# Ruling out MI - Pressing on Patient's Chest



## sdafbkfsdbkjdsf (Nov 28, 2012)

Hello all,
   I've been hearing from a couple of medics that if you have a pt who has a chief complaint of chest pain. And if they were to complain of pain when you press on their chest where the heart lays you can "rule out" an MI. I'm just interested if you guys ever  heard of this before.


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## NomadicMedic (Nov 28, 2012)

Reproducible chest pain is most often musculoskeletal rather than ischemic, but I certainly wouldn't "rule out" an MI by just pushing on someone's chest.


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## EMSrush (Nov 28, 2012)

For what it's worth, none of our equipment can "rule out" an MI.


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## NomadicMedic (Nov 28, 2012)

EMSrush said:


> For what it's worth, none of our equipment can "rule out" an MI.



Very true. A12 lead, a troponin and a trip to the cath lab are the steps in ruling out an MI. 

As for a BLS assessment, if you have a patient that's been lifting boulders in his backyard for a landscape project and now he has chest pain made worse on palpation, I'd lean toward musculoskeletal pain.  The same way I'd consider point specific, sharp pleuritic pain in a patient who has been coughing up green gunk as a non cardiac problem. 

However, a patient with a cardiac history or a patient that presents with any of the other typical "MI signs" should get an ALS evaluation.


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## RocketMedic (Nov 28, 2012)

The "pain on palp" is a _highly_ leading and subjective question. Presentation and history will be far better guides. 

Pain that changes on respiration, palpation or motion is _probably_ not cardiac, but it's a lot to rule out.


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## Achilles (Nov 28, 2012)

Isn't there a test that can be done with the phosphocreatine levels to detect if a PT has had an MI?


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## Sublime (Nov 28, 2012)

Achilles said:


> Isn't there a test that can be done with the phosphocreatine levels to detect if a PT has had an MI?



As far as I know Troponin and CKMB are the only diagnostic tests used in diagnosing MI. Never seen a doc order phosphocreatine levels in a chest pain patient. 

To the OP. Like others have said reproducible chest pain on palpitation is highly suggestive of non-cardiac related pain. But you certainly can't rule it out without labs.


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## triemal04 (Nov 28, 2012)

Don't fall into that trap, and if your partner does quietly smack them upside the head.

Multiple studies have shown that people with diagnosed AMI's can have reproducable pain and/or chest wall tenderness and/or point tenderness.  Think it's been as high as 15% or more in a couple.  

This isn't to say that you shouldn't check for that, just that you need to apply the results to your overall opinion of what is going on and not use it as your sole criteria for ruling a MI in or out.


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## Smash (Nov 28, 2012)

As Triemal says, around 15% of true MI has pain that is reproducible.  Not a good number to take a punt on I reckon.


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## the_negro_puppy (Nov 28, 2012)

triemal04 said:


> Don't fall into that trap, and if your partner does quietly smack them upside the head.
> 
> Multiple studies have shown that people with diagnosed AMI's can have reproducable pain and/or chest wall tenderness and/or point tenderness.  Think it's been as high as 15% or more in a couple.
> 
> This isn't to say that you shouldn't check for that, just that you need to apply the results to your overall opinion of what is going on and not use it as your sole criteria for ruling a MI in or out.



This. While there are certain characteristics that make A.M.I / ACS more likely, nothing is certain or set in stone. Age, co-morbidities and other factors can all influence presentation, with there not really being a 'typical' presentation these days. If you think of the organs/pathophysiology of different causes of chest pain, it really needs to be taken seriously to exclude the more serious causes that can cause big trouble if missed.

I don't think I have ever not transported a chest pain patient. When you think about it, the pt is so worried that they have called 911/000 it PROBABLY deserves further evaluation. Even the 20 y.o F pt who has just broken up with her boyfriend, hyperventilating and crying c/o chest pain probably needs to be transported. You might be able to calm them down, but they will probably ring back in 30 minutes. People will probably disagree.


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## Medic Tim (Nov 28, 2012)

Smash said:


> As Triemal says, around 15% of true MI has pain that is reproducible.  Not a good number to take a punt on I reckon.



