Prehospital Abdominal Assessment

[MS Medic]

The problem isn't as much an issue of education in my opinion as it is one of integration of EMS and ED. I leaned most of that stuff in school then reality of the job kicks in: If you are in a large urban environment and you rule out trauma or ectopics then most large hospitals can handle an acute ABD and if you are in a rural area, (I've worked both) just about all of your transport options can't. As far as assessment and treatment go, you spend all this time on scene to the super detailed assessment only to be able to nothing with your findings the majority of the time. Then, when you get to the ED the staff hears ABD pain then turn your back on you and ignore the reset of your report.

There are many day to day problems that need to be focused on before beating everyone over the head with the education mantra. A strong reality is that the basic education of a paramedic USUALLY exceeds that of an associate RN. We just have our hands tied with what we can do with it.

 

[mycrofft]

Let's ask the panel...

OK, given a rural or frontier situation, what abdominal conditions would benefit from a higher than basic degree of differential diagnosis, then what interventions could a tech perform in the intervening response times before definitive care and support are obtained?

I.E., "Is this illeus or ectopic preg or diverticulitis or what? What would I do differently, based on my assessment, to yield a better outcome and lessen suffering before I can get this patient to a place with imaging diagnostics and surgeries and labs?".

Canada has first aid laws which incorporate distance from definitive care, maybe we need something along those lines. Quit thinking New York and consider New Brunswick.

 

[EpiEMS]

Maine has the following language in its protocols:

"Graduates with a current certification from a Maine EMS approved wilderness EMT course may apply the principles of care taught in that course with the approval of the service medical director and when patient arrival at a definitive care setting will be more than 2 hours."

Just a thought for distance from definitive care stipulations.

As far as abdominal pain (not just gas or epigastric pain that seems to be "heartburn"), at least at the BLS level, I'm hard pressed for anything beyond O2, POC, and transport.

 

[NYMedic828]

Not to change the topic,

but until EMS as a service finds a way to weed out the mass of incompetence and lack of proper education in some areas this isn't worth the time to teach.

Like Ven posted, the list of possibilities is massive.

I'd love to see EMS advance as a service, but we need to focus our attention on integrating into a real part of the continuum of patient care before we can worry about extensive assessments.

The reality is we could spend 30min onscene assessing every last thing we can think of but the hospital is still going to ask for a chief complaint, any main symptoms sign your PCR have you on your way followed by starting from square one regardless of what you did. (not always, but most times...)

Unless you have the means to right the problem, just realize the need for further care and get them there. If their sugar is low, fix it. If you think they have cholecystitis thats great that you think you know what it is. But, there fact remains you can't do anything about it beyond writing it on your PCR.

Our goal might be to treat life-threatening conditions, but most of the time our goal is just to keep the reaper away until we get to somewhere that can actually treat the condition definitively.

Every single problem we have as a service essentially relates back to the fact that we aren't really the first part of patient care in anyone's eyes but our own. Sorry if it seems like a crappy attitude, but the truth is the truth.

just my 0.02.

 

[Veneficus]

I'd love to see EMS advance as a service, but we need to focus our attention on integrating into a real part of the continuum of patient care before we can worry about extensive assessments.

This should probably a thread all of its own, so I will not comment on it here.

The reality is we could spend 30min onscene assessing every last thing we can think of but the hospital is still going to ask for a chief complaint, any main symptoms sign your PCR have you on your way followed by starting from square one regardless of what you did. (not always, but most times...)

I think this is one of the biggest misunderstanding in EMS. (I also misunderstood it at one point) Every provider has an obligation to conduct their own exam on the patient.

The first reason is to reduce the amount of missed findings which may result in a misdiagnosis and improper or ineffective treatment.

The second reason is that certain pathology changes/develops presentation over time. Quick examples of this is the shift of pain location sometimes found in appendicitis to the development of a hemo or pneumo in trauma.

Third, different providers need different information about the patient. It is very impractical to do a full assessment on every patient. It could take hours for each. But most proivders develop a system for their exam techniques and in order not to forget something, do the same things all the time.

EMS providers need to understand, whether a medic is re-examining a patient handed off by a basic or a nurse or physician is re-examining the patient you brought in, this "from scratch" examination is for the benefit of the patient. It has nothing to do with mistrust or lack of continuity.

Unless you have the means to right the problem, just realize the need for further care and get them there. If their sugar is low, fix it. If you think they have cholecystitis thats great that you think you know what it is. But, there fact remains you can't do anything about it beyond writing it on your PCR.

Maybe treat the pain?

or not treat the pain if the dx indicated it might actually cause more complications.

Our goal might be to treat life-threatening conditions, but most of the time our goal is just to keep the reaper away until we get to somewhere that can actually treat the condition definitively..

Just my opinion, but I don't think this is true.

I think it was the original intent of EMS.

I think it is still perpetuated in EMS.

But I also suggest that as pathology and the medical system has changed over the years and decades that this is not the main purpose of EMS anymore.

If I was pressed to tell somebody what the purpose of EMS is today, I would suggest it is firstly the entry into the healthcare system at the initial point of illness/injury. EMS also plays a limited role (which should be expanded) in proper destination decisions.

