Data quality, lead placement, your patient’s dignity, and undressing female patients

I thought long and hard about allowing anonymous comments on the PH12ECG blog.

In my experience, anonymous posters don’t exercise the same level of responsibility as posters who use their real names or blogger identities.

Anonymous posters are often bomb throwers. Or, they engage in proselytizing, propagandizing, sensationalizing, or advertising.

For them, there are no consequences. That’s why it’s almost always a mistake to get into a discussion with an anonymous poster.

On the other hand, some anonymous posters might have something of value to add. Perhaps they simply have not bothered to register with a blogger account. Or, maybe they have their own reasons for posting anonymously, but they are intelligent, responsible people who want to express their opinions.

I received a comment from an anonymous poster yesterday who was replying to Muscle Tremors, Your Patient’s Dignity, and Staying Organized.

Anonymous wrote:

If you remove the bra of a female patient and you do not have her written consent be prepared for a law suit in most states. There is absolutely nothing to be gained in terms of quality unless you are a novice in removing the bra in doing an ekg. Remember this is not a decision that you make. The patients body belongs to the patient. NOT TO YOU.

Because this was in reference to a non-recent post, the comment ended up in my mailbox awaiting moderation.

This didn’t sound like a random comment left by one of my usual readers.

Here’s what I found under Recent Keyword Activity.

Whoever anonymous is, s/he typed the words “paramedics right to undress female patients” into Google and that’s apparently how s/he found my blog.

Let’s take this one step at a time.

If you remove the bra of a female patient and you do not have her written consent be prepared for a law suit in most states.

In the words of Daniel Patrick Moynihan, you are entitled to your opinion. You are not, however, entitled to your own facts.

Patients who possess the present mental capacity to understand their situation are presumed to have the ability to consent to medical procedures, and that consent need not be in writing.

Performing a 12 lead ECG is no different from placing a patient on oxygen, backboarding a patient, starting an IV, or taking a patient’s blood pressure. Paramedics aren’t required to obtain written consent for those procedures, and we aren’t required to obtain written consent to remove a patient’s clothes either.

If I explain to a patient that I need to perform a 12 lead ECG, and that I would prefer the patient be undressed from the waist up, and the patient says, “Do whatever you need to do.” and then leans forward so that I can unfasten her bra (or I hold up a sheet while she unfastens her bra) then the patient has legally consented to the procedure.

There is absolutely nothing to be gained in terms of quality unless you are a novice in removing the bra in doing an ekg.

I do not consider myself a novice when it comes to capturing and interpreting 12 lead ECGs, and I have found it to be beneficial to remove a female’s bra for several reasons, not the least of which is to help identify the correct landmarks for the placement of the V1 and V2 electrodes (which are frequently misplaced).

I have also found that attempting to place electrodes under clothing (including the bra) often leads to poor data quality.

As a practical matter, if the patient’s arms are through the bra, and you start an IV (as you should for any patient complaining of chest pain, shortness of breath, syncope, etc.) then you will eventually have to pass the IV bag through the shirt and bra if the patient is not undressed at the beginning of the patient encounter.

What would be the point of all that?

The patient will end up undressed and gowned at the hospital anyway.

For a female patient who is particularly modest or uncomfortable being undressed from the waist up in the back of an ambulance, I can see unfastening the bra and having the patient remove her arms, but keeping the cups of the bra over the breasts, if that would somehow help the patient psychologically.

Having said that, you would still need to lift the bra up to correctly place the V1 and V2 electrodes.

So what’s the difference between a bra and a sheet (or gown)?

In any case, you should only uncover the patient’s breasts as long as necessary to complete the procedure, and you should make every effort to protect the patient’s dignity.

I thought I had made that clear.

Remember this is not a decision that you make. The patients body belongs to the patient. NOT TO YOU.

I have no quarrel with the idea that the patient’s body belongs to the patient.

However, there is a third possibility you are overlooking.

Maybe it’s a decision you make with the patient’s consent.

The patient or the patient’s family, I presume, contacted 9-1-1 because some type of situation evolved beyond their span of control. Patients trust that paramedics will do what is in their best interest, with a high degree of expertise and professionalism.

In the 14 years I’ve been a paramedic, I have never had a female patient refuse to remove her bra for a 12 lead ECG once I explained the procedure, why it was indicated, and assured the patient that everything possible would be done to protect her dignity.

If, for whatever reason, my next female chest pain patient says, “I’d rather not take my bra off” then I’ll explain that the lead placement will have to be modified slightly to accommodate the request, but I will respect the patient’s right to refuse.

If I didn’t explicitly say that in my previous post, it’s because my readership consists mainly of medical professionals who already understand that.

Obtaining consent for procedures is part of every medical professional’s basic education.

If you had a bad experience with a particular paramedic or EMS system, I would suggest contacting the director of that system and filing a written complaint.