I have also read it is in the 15%-20% range


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## Clare (Nov 28, 2012)

There is no one test that can be done in the pre-hospital environment to rule in or rule out MI.  Chest pain that is only present upon palpation or movement is in theory more likely to be MSK pain but chest pain severe or worrying enough for somebdy to call an ambulance is myocardial ischaemia until a very clear and very obvious alternate cause is identified.


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## Aidey (Nov 28, 2012)

Clare said:


> ... chest pain severe or worrying enough for somebdy to call an ambulance is myocardial ischaemia until a very clear and very obvious alternate cause is identified.



:rofl: :rofl: :rofl: 

I think that might be just a tad of an overstatement.


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## Christopher (Nov 28, 2012)

lill91210 said:


> Hello all,
> I've been hearing from a couple of medics that if you have a pt who has a chief complaint of chest pain. And if they were to complain of pain when you press on their chest where the heart lays you can "rule out" an MI. I'm just interested if you guys ever  heard of this before.



You push on a STEMI patient's chest hard enough...it'll hurt. The test is suspect


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## Christopher (Nov 28, 2012)

Clare said:


> There is no one test that can be done in the pre-hospital environment to rule in or rule out MI.



We certainly can rule in an MI in the field, we can even rule in which artery is closed...


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## NomadicMedic (Nov 28, 2012)

True aidey. It seems like many of my chest pain calls are the result of an over active imagination fueled by the "I'm having a heart attack" bayer aspirin commercials. 

But, I always err on the side of caution.


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## Clare (Nov 28, 2012)

Christopher said:


> We certainly can rule in an MI in the field, we can even rule in which artery is closed...



You can make a provisional diagnosis of MI yes but such a diagnosis is subject to confirmation.  

It's not hard to go "I think you are having an MI" if you're doubled over with chest pain, grey as a winter cloud and having crazy ST changes but something like half of all patients who have an AMI present with normal physical examination and/or normal ECG.

There is no one test that is specific and sensitive enough to rule in or out an MI especially in pre-hospital without blood tests and angiography.  

A provisional diagnosis must take into account all the findings from history, assessment and a good quality 12 lead ECG.  

If there is not a very clear and very obvious non-cardiac cause for somebody who has chest pain and they have cardiovascular risk factors (e.g. age, hypertension, hypercholesterolaemia, previous MI/IHD, diabetic, smoker, obese etc) then they are getting transported.


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## Christopher (Nov 28, 2012)

Clare said:


> You can make a provisional diagnosis of MI yes but such a diagnosis is subject to confirmation.
> 
> It's not hard to go "I think you are having an MI" if you're doubled over with chest pain, grey as a winter cloud and having crazy ST changes but something like half of all patients who have an AMI present with normal physical examination and/or normal ECG.
> 
> ...



Is "provisional diagnosis" somehow not "rule in"? I wouldn't give ASA or NTG if I didn't "rule in" ACS. I'm not quite sure what you're trying to say here.

(And I wasn't talking about frank ST/T-wave changes, 1mm+ in 2+ leads isn't a tough call and is a poor definition for "ruling in" or "ruling out" an MI.)


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## Aidey (Nov 28, 2012)

n7lxi said:


> True aidey. It seems like many of my chest pain calls are the result of an over active imagination fueled by the "I'm having a heart attack" bayer aspirin commercials.
> 
> But, I always err on the side of caution.



Or they are people who have figured out that "chest pain" is one of the magic phrases that gets people there faster. Or the people who were led there by the non EMD dispatch center during their triage of the 911 call. Sorry dispatch, but "My upper chest hurts from throwing up" is not a delta chest pain call.


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## Christopher (Nov 28, 2012)

Aidey said:


> Or they are people who have figured out that "chest pain" is one of the magic phrases that gets people there faster. Or the people who were led there by the non EMD dispatch center during their triage of the 911 call. Sorry dispatch, but "My upper chest hurts from throwing up" is not a delta chest pain call.



And if it isn't Delta traffic chest pain it is 6-D-1 because they're having trouble breathing...because they're puking...


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## usalsfyre (Nov 28, 2012)

Clare, I think you're getting hung up on terminology here. Not an unusual thing, but just understand "provisional" doesn't really offer any protection.

I practice medicine and make diagnosis every time I'm on the truck. It may have some warm a d fuzzy "provisional", "field", "working" ect in front of it but it is a diagnosis. A LOT of patients get admitted from the ED doc with a diagnosis as vague as "short of breath".