In 2012, thinking EMS is just to save lives or that paatients without acute lifethreatening pathology are abusers just demonstrates a lack of understanding of the evolution and value of EMS.

Every single problem we have as a service essentially relates back to the fact that we aren't really the first part of patient care in anyone's eyes but our own. Sorry if it seems like a crappy attitude, but the truth is the truth.

I'll admit it could be better. But the reasons are many.

There is the politics of emergency physicians reducing their own patient census, esentially taking money out of thier own pocket.

The is the lack of ability of EMS providers and the lack of drive to do what it takes to become more.

There is also the reality that most people who call for an ambulance need some kind of medical care, though perhaps not emergently. Giving a pt a ride for a nonacute complaint can actually have great benefit to them later.

If an EMS provider got into the industry to save lives and combat death, they are about 30 years too late.

 

[NYMedic828]

This should probably a thread all of its own, so I will not comment on it here.



I think this is one of the biggest misunderstanding in EMS. (I also misunderstood it at one point) Every provider has an obligation to conduct their own exam on the patient.

The first reason is to reduce the amount of missed findings which may result in a misdiagnosis and improper or ineffective treatment.

The second reason is that certain pathology changes/develops presentation over time. Quick examples of this is the shift of pain location sometimes found in appendicitis to the development of a hemo or pneumo in trauma.

Third, different providers need different information about the patient. It is very impractical to do a full assessment on every patient. It could take hours for each. But most proivders develop a system for their exam techniques and in order not to forget something, do the same things all the time.

EMS providers need to understand, whether a medic is re-examining a patient handed off by a basic or a nurse or physician is re-examining the patient you brought in, this "from scratch" examination is for the benefit of the patient. It has nothing to do with mistrust or lack of continuity.



Maybe treat the pain?

or not treat the pain if the dx indicated it might actually cause more complications.



Just my opinion, but I don't think this is true.

I think it was the original intent of EMS.

I think it is still perpetuated in EMS.

But I also suggest that as pathology and the medical system has changed over the years and decades that this is not the main purpose of EMS anymore.

If I was pressed to tell somebody what the purpose of EMS is today, I would suggest it is firstly the entry into the healthcare system at the initial point of illness/injury. EMS also plays a limited role (which should be expanded) in proper destination decisions.

In 2012, thinking EMS is just to save lives or that paatients without acute lifethreatening pathology are abusers just demonstrates a lack of understanding of the evolution and value of EMS.



I'll admit it could be better. But the reasons are many.

There is the politics of emergency physicians reducing their own patient census, esentially taking money out of thier own pocket.

The is the lack of ability of EMS providers and the lack of drive to do what it takes to become more.

There is also the reality that most people who call for an ambulance need some kind of medical care, though perhaps not emergently. Giving a pt a ride for a nonacute complaint can actually have great benefit to them later.

If an EMS provider got into the industry to save lives and combat death, they are about 30 years too late.

I guess my attitude is a bit poor at this point. NYC is a miserable place to work. Probably more nonsense calls and medicaid abuse than anywhere in the nation.

The medical directors don't trust anyone further than they can throw them.

I was using both hands to draw up zofran the other day while calling the medical director for morphine holding the phone on my shoulder, alone in back and the MD made it a whole production to just say "ok you can give morphine." Like im really trying to harm my patients care. Its the only time in 3 months i've called for pain management, the poor woman was in tears she wasn't faking it... (Was diffuse chest pain radiating to left arm, hypertensive non-tachycardia no ST elevation.)

Why does it matter what assessment level we complete when no one including our own supervisoring body does not trust us.

The workforce needs to change to one with higher standards and education before the things we practice can be altered.

 

[Veneficus]

The medical directors don't trust anyone further than they can throw them.

I was using both hands to draw up zofran the other day while calling the medical director for morphine holding the phone on my shoulder, alone in back and the MD made it a whole production to just say "ok you can give morphine." Like im really trying to harm my patients care. Its the only time in 3 months i've called for pain management, the poor woman was in tears she wasn't faking it... (Was diffuse chest pain radiating to left arm, hypertensive non-tachycardia no ST elevation.)

Why does it matter what assessment level we complete when no one including our own supervisoring body does not trust us.

The workforce needs to change to one with higher standards and education before the things we practice can be altered.

Sounds like the problem is with medical direction to me.

 

[NYMedic828]

Sounds like the problem is with medical direction to me.

Its not really their fault though...

There are many people who are just so incompetent that it has led to them being very skeptical of allowing us anything.

When I did a rotation over there, an ALS crew actually called for orders for dopamine, when the doctor asked "whats the carotid pulse rate" they replied "there isn't one."

Not to mention the 5 calls or so for people "thinking" they have a STEMI but the 12 lead blatantly shows no elevations. The doctor I did my rotation with so happens to be the one who I spoke to for morphine orders. Hes probably the biggest hard-*** but he told me himself when I was there about why he doesn't trust people, and after listening to some calls I don't blame him.

I can't really blame them for being so distrustful. People are honestly morons and as you stated have no desire to do what is necessary and strive for more.

Its very disappointing and frustrating when you enjoy what you do most of the time but everyone around you could care less if it all went up in flames. All they do is put on weight and complain about their paycheck. Very few have any desire to be part of the solution.