# Misdiagnosis May Have Been Death Sentence



## VentMedic (Dec 3, 2008)

*Misdiagnosis May Have Been Death Sentence for District Man*
posted 5:30 pm Wed December 03, 2008 

http://www.wjla.com/news/stories/1208/574697.html



> Washington - Authorities are currently investigating whether a District man's sudden death could have been averted if Emergency Medical Services personnel had not misdiagnosed his condition as mere acid reflux. According to Lolitha Givens, mother of *39-year-old* Ed Givens, he was a healthy father of two teenage boys with no history of heart trouble or breathing problems. His general good health was one reason why his *complaints of chest pain and shortness of breath* Tuesday night concerned her.
> 
> Givens called an ambulance, and EMS personnel examined Givens. *After hearing his symptoms, they diagnosed him with acid reflux and suggested an antacid,* according to Ed's brother.
> 
> Mere hours later, Givens was dead.


 


> "To wake up and find him dead on the floor is breathtaking, just breathtaking," said Lolitha Givens. "The thing that gets me is the ambulance refused to take him. *They convinced us he was OK."*


More at:
http://www.wjla.com/news/stories/1208/574697.html


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## traumateam1 (Dec 3, 2008)

Huh... I didn't know that medics could dx in the field.
SOB and C/P and they were convinced he was okay because he didn't have a past medical hx. Hmm....

Truly an unfortunate event.. guess this is a reminder to all of us, not to get that ParaGod complex going on, after all, we aren't doctors and can't do all the tests in the field.


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## JPINFV (Dec 3, 2008)

traumateam1 said:


> Huh... I didn't know that medics could dx in the field.



Anyone that is critically thinking about their patient's condition will form a differential diagnosis. Of course I don't quite know how many paramedics that exhibit critical thinking would think about pushing for an AMA from a patient with chest pain.


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## RailFan77 (Dec 3, 2008)

I've always been under the impression, from what I've been taught, that EMT's and medics are not supposed to make a diagnosis to the patient, but rather our jobs are to treat symptoms.


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## Sasha (Dec 3, 2008)

JPINFV said:


> Anyone that is critically thinking about their patient's condition will form a differential diagnosis. Of course I don't quite know how many paramedics that exhibit critical thinking would think about pushing for an AMA from a patient with chest pain.



But they cannot officially dx. We had a medic tell someone he was having a heart attack, turned out it wasn't a heart attack. He got fired because as the super said "We aren't doctors, we aren't diagnosing people. If you think you know what it is, keep it to your d@mn self."


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## mycrofft (Dec 3, 2008)

*Curmudgeon mycrofft says "Believe nothing the press says".*

I find it hard to believe "heart problems" as bad as respiratory difficulty would go un-dx by paramedics. They probably declined tretment and promised to see their MD.


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## Sasha (Dec 3, 2008)

mycrofft said:


> I find it hard to believe "heart problems" as bad as respiratory difficulty would go un-dx by paramedics. They probably declined tretment and promised to see their MD.



I've seen a lot of medics weasel their way out of serious calls because they wanted to go to bed.


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## reaper (Dec 3, 2008)

That is a brash statement to make, without proof!

We are taught to form a differential dx on every pt we assess! I have no problem telling a pt what I think is wrong with them. I would rather tell a pt that they may be experiencing cardiac problems and have them go to the ED and find out it is reflux. At least it got them there and they were examined by the Dr..

I have seen a lot of EMT's that think a medic is brushing off a pt or over treating a pt. But, they have no idea what that medic is thinking or do not have the education to know what they should be thinking!


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## VentMedic (Dec 3, 2008)

mycrofft said:


> I find it hard to believe "heart problems" as bad as respiratory difficulty would go un-dx by paramedics. They probably declined tretment and promised to see their MD.


 
One of the symptoms of a cardiac problem is denial. It doesn't take much to sway a person if you tell them what they want to hear. This guy was probably delighted to hear from Paramedics that he just had a little reflux even though he probably knew something was wrong. 

Unfortunately this scenario happens. Some Paramedics will even do a 12-lead ECG and rely on those results to reassure the patient that nothing serious is happening. Usually it is the female patients who are the most nondescript in their signs and symptoms that will later die. They are wrote off as "just anxiety" or "hyperventilating". Several times I've seen females brought to the ED by EMS, if they are brought at all, with their faces stuck in a paper bag or 4 l/m NRBM only to code as soon as they cross through the doorway.


