What about the Physical Exam?

Case of the Month


 
 

Mark Rock, BA, NREMT-P | | Monday, June 25, 2007


Editor's note: This isbonus content to the May 2006 JEMS Case of the Month.



Exploring the reasons providers may not be giving patients a full physical assessment in the field

Given the importance of the physical exam in patient care, why is it often neglected? In discussing the issue with EMTs and paramedics in the field, I_ve concluded that there are five primary reasons why providers don_t perform physical exams on all patients:

1. ˙Only critical patients need a detailed exam.Ó The EMT curricula today teaches that the physical exam is to be performed only on patients who have suffered ˙seriousÓ trauma and/or exhibit an altered level of consciousness.1 From this training, it_s easy for students to infer that it_s a non-essential component of patient assessment, and it allows for a wide latitude of discretion on the part of providers in determining who does and doesn_t need an exam. The problem with this viewpoint is that it overlooks the fact that it may be the physical exam itself that provides the information needed to begin necessary interventions so that a non-critical patient doesn_t become a critical patient. Neglecting the physical exam because the patient has a minor complaint, has ˙no significant mechanismÓ, or is ˙obviously just fine,Ó can lead to the kind of mistakes made in the examples above.

2. ˙You can Âjust tell_ if someone needs that kind of assessment.Ó Time and again, we_re called to provide care for patients with minor complaints or injuries. These are patients who, in all honesty, probably don_t truly need paramedics or an ambulance. We feel the best thing we can do is to offer reassurance and safe transport, then quickly go back into service to make ourselves available for a ˙real emergency.Ó Over time, we get so used to not making full use of our skills that we get in the habit of not providing total patient care, and come to rely on our subjective impressions instead of actual physical findings. Some providers behave as if they possess an almost clairvoyant ability to determine the severity of a patient_s condition. And it_s true that in the course of our training, we_re taught to get a ˙first impressionÓ of a situation and of a patient, but only with a physical exam are we able to confirm our initial impression with findings that substantiate this impression.

3. ˙It_s embarrassing to the patient.Ó It can_t be over-emphasized: a proper physical exam requires that clothing be removed. It_s simply not possible to do a thorough exam through layers of clothing. The necessity of removing clothing makes many care providers uncomfortable, particularly in the field setting. If our patient_s modesty is truly an issue, then we have to decide if this concern should override our concern for their health. The blankets and sheets we carry with us provide an excellent means to maintain modesty and also perform an exam; simply remove the clothing and then cover the patient with a blanket. The blanket may then be removed for reassessment or to perform a necessary intervention. Also, if the patient is stable and we determine that the assessment can truly wait, then we can perform our exam in the back of our ambulance. However, at no time should we use modesty as an excuse to not perform a proper assessment.

4. ˙The patient might get cold.Ó Again, we have blankets. In those situations in which the patient has been exposed to a cold environment, warm blankets are in fact better for maintaining body heat than cold or wet clothing.



5. ˙There isn_t enough time.Ó There_s no question that we_re pressed for time in the field. Particularly with a short ETA to the ED, the provider may feel that it_s all they can do to get vital signs, provide oxygen, monitor the patient_s respiratory and cardiac status, establish IV lines and administer the appropriate medications. But with practice, a physical exam should take no more than one minute, and it should be done before such interventions as establishing a routine IV.

It_s true that most of the time, a physical exam will be unremarkable, will provide little to no additional information and will not change the course of your treatment. Now and then, however, a finding will be significant, and will provide you, the provider in the field, with beneficial information. It_s on these occasions that you_ll truly make the difference when it matters most, to those who matter most: your patients.

Editor_s note: To read the companion article that this information supplements, see ˙Underexposed: The neglected art of the physical exam,Ó Case of the Month, May JEMS.

References

1.Limmer D, et al: ˙Patient Assessment.Ó In Emergency Care. Prentice Hall: Upper Saddle River, N.J., 2005. pp. 261, 274Ï277.

Mark Rock is a paramedic with American Medical Response in Ventura, Calif.




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