Exposing Patients: Balancing Necessity and Dignity

The issue of exposing patients, and especially female patients, comes up fairly frequently on EMS forums and blogs . This post will examine the issues surrounding exposing patients, guidelines for doing so appropriately, being sensitive to various cultural considerations, and limiting your liability when you undertake to expose a patient.

I. Issues Surrounding Exposing Patients
The main issue people raise is being accused of inappropriately exposing or inappropriately touching an exposed patient. This is not an imagined threat as we will discuss in more detail below. Nonetheless, as professional providers of pre-hospital emergency care we should have a thorough understanding of when we need to expose a patient and how to properly assess the exposed patient.

First off, I feel the need to suggest we refine "exposure" into two iterations: 1. Partial Exposure and 2. Complete Exposure ((This is a construct I created for this article. I have not encountered this parsing of the concept of exposure before, however if you have, let me know so that I can give the proper attribute.)). For this article, partial exposure will refer to exposing any upper or lower extremity only, and complete exposure will refer to exposing any body surface area from the neck to the genitals alone or in conjunction with exposure of any upper or lower extremities.

When do we partially or completely expose a patient? When we need to assess or treat a body surface area that is concealed from view, restricts palpation or auscultation and/or where clothing restricts or prevents the appropriate application of interventions ((This is my definition. I have not located an official definition.)).

Let's examine two routine instances where exposure of patients is likely required.

A. Trauma Patients
The obvious situation is the trauma patient. Nearly every paramedic or emergency physician text or handbook directs the complete exposure of the trauma patient. To wit:

"Intitial evaluation of the trauma patient begins with the primary survey, part of which is the complete exposure of the patient ((An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, By Swaminatha V. Mahadevan, Gus. M. Garmel, Published by Cambridge University Press, 20057, page 102)). Failure to completely expose the patient may result in missing a serious traumatic injury ((Id. at 102))."

"Exposure is obtained by completely undressing the patient. Patients must be fully undressed to allow a complete evaluation. ((Manual of emergency medicine, By Jon L. Jenkins, G. Richard Braen
Edition: 5, Published by Lippincott Williams & Wilkins, 2004, page 33))"

"The final part of the primary survey involves a quick scan of the patient's body to note any other potentially life threatening injuries. In general, this requires removal of the patient's clothes...Injuries cannot be treated unless they are identified." ((Trauma By Ernest Eugene Moore, David V. Feliciano, Kenneth L. Mattox page 115.))

That last bit is the key: you can't treat what you can't see.

However, this does not mean that we completely expose every trauma patient. Where your assessment determines the patient's traumatic injury is limited to only an upper or lower extremity, I feel that partial exposure if the injured extremity is required to appropriately assess and treat the injury. Complete exposure in these instances may likely be unwarranted.

B. 12 Lead EKGs
Prehospital 12-lead EKG with computer analysis and transmission to the emergency department is recommended by the American Heart Association (AHA) and the National Heart Attack Alert Program (NHAAP) for patients with chest pain and possible acute myocardial infarction (AMI).

Proper electrode placement in the precordial leads is critical.
Proper and consistent placement of the precordial leads is essential for obtaining accurate ECG tracings. ((Sensible analysis of the 12-lead ECG By Kathryn Monica Lewis, Kathleen A. Handal. Published by Cengage Learning, 2000, page 12.))

Correct placement is important because the 12-lead ECGs are compared with previous ECGs. For the comparison to be reliable for identifying existing problems or highlighting the appearance of new problems, the electrodes must be placed consistently. ((NANCY CAROLINES EMERGENCY CARE IN THE STREETS By AUTOR NAO LOCALIZADO, Nancy L Caroline Published by Jones & Bartlett Publishers, 2007, page 27.65.))

V1 and V2 often times present little problem, however in the female patient or obese male patient, properly placing leads V3 through V6 may require complete exposure of the chest.
When performing 12-lead ECGs on female patients, place the electrodes for leads V3 through V6 under rather than on the breast. ((Prehospital 12-Lead ECG: What You Should Know, http://www.physio-control.com/uploadedFiles/learning/clinical-topics/Prehospital%2012-Lead%20ECG%20What%20You%20Should%20Know%203009852-000.pdf))

Can a 12-lead be properly performed with the bra unfastened, yet in place? It is likely so. Underwire bras may interfere with the electrical conductivity of the electrodes ((http://www.cigna.com/healthinfo/aa10253.html)), however I have not located any studies confirming underwire interference with 12-lead EKGs.