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## Sasha (Dec 3, 2008)

reaper said:


> That is a brash statement to make, without proof!
> 
> We are taught to form a differential dx on every pt we assess! I have no problem telling a pt what I think is wrong with them. I would rather tell a pt that they may be experiencing cardiac problems and have them go to the ED and find out it is reflux. At least it got them there and they were examined by the Dr..
> 
> I have seen a lot of EMT's that think a medic is brushing off a pt or over treating a pt. But, they have no idea what that medic is thinking or do not have the education to know what they should be thinking!



Or, you have a really drug happy or bad medic. I don't have to be a medic to know all chest pain should be seen by a doctor because you have no way of knowing for sure in the field.

I also am more than halfway though medic school so I usually have some idea of what's going on.


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## VentMedic (Dec 3, 2008)

reaper said:


> That is a brash statement to make, without proof!


 
Tell me you have not come across that at least twice in your career if not more.


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## JPINFV (Dec 3, 2008)

Sasha said:


> But they cannot officially dx. We had a medic tell someone he was having a heart attack, turned out it wasn't a heart attack. He got fired because as the super said "We aren't doctors, we aren't diagnosing people. If you think you know what it is, keep it to your d@mn self."



Just because you might not verbalize it doesn't mean it doesn't happen. For example, I can think of at least two (I can remember thinking of 3, but the third one escapes me) that can make a person altered, hot, flush, and dry. They have complete opposite treatments. How can I decide which treatment to provide given more information without forming a DDX?

DDX: CO poisoning TX: remove from shelter to fresh air.

DDX: Heat stroke TX: seek shelter/shade.


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## VentMedic (Dec 3, 2008)

JPINFV said:


> Just because you might not verbalize it doesn't mean it doesn't happen. For example, I can think of at least two (I can remember thinking of 3, but the third one escapes me) that can make a person hot, flush, and dry. They have complete opposite treatments. How can I decide which treatment to provide given more information without forming a DDX?
> 
> DDX: CO poisoning TX: remove from shelter to fresh air.
> 
> DDX: Heat stroke TX: seek shelter/shade.


 
Many things are not that easy for a working or field diagnosis. Also, too many get over confident that they "fixed" the problem with fresh air or O2 and forget all of the effects that CO will have on the body. The same with heat stroke. 

What some also do not understand, and this definitely includes Paramedics, treating a symptom does not necessarily "fix" the problem. If lasix and/or CPAP is given for CHF, that symptom may alleviate momentarily but it may not provide definitive treatment to the cause of the CHF. 

Give Dextrose to a diabetic may alleviate the immediate problem but it does NOT fix what cause the glucose instability whether it is an endocrine change with the insulin or diet out of acceptable control.

Giving albuterol (or Xopenex) to someone that is wheezing may not fix the unlying cause even if the wheezes decrease or even stop. There may still be an inflammatory or infection response that may still need to be investigated. 

Chest pain? I've actually heard Paramedics brag about "fixing an MI". What they don't realize is the whole process that is about to start at the hospital and will continue for the next few days for that patient if they survive.

Few understand the value of labs and other diagnostics that must be done to achieve a correct or at least a temporary medical diagnosis made by the doctor(s). That is why there are many specialists and ED physicians are more than happy to consult one of them as soon as possible.


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## Sasha (Dec 3, 2008)

JPINFV said:


> Just because you might not verbalize it doesn't mean it doesn't happen. For example, I can think of at least two (I can remember thinking of 3, but the third one escapes me) that can make a person altered, hot, flush, and dry. They have complete opposite treatments. How can I decide which treatment to provide given more information without forming a DDX?
> 
> DDX: CO poisoning TX: remove from shelter to fresh air.
> 
> DDX: Heat stroke TX: seek shelter/shade.



Yes you form differential diagnosis. You don't get too cocky with it, nor do you go around telling your patient what you THINK is wrong with them. They can turn around and sue you for that if you really wanted to get right down to it. 

You think it's acid reflux? Good for you, patient still could be having a heart attack. You aren't a doctor. Form your DDX, keep it to yourself.


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## reaper (Dec 3, 2008)

VentMedic said:


> Tell me you have not come across that at least twice in your career if not more.




Yes, have seen more then a few times over the years. But, I don't say a lot of medics do it!


