'Hand sandwich' key to doctors examining ticklish patients

[March 10, 2016]  By Gene Emery

Reuters Health - Sometimes patients are tickled to see their doctor, but not in a good way, according to a letter from U.K. cancer doctors who suggest a way to examine lymph nodes without inducing giggles.

A "hand sandwich" can be used to block the tickle reflex in patients too sensitive to be palpated in sensitive spots, the authors write in the New England Journal of Medicine.

The sandwich is built by placing the physician's hand on the patient, placing the patient's hand on top of that, and the physician topping off the stack with his or her other hand.

The doctor uses the top hand to press on the patient's hand. The patient is instructed to press on the doctor's lower hand in the same way.

With that method, the top hand controls the force placed on the patient and the lower hand feels for abnormalities.

The system makes the patient feel in control of the examination and takes advantage of the fact that most people can't tickle themselves.
 

"With this technique, patients feel that they are initiating the palpation - albeit at the direction of the clinician - and thus anticipate the sensation and do not tickle themselves," the researchers said.

Dr. Christopher Dobson of Royal Preston Hospital in Lancashire, one of the letter’s authors, said he uses the technique to palpate lymph-node basins in the dermatology clinic when examining patients with skin cancer. "In children, ticklishness is much more common, and the utility of the technique is potentially much more widespread in paediatric oncology clinics."

"I had one patient so ticklish that even with the most gentle, slow and forewarned palpation, (the patient) could not stop laughing during and after the examination, at a time when they were clearly distressed," Dobson told Reuters Health in an email.

"Patients pick this up very quickly," Dobson said. "The first time it takes about a minute to explain the technique. This undercuts the time required to calm the anxious ticklish patient and the painstakingly slow movements that one has to use if you don’t use this technique."

Traditional techniques aren't the best, he said, because even with calming, reassurance and slow movements, "a degree of muscle tensing would often remain."

Dobson said the hand sandwich technique would probably work in other types of examinations as well.

"There have been two patients with tender groins who have found the technique is much more comfortable than standard palpation. This gives rise to the possibility of the technique being used in other areas of medicine such as palpating a tender abdomen," he said. "The technique might be applicable, in modified form, for tenderness or ticklishness with ultrasound scans, though we have not explored that."

SOURCE: bit.ly/1QAs3A2 New England Journal of Medicine, online March 9, 2016.

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