi driver would take them where they wanted or needed to go. (a lot cheaper I might add)

EMS will never be professionals as long as they claim changing practice does not change anything for the patient.

If it doesn't the failure is not on the practice, but the practicioner.

 

[mycrofft]

My ignorant impression here where I live is that the difference between emergency departments (the only way to get an ambulance pt in besides IFT) is mostly nil, other than stroke and pedi (and those specialties are not assigned, they are also diffusing).
So where is the watershed for a belly (a dark and dangerous place as one anatomy professor told us) that demarcates what can be done to pt benefit best in the field (promptness), versus what can be done to pt benefit best in the hospital (more-extensive technical and diagnostic resources).
(Yes, I know, time from site to receiving facility can tilt this towards field if the time is long).

 

[Maine iac]

This is almost a two part question.

First, is should we as providers have a better working knowledge of abdominal issues? Yes of course. I say that because I am pro education and want to learn as much as possible to better serve my patients.

The second part which is coupled with this is what hospital will better serve my patient. Well, if you only have 1 or 2 choices that is pretty easy to figure out. In my situation I have upwards of 15 hospitals that I could potentially transport to, but 8 close at hand. In my system it is pt's choice unless I decide otherwise. If I am running in a stroke pt who is pushing 6 hours, and it is after hours which might cause my pt to wait an extra hour before TpA, I might skip many "stroke centers" and go to my level 1 trauma because they accept and actively treat stroke pts up to 24 hours.

It does my pt no good if I do not take the time to preform an assessment and listen to my pt's complaints and instead go "bad ab pain? holy smokes! what hospital? sure we can do that. They won't treat you well, and I can't talk to your doctors because this is bad pain and I didn't spend 5 minutes assessing you and we need to get going. Ill see you later tonight when they transfer you back out because they don't have a general surgeon on call."

 

[mycrofft]

Hand out color pamphlets and ask the pt?

 

[Veneficus]

Ddx of Acute abd by quad.

RUQ

cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumor, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis, pleurisy, pneumonia, PE, pericarditis, inferior MI.

LUQ

PUD, perforated ulcer, gastritis, splenic injury, abscess, reflux, dissecting aortic aneurysm, pleurisy, pneumonia, PE, pericarditis, inferior MI, pyelonephritis, nephrolithiasis, hiatal hernia, boerhaave's syndrome, mallory-weiss tear, splenic artery aneurysm, colonic disease.

LLQ

Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, UTI, small bowel obstruction, inflammatory bowel disease, pyelonephritis, nephrolithiasis, AA aneurysm, referred hip pain, all gyn diseases.

RLQ

Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, UTI, small bowel obstruction, inflammatory bowel disease, pyelonephritis, nephrolithiasis, AA aneurysm, referred hip pain, all gyn diseases, appendicitis, mesenteric lymphadentitis, cecal diverticulitis, meckel's diverticulum, intussusception.

Best of luck.

 

[Craig Alan Evans]

Thanks Ven. Your list, although comprehensive, is too much for prehospital medicine I think. I'm going to try and weed it down to the most serious conditions and KISS it in an attempt to improve prehospital abdominal assessment. Thanks for the input. Very good.

 

[Veneficus]

The trouble with abd assessment is you cannot replace one inadequate assessment with another inadequate assessment and be any better off.

You would be better off just transporting patients to a trauma center for their obligatory surgery consult.

 

[Craig Alan Evans]

That doesn't improve prehospital education at all. Now you are starting to sound like a physician. Lol. "this is Rampart, just start an IV of D5W and transport".
I'm not buying it. I still think we can find a middle ground and do better in this area.

 

[mycrofft]

Work backwards.

A. Go to your stats, find what is being admitted from the field. That weights your training and preparation.

B. What interventions can you profitably do in the field in a given setting (urban versus rural)?

Then what ailments (A) can they (B) be applied to?

If there are any A's not covered by B, find a way to get the pt to care, or care to the pt, better.

Oh, yeah. Find way to do it without breaking the bank or having paramedics on every other farmstead or street corner.

 

[Veneficus]

That doesn't improve prehospital education at all. Now you are starting to sound like a physician. Lol. "this is Rampart, just start an IV of D5W and transport".
I'm not buying it. I still think we can find a middle ground and do better in this area.

So what are you hoping to achieve exactly?

 

[Craig Alan Evans]

To improve prehospital abdominal assessment by teaching differentials for each quadrant based on life threatening conditions. Just expanding the scope of assessment skills. For example a liver abscess or tumor is good to know for a physician but I would exclude it as not immediately life threatening so therefore remove it from the list of differentials for prehospital providers. It's not rocket science but I think we can improve the education we give prehospital providers and thereby improve customer service to both the patients in the field, as well as, the receiving ER physicians. I'm always trying to move forward.

 

[Veneficus]

To improve prehospital abdominal assessment by teaching differentials for each quadrant based on life threatening conditions. Just expanding the scope of assessment skills. For example a liver abscess or tumor is good to know for a physician but I would exclude it as not immediately life threatening so therefore remove it from the list of differentials for prehospital providers. It's not rocket science but I think we can improve the education we give prehospital providers and thereby improve customer service to both the patients in the field, as well as, the receiving ER physicians. I'm always trying to move forward.

I can sympathize with your endeavor, but I think in this case, it is a "go large or go home" conundrum.

You can't really benefit the patient or physician when you have ruled in or out only a handful of potential pathology.

If I could?

The problem with EMS education is the idea that you can somehow use a physical exam and history to to look for a handful of conditions without understanding the totality.

Once a person understands how the body works, it is easy to figure out how it breaks down. (at least I think so)

One of the reasons that it seems like doctors are always so hell bent on finding a dx and not treatment, is because once you know what is going wrong when you understand what should be hapening, the treatment is actually intuitive. It doesn't really have to be communicated.

You look at the list and see a host of diagnosis, a ruptured cyst or mass effect tumor can produce an acute life threatening event. Probably no less often than you will see an acute pancreatitis.

But there is an easier way that searching for 100 or so individual dx.

Decide if the presenting pathology is acute or chronic. (easily found with a good history)

At that point, you can explore whether or not it is an infective process, a neoplastic one, autoimmune, physical, or physiological defect. (all done with history and physical)

Perhaps after you come to a handful of DDx, you can start using physical exam techniques to rule specific things in or out.

The time it takes will depend largely on how good a provider is.

But I can tell you that you will have lots of headaches and sleepless nights if you try to use physical exam as the basis for determining pathology instead of using pathology to interpret your exam findings.