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## reaper (Dec 3, 2008)

Sasha said:


> Yes you form differential diagnosis. You don't get too cocky with it, nor do you go around telling your patient what you THINK is wrong with them. They can turn around and sue you for that if you really wanted to get right down to it.
> 
> You think it's acid reflux? Good for you, patient still could be having a heart attack. You aren't a doctor. Form your DDX, keep it to yourself.



Just for my knowledge, can you produce a protocol or SOP or a law, that states I am not allowed to give my pt, my opinion?


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## Sasha (Dec 3, 2008)

reaper said:


> Just for my knowledge, can you produce a protocol or SOP or a law, that states I am not allowed to give my pt, my opinion?



My textbook says specifically it is bad practice to tell a patient what you THINK is wrong with him, especially if it may or may not be serious.

It's along the same lines as "Is he going to live?" They will sue the crap out of yoou if you say "He'll be fine!" and they die.


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## reaper (Dec 3, 2008)

Thank you, You answered my question!


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## VentMedic (Dec 4, 2008)

You want to know how many patients have been told by the Paramedic aka Pulmonologist on the ambulance that they have asthma because a few wheezes where heard? Do you know how many patients will remember that FOREVER and say they have asthma in their history that  distracts from their real problem which could be cardiac? Or, it could have been a vocal cord irritation or PNA? 

A friend and former Paramedic, who is now a physician, still states that making a diagnosis as a Paramedic was easy because he not yet been to med school to realize how many potential diagnoses there were for the same symptoms. I also made that discovery when I went back to school after being a Paramedic for a few years.

And yes, both in and out of the hospital, I am very careful with my choice of words to the patient because even at their sickest they or their families will remember everything you say. Sometimes the problem appears obvious because the patient has been through it before. Sometimes that MI which the patient has felt before turns out to be a dissecting aneurysm. Bummers for the patient who had their hopes on only having another MI with which they are familiar with.


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## reaper (Dec 4, 2008)

How many Pt's have been DX with a certain disease or condition, by a Dr. Only to find out they were wrong!

This can be said of every person in the medical field. It all comes down to knowledge and experience. Know when to say to something and when not to.

Paramedics are not Rn's. Rn's are not Dr's and Dr's are not GOD! Every one has those people that have no clue about what is going on. They all also have great ones in every group.

I don't put all medics in a group as good or bad. I don't put all Rn's in a group as smart or stupid. I don't put all Dr's into a group as good or Gods. You judge them all on a one on one basis.

Tell me you have not known bad apples in all groups?


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## VentMedic (Dec 4, 2008)

reaper said:


> How many Pt's have been DX with a certain disease or condition, by a Dr. Only to find out they were wrong!
> 
> This can be said of every person in the medical field. It all comes down to knowledge and experience. Know when to say to something and when not to.
> 
> ...


 
RNs and RRTs *KNOW* what they are allowed to discuss and not discuss with the patient. We also know what the physician wants disclosed about the patient's treatment plan until he/she has a chance to discuss it. As seen on the EMS forums, many in EMS don't receive the same quality training or read their P&Ps.

RNs and RRTs also work from off of a working or clinical diagnosis in many situations. The patient has a right to know the details of their care as long as it is not detrimental to the immediate situation. With experience you become a master at providing comfort and instilling confidence with few words while providing care. Talking to a patient is essential but choose your words carefully. 

If anyone has read a physician's note on all of their differential diagnoses or tried to figure out what direction the diagnosis is taking by the diagnostics, you may find that one may never know the actual root cause of an emergent situation. It may takes days, weeks or even months to derive a conclusive definitive medical diagnosis and then it may not be a single diagnosis.

If a doctor messes up on the diagnosis, he/she has the education and diagnostic data to better explain how the diagnosis was derived. As I said before, there are many different diagnosis possibilities for the same signs, symptoms and even similiar diagnostic tests. 

Humans are complex and it would be great if the only diseases out there were the few that are mentioned in a Paramedic text.


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## mycrofft (Dec 4, 2008)

*If I sent every chest pain to the hospital the jail would be empty.*

If every chest pain at an ER was seen first, everyone would c/o CP. Does every hospital do CPK etc on every chest pain? And expect to get paid for it? Statistically speaking, chest pain being cardiac in origin is not as common as chest wall pain by a long shot, and I am guessing esophageal pain is more common, although closer. As I say, show me the bodies on the sidewalk, because 70% of MI's present as clinically dead (probably due to delay secondary to denial...or being told you have reflux....).