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## Clare (Nov 28, 2012)

Christopher said:


> Is "provisional diagnosis" somehow not "rule in"? I wouldn't give ASA or NTG if I didn't "rule in" ACS. I'm not quite sure what you're trying to say here.



I guess I am agreeing with you that yes, you can "rule in" an MI but that you cannot rule one out just because the chest pain is only reproducable upon palpation.



usalsfyre said:


> Not an unusual thing, but just understand "provisional" doesn't really offer any protection.
> 
> I practice medicine and make diagnosis every time I'm on the truck. It may have some warm a d fuzzy "provisional", "field", "working" ect in front of it but it is a diagnosis. A LOT of patients get admitted from the ED doc with a diagnosis as vague as "short of breath".




I am not saying it does offer any protection; a provisional diagnosis is something I've made plenty of so no problem there; if you cannot find a cause of their chest pain that is very obviously not cardiac then they have myocardial ischaemia until proven otherwise and should be taken to the hospital for further evaluation.


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## usalsfyre (Nov 28, 2012)

Christopher said:


> And if it isn't Delta traffic chest pain it is 6-D-1 because they're having trouble breathing...because they're puking...



Dispatch:"Are you having any problems breathing"

Caller:"Well my nose is a little stuffy..."

Dispatch "OMG DELTA LEVEL CALL"

Thank you EMD...


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## Aidey (Nov 28, 2012)

usalsfyre said:


> Dispatch:"Are you having any problems breathing"
> 
> Caller:"Well my nose is a little stuffy..."
> 
> ...



Urgh... Our main dispatch center doesn't use normal EMD. They have their own in house developed version, and all sorts of stuff gets coded as a delta that would be Charlie under normal EMD standards.


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## Christopher (Nov 28, 2012)

Clare said:


> I guess I am agreeing with you that yes, you can "rule in" an MI but that you cannot rule one out just because the chest pain is only reproducable upon palpation.



Yep.

"Ruling out" is a tricky subject. You have to talk about pre-test probabilities and likelihoods and risk assessments (PERC? EMS don't need no steenkin PERC) which we were never properly educated about.

Which unfortunately is why lots of seemingly obvious non-ACS "chest pain" patients still get 324mg ASA, an IV, and a "trial" of NTG in the field.


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## Clare (Nov 28, 2012)

Christopher said:


> "Ruling out" is a tricky subject. You have to talk about pre-test probabilities and likelihoods and risk assessments (PERC? EMS don't need no steenkin PERC) which we were never properly educated about.
> 
> Which unfortunately is why lots of seemingly obvious non-ACS "chest pain" patients still get 324mg ASA, an IV, and a "trial" of NTG in the field.



I haven't heard of PERC?

For somebody to get GTN they should have no obvious non-cardiac cause for their chest pain as well as findings that are consistent with myocardial ischaemia.  If I am seriously in doubt and it's 50/50 as to whether somebody has myocardial ischaemia then they will probably get 0.4 mg of GTN as a "tester".

You must not assume that a "good" response to GTN means it is cardiac chest pain as it might just be a placebo effect.

If somebody has "chest pain" or "chest tightness" but a normal ECG and no history that is significant for MI risk factors or prevoking events then they aren't getting GTN from me.

At the end of the day 0.4 mg of GTN is not going to kill them, might make them a bit light headed or give them a headache but it should not be given if not indicated.  

In saying all of that I am not overly convinced there is a significant role for GTN in a MI; it is a treatment for angina and not MI.  It might help a bit by reducing preload but certainly aspirin has been shown to be far more beneficial.  

Now as for putting in an IV, I was once told to put an IV into everybody I thought was having a cardiac event to save having to do it when they arrested.


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## Christopher (Nov 29, 2012)

Clare said:


> I haven't heard of PERC?



Pulmonary Embolism Rule-Out Criteria usually thrown in with Wells' Score. Which are great tools...if the patient meets the appropriate pre-test probability of having a PE ;-) Often, simple clinical gestalt is as accurate; but that'd get you in trouble if you "miss" something.



Clare said:


> For somebody to get GTN they should have no obvious non-cardiac cause for their chest pain as well as findings that are consistent with myocardial ischaemia.  If I am seriously in doubt and it's 50/50 as to whether somebody has myocardial ischaemia then they will probably get 0.4 mg of GTN as a