Authors Dr. Sanjiv Haribhakti
- Abstract Component separation technique for a very large abdominal wall hernia
- 28 years male.
- Abdominal distention since 1 month.
- P/A- Large Ventral Hernia with widely gapping recti muscles, thinning of overlying skin, gross abdominal distention.
- Past history: Ileostomy and Colostomy for megacolon with Crohn’s Colitis followed by closure of stoma.
You know what I am intensely interested in right now? ABDOMINAL PAIN! I know, I know. Jeez bram, get some new hobbies, you nutter!
Excuse you, I do have hobbies. I bake!
Do you know why I am interested in abdominal pain?
Because I used to absolutely hate having to treat patients with abdominal pain. I hated it because you just can't diagnose them.
And I was totally right. You can't diagnose them in the pre-hospital setting, we just don't have the tools to be 100%. But it is actually really fun and challenging trying to. One of the things that I am so happy to have learnt as a clinician is that you don't need to be able to diagnose everything, and you don't have to feel stupid if you can't.
But something that more than half of all patients will ask you is: "what do you think is wrong?" or, you know, they'll scream or cry it.
And there is nothing wrong with saying, "well I can't say for sure, but it could be a, b or c."
At the moment, I am trying to learn how to do a really thorough abdominal exam, because I have only worked with one person who bothers to do it (with phenomenal results). And he is a truly amazing human being and someone to strive to be more like.
So basically I wanted to give some tips on learning to do a proper clinical assessment in order to form a preliminary diagnosis. This isn't limited to abdo assessment, but that's what prompted it.
This post is less of a resource for writers as is this blog's primary intention, but it could be helpful for paramedic students maybe. Well, I just wish someone had told me some of these things sooner is all.
As always, I myself am still learning (we all are), the minute I stop learning will be the day I die, so if you have any questions/want something clarified/think something is inaccurate/want to add something, shoot me an ask or reblog with additions. I would truly love to hear from you!
OKAY!
So here are some general rules for your examination of a patient who is in pain or discomfort, or you know, those ones who are just ~generally unwell~ (this of course, excludes stuff like obvious trauma, etc). These rules might not work for everyone, but hey, if they help one person then that is awesome.
Rule number one:
Dicking around trying to diagnose in the pre-hospital setting is absolutely irresponsible if you are prioritising it over treating the patient.
If someone tells you they are in 10/10 pain and they look it, do your drug checks and give them analgesia before working out when their last bowel motion was.
If someone looks really fucking sick (pale and sweaty), and their vital signs tell you that something is up, treat them and drive them to hospital really flippin fast.
Because, in the end, there are only so many benefits that you can get from diagnosing a patient in the pre-hospital setting.
Though there are benefits to having a preliminary diagnosis, including but not limited to:
It might help you to pick the best drug for them (analgesics and antiemetics), or it might help you decide not to give a certain drug.
It will help you be prepared in case they deteriorate on you
It will help the hospital as a place to start looking, which will lead to quicker permanent relief of whatever the patient's presenting complaint is (hopefully).
It is nice to keep the patient informed about their condition
(because they will ask you what could be wrong with them. They will ask you what the hospital will do when they get there. They will ask you why the pain might be worse today. And you will find that GPs tell patients fuck all about their own conditions, and about the medications they are taking and why, it is something that makes me very angry. If you know that what they are experiencing is a common symptom of their diagnosed condition, tell them. People get understandably scared and anxious when they don't understand what is going on.)
You might be able to predict what the hospital will want to do. For example: a scan, or bloods. For the former, you'd put them on a trauma mat (depending on hospital), for the latter, you could cannulate them before you get there if you have time and can.
(as a sidenote, it is totally okay to not know what the hospital will do. This is a big learning curve. And it is totally okay to say, 'I'm not sure, but here is a list of things they might do.' Or, 'I'm not sure', and then ask your partner, '[partner's name], what do you think?'
LEARNING! My favourite.
Being able to look smart in front of your patients/colleagues/the mean nurses at hospital.
But none of those things mean squat if you are withholding or delaying treatment in order to diagnose. So basics first is what I'm getting at. Find it fix it. Having a preliminary diagnosis is a luxury not a requirement.
Don't let your colleagues shame you for being interested in finding out what exactly is causing the presentation. Being interested is awesome. You'll end up being a much better clinician than the people who don't give two fucks.
Rule number two:
Have differential diagnoses!! Have lots of them! Because as we've discussed, you can't know for sure, you just can't, because there is always going to be that portion of the population that is so atypical it hurts. Everyone is different! I can't use that phrase enough. It is my favourite.
So you can say, 'Okay, it could be this, but it could also be a number of other things!' Don't get so fixated on one idea that you forget to ask about other things. That is bad work! (but that is okay, learn from it, buddy, its the only thing you can do).
All of that brings me to the rest of this post which is Rule number three:
LEARN HOW TO DO A REALLY GOOD ASSESSMENT!
This is really hard, so I am going to share with you some secrets that I am still in the very beginning stages of learning. First of all ~ learn to do some really good history taking!
You might be familiar with a few simple mnemonics like SAMPLE (Signs and symptoms, Allergies, Medications, Past medical history, Last ins and outs, Events leading up to) and OPQRST (Onset, Palliation/provocation, Quality, Region/radiation, Severity, Time). There are a couple of other good ones floating around, but those two work for me. Find what works for you and practice it. Learn it.
Form a system (It's okay if this takes time). Here is a list of other questions/ways of asking questions that might be helpful:
- A good one to get in early for people who waffle is: “are you in any pain?” because it can and does happen that a patient will go on about their constipation for 20 minutes and forget to tell you about their cardiac chest pain.
- “Have you ever experienced anything like this before?/Did you see a doctor for it then?”
- “Have you taken anything for the pain/nausea/etc?”
- If you ask people if they have any medical conditions, 90% will say no. After they say no, ask them something like: “No asthma, epilepsy, diabetes, high blood pressure, anxiety, headaches? Never had anything wrong with your heart?” Usually, this list prompts them to remember their own medical history or say “oh yes that! I've had three heart attacks!"
- “Do you keep a list of medications? Where?” (because very few sick people remember everything they take)
- For people with long-winded stories and chronic conditions, “What is different today that made you call the ambulance?” (be polite)
- “Can you use one finger to point to where the pain is worst?” (can they localise? Also helps to work out how the pain radiates)
- “Have you been going to the toilet like normal?”
- “Have you been eating and drinking like normal?”
- “Is there anything that makes it worse or better?”
- “What were you doing when it started?”
- “Besides [presenting complaint], do you have any other symptoms?/is there anything else that is abnormal/that is worrying you?
- “Are you sexually active?” (where appropriate)
- "Have you been feeling generally well lately?"
- Most important question: “Is that normal for you?” (because there is no such thing as normal!)
There are heaps more things that you might want to ask, but you need to work out what kind of questions work well for you. Then later you can make your questioning more specific to individual presentations.
Probably the most important thing about all of this is that you need to listen to their answers. Having to ask the same question 8 times is just going to make both of you frustrated. Repeat stuff back to them so you know you're both on the same page.
Try to move at their own pace with questioning (if it's not time-critical), but sometimes it is okay to stop them (politely) and ask time-critical questions, like the pain question.
And of course, sometimes you will get patients who know nothing about their own history, or who, because of a medical condition, are in no state to communicate their ails, so don't be afraid to use bystanders who know the patient well, or who at least know where they keep their meds.
A good question to ask bystanders (particularly if you are unsure if the patient may be a little bit confused/agitated/ALOC) is:
- “You know [patient's name], a lot better than I do; do they seem like they are acting normal to you?”
Rule number four:
Do not be afraid to touch your patients! Even if you aren't suspecting that there is anything at all wrong with them, auscultate their chest! Palpate their abdomen! "Why?!" I hear you cry? "That's unnecessary!" Because the only way you are going to learn if something is abnormal is by learning what is NORMAL!!!
The other part of this is getting in the habit of doing a proper assessment: maybe you think your patient is a giant spoon, and chances are, they probably are, but if you don't do a thorough assessment and there IS something wrong with them, your are gonna feel like a real silly butt, and hopefully your poor assessment didn't lead to a poor patient outcome (but okay, we can still learn from it).
So get in the habit of doing thorough assessments on everyone (where appropriate and where transport time permits). The exceptions to this are if it causes them distress or makes them uncomfortable, if they refuse, or if you need to prioritise other stuff because of time constraints.
Rule number five: and as an adjunct to all other rules!
CONSENT! Always ask your patient's permission to touch them and explain WHY! Do this before you start touching them! It is really easy to get to a point where you are totally cool with touching people (it comes with time), but you always need to keep in mind that most patients don't know what you need to do for your assessment, and they might not be okay with touch.
“I am just going to lift up your shirt and have a feel of your stomach. Is that okay?” Get permission.
“I'm just doing this to check for ______” So they don't feel like you are just touching them because you feel like it.
“Let me know if it hurts and I'll stop right away, but it shouldn't hurt” And keep that promise.
Tell them if you find anything abnormal. Ask them if that's normal for them because it might be (everyone is different). Try not to make them anxious, but try not to lie to them.
“Your blood pressure is a little bit high, is that normal for you? No? Oh well it could be caused by a lot of things, for example if you are anxious or in pain.”
People deserve to be informed about their health. Having said that, don't tell them they could die unless they are refusing treatment and transport against your advice, in that case, lay it on.
Communicate with them. They deserve that from you.
And ask them what they want, or what they think they are capable of doing.
“Can you walk to the stretcher or would you like us to lift you/move it closer/get a wheelchair?”
Always ask “would you like something for the pain?” explain their options but limit it to what you are willing to give them based on their presentation (The worst thing is deciding on a drug for a patient who looks like they are absolutely suffering, and then drawing it up only for the patient to decide they don't want anything).
“I can give you a drug that you inhale/swallow/whatever, or I can put a little needle in your hand and give you something else.”
“I can give you a drug to help with your nausea, but I'll have to give you a needle.”
“Based on what I've found, I think you need to go to hospital, but I can't force you. Are you happy to come to hospital with us?”
“I think you could probably go and see your GP tomorrow about this, but I am happy to take you to hospital now if you'd like to go. You can always call us back if...”
It's their health, it's their choice.
Learn different assessment techniques!
Learn something new every day! Learn what normal bowel sounds sound like (best place to auscultate the right lower quadrant, and you want 5-15 per minute).
Best place to auscultate the chest is on the back, or for patients who are a bit larger, the axillary line. Try not to auscultate through clothing!
Try learning percussion (a bit hard in the pre-hospital setting).
Watch youtube videos on different assessment techniques, they are useful!
Use all your senses to assess!
Learn about different kinds of pain! Learn different types of referred pain! Have a really good understanding of your anatomy and physiology or your organs!
Learn percussion! Don't forget your vital signs! Never forget to take a temperature, particularly if you can't work out what's wrong. Learn which kinds of analgesia are better for which kinds of pain! Keep learning! Never stop learning!
And I think that is the end of that unless I think of something else to add later.
Okay, next post I want to make is about specific kinds of pain and what the patient might have based on the information you gather in your awesome assessment.