Meld your observation and vital signs with the hx, shake well in your head, open your  mouth and reassure the pt unless you need to scare the whizz outta them to do as you say. 

One clinical sign I never hear about, but have used, is the irregularly strong pulse. If you get stray systolics, go for an apical while you GENTLY plap the pulse. You are not unlikely to feel and maybe hear some pulses stronger or sounding different from others, maybe even stray systoles crowding up on others. Even if the pulse _rythm_ is regular an EKG can be surprising at that point.


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## reaper (Dec 4, 2008)

VentMedic said:


> RNs and RRTs *KNOW* what they are allowed to discuss and not discuss with the patient. We also know what the physician wants disclosed about the patient's treatment plan until he/she has a chance to discuss it. As seen on the EMS forums, many in EMS don't receive the same quality training or read their P&Ps.
> 
> RNs and RRTs also work from off of a working or clinical diagnosis in many situations. The patient has a right to know the details of their care as long as it is not detrimental to the immediate situation. With experience you become a master at providing comfort and instilling confidence with few words while providing care. Talking to a patient is essential but choose your words carefully.
> 
> ...



I never stated that there were not multiple Dx to a pt.

Please do not group all Rn's and RRT's into one group. While there are many out there that are excellent at what they do and have the knowledge to do their jobs. You also know that there are just as many that have no right treating a stray dog.

I will never defend Paramedics in a group. There are good ones and there are s***t ones. Same goes for Rn's,RRT's,PA's,RNP's and Dr's.

Just because the standard of education in a single group may be low or high, does not mean all are that way.

I did state that you need the clinical experience to know when to talk with a pt and when to divert a question. I do not disagree with you on that basis.

I just do not like all Rn's being grouped as educated and highly trained. All are not. Same way as all Paramedics are not undereducated and do not have the knowledge to treat a pt correctly.

 I never mentioned anything about being able to fix a pt! I am a firm believer in continued assessment at a hospital, for any pt I treat. But it is not wrong or illegal for me to discuss a possible Dx and treatment with a pt, if I feel it will help in them deciding on continued care. That is part of our job as a Pt's advocate. We are to do everything legally within our power to get that pt to the care they need.

If a medic signed off a pt complaining of chestpain and sob, without doing everything in their power to convince them to go to the ED. Then they should be run out of the profession. As they do not have the best care of their Pt's in mind!


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## VentMedic (Dec 4, 2008)

reaper said:


> Please do not group all Rn's and RRT's into one group. While there are many out there that are excellent at what they do and have the knowledge to do their jobs. You also know that there are just as many that have no right treating a stray dog.
> *********************
> I just do not like all Rn's being grouped as educated and highly trained. All are not. Same way as all Paramedics are not undereducated and do not have the knowledge to treat a pt correctly.


 
Get off your high horse! My statements were NOT about who is better than who in what profession but what is SAID TO THE PATIENT and the many possibilties for diagnoses. 

That is largely what the news article was about also. 

RNs and RRTs are aware of what they can discuss to the patient and what they can not but it doesn't make them any less educated or professional than a Paramedic. There are not such clear boundaries in EMS and some do not fully understand what should, can and can not be said or the timing of saying it.

You can tell your patients whatever you want. Just remember that the other EMS agencies have their own medical directors to write the specifics for their P&P to which they must follow.


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## reaper (Dec 4, 2008)

VentMedic said:


> Get off your high horse! My statements were NOT about who is better than who in what profession but what is SAID TO THE PATIENT and the many possibilties for diagnoses.
> 
> I am not on a high horse! I am not stating who is better. I stated not to put blanket statements over a single profession.
> 
> ...



I did not make statements here to argue Medic vs RN. I just stated that I am tired of grouping together of a profession, when there is to much difference inside it!


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## daedalus (Dec 5, 2008)

This is still a CNN worldwide headline.

Not good for our image people.


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## rhan101277 (Dec 6, 2008)

Yeah you have to be very careful what you say.  How do you handle people, who constantly ask what is wrong with him?  Just say I am not sure, we are going to get him to the hospital as soon as possible.  The general public thinks that when an ambulance shows up that those are some of the best trained people available.  People should try to live up to that standard by acting in a professional manner.  I guess the best answer would be, I am not sure what is wrong with him/her, it could be serious or not a doctor will know for sure when we get to the hospital.


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