In any event, when performing a 12-lead EKG, complete exposure of the chest is likely warranted.

II. Guidelines for Patient Exposure

So we have identified two routine instances that may be required to expose our patients, and identified some issues surrounding the exposure. Let us focus now on some general guidelines for exposing patients.

1. Inform Your Patient You Need to Expose Them.
If your patient is conscious and alert, tell them what you need to do and why you need to do it. Be professional, and explain to the patient that as soon as you have completed your assessment/treatment/electrode placement that you will cover them up.

Remember, however, that if your assessment reveals the patient has the appropriate present mental capacity, they can refuse any or all treatments or interventions. Respect your patient's right to refuse. Improvise, adapt and overcome. Oh, and document the patient's refusal of course.

2. Limit the number of people who see the patient exposed.
While this may be difficult during a trauma scene in the middle of the street, it is not impossible. You can use screening devices such as sheets or tarps to obstruct the view of onlookers. Alternatively, you can cover the patient and expose areas systematically while keeping the bulk of the patient covered.

This is easily accomplished in the living room of a chest pain patient. Prior to exposing your patient, ensure all non-essential personnel are out of the room. I politely boot out the security guard who responded, ancillary relatives, the nosy next door neighbor, etc. Need to do a 12-lead in the bar area of a restaurant? Clear it out. Take command; it is your scene. You patients will appreciate your concern over who sees them exposed.

I know what you are thinking. "Can't we just get them in the back of the Ambulance and then do the 12-lead?" Sure we can when the situation dictates. But even then, pay attention to who is in the Ambulance and remove non-essential personnel. Keep the doors closed, and do not permit entry to or egress from the ambulance while the patient is exposed.

3. Limit the time your patient is exposed.
Don't dawdle. Expose, assess/treat/place the leads, then cover the patient up. Trauma patients should be covered anyway to prevent hypothermia and for potential of shock. Additionally, sheets, towels, and gowns definitely do NOT interfere with electrical conductivity of the EKG electrodes.

3. Use the Back of Your Hand.
When placing electrodes for V3 through V6, use the back of a gloved hand to lift a woman’s left breast AFTER informing her. It is difficult to construe this action as sexual contact versus using the front of a cupped hand. An easy alternative is to ask the female patient (or male patient with large breasts) to lift their left breast to permit you to place the electrode and wire. ((12-Lead Acquisition Training, Ontario Base Hospital Group Education Subcommittee Group, 2008, PowerPoint Presentation, slide 22.))

4. Document Your Exposure.
If you expose any patient, you should thoroughly document what body surface areas you exposed and why you exposed them. You should further include the details of your assessment of those exposed areas and the treatments or interventions applied to those exposed areas. Additionally, it may be prudent to note when and how you covered your patient after assessment/treatment of the exposed areas.

III. Recognizing Cultural Sensitivities

Our communities are more diverse than ever. Female modesty is valued in many cultures and it may be difficult for patients of different cultures to undress in front of a male health care provider. Some cultures consider the area between the waist and knees particularly private. In fact, traditional Asian physicians do not touch a woman's body except to take her pulse. Instead, the woman points to the corresponding area of a doll to indicate the site of her problem.

If you are presented with a patient whose is culturally sensitive to being exposed, even for treatment of an emergent condition, there is not much you can do except respect the patient's modesty and keep as much of the patient covered as possible. You should ensure that only procedures that are absolutely necessary should be performed.

If possible, it may be best to assign a female practitioner in such instances to limit the psychological impact on the patient. ((Caring for Patients from Different Cultures: Case Studies from American Hospitals, By Geri-Ann Galanti
Edition: 3, revised, Published by University of Pennsylvania Press, 2004, pages 102-3.))

IV. Limiting Your Liablility

Last December The Associated Press published an article entitled, "Ambulance Attendants Molesting Patients". Read it, and pay special attention to the plaintiff's lawyer's comment
"It's a dream job for a sexual predator," said Greg Kafoury, a Portland, Ore., lawyer who represents three women who were groped by a paramedic. "Everything is there: Women who are incapacitated, so they're hugely distracted. Medical cover to put your hands in places where, in any other context, a predator would be immediately recognized as such."

This is the image a good lawyer will place in the jury's mind: The defenseless patient at the mercy of the predatory paramedic.

Patients or their families may not understand our need to expose trauma patients or expose patients for 12-lead EKGs. Protect yourself by following the guidelines discussed above, namely informing your patients of the medical necessity to expose them, limiting the number of people who see them exposed, limiting the time that they are exposed, and ensuring that you fully document all patient exposures.

Our patients place their trust in us in their most dire moments of need. That is an enormous responsibility. A responsibility that we must protect, not abuse. Exposing our patients when it is medically necessary is a part of our job, but we must balance that need with the respect to actively protect our patient's dignity.


Herbie said...

Excellent post.

One good point to bring up when it comes to female trauma patients: Unless there is blood on the bra or panties, there is no need to cut them.

Rogue Medic said...

I agree with Herbie. Excellent post. This is something not given enough attention in EMS.

This can also be a huge problem with adolescents of all genders.

Anonymous said...

Simple solution - always keep a 'johhny' under the head of your cot. Undressing a patient and immediately slipping on the gown makes everyones life much easier and more dignified. 12 leads are no problem, AND the hospital staff will think you're awesome because you saved them this step.

Adam Thompson, EMT-P said...

This post reminds me of a recent incident with my own agency,

A flight medic responded to a trauma alert victim. It was a 16 year/old female that was ejected from an enclosed vehicle. This patient presented with an asymmetrical chest. Unsure of the actual details, but it is said that the flight medic exposed the patient's chest entirely and made sure that she did not rupture an implant by way of physical exam. The EMT in the front seat wrote this flight medic up, and the flight medic lost his job; only after being escorted to the police station a month after the incident by our chief. The flight paramedic told me that he never touched the breast, but he did expose.

I personally have no problem with whatever he did because I know this paramedic and he was always a true advocate. He was one year away from finishing med school before running out of money. Further more, this patient sounds like she was in bad shape and should have been completely exposed. A ruptured implant is a plausible condition, not that I would have felt her up, but this is something you may need to rule out.

Good post, keep it up!

Anonymous said...

I can speak to the implant issue, since my wife actually has them. She has the silicone implants, and I can safely say that even if they DID rupture, there would be no emergent issue as a result. They are filled with more of a solid than a liquid, which at very worst would sort of 'ooze'. Her surgeon pointed out that it is EXTREMELY rare even under traumatic conditions for them to rupture, since they are implanted BEHIND the muscles of the chest wall.

Saline implants would be more prone to rupture, but I doubt that the saline would cause much of a problem (although I don't know its tonicity I'd suspect it is isotonic). I'm guessing here, though.

Beyond a standard head to toe exam I wouldn't linger over the chest any more with a patient with suspected implants vs natural breasts.

Just some extra info you may find useful.

Adam Thompson, EMT-P said...

Its not that a ruptured implant would pose an emergency. Its that an asymmetrical chest that isn't due to a ruptured implant is an emergency.

WTF said...

What ridiculousness. Treat your patient with the respect and dignity they deserve, end of story. This business about exhaustive documentation of "the exposure" as if it were an incident is asking for trouble. I have never, ever ever seen a patient's chart document an exposure like you suggest it should be here.

"I first uncovered her left breast to check for deformities or discoloration, found none, and then immediately covered that breast with a towel that I had readily available. The examination spanned a period of approximately 10 seconds, and I averted my eyes in such a manner so that I never fully appreciated the entire breast in one clear image, but rather in aggregate parts. I then proceeded to examine the right breast....."


Anonymous said...

"A ruptured implant is a plausible condition, not that I would have felt her up, but this is something you may need to rule out."

You don't need to rule it (implants) out, since it's not a factor in your assessment. That's what I was trying to point out. Of course you need to complete your standard head to toe and examine the anterior and posterior chest.

Star of Life Law said...

Response to WTF posted on my blog at www.staroflifelaw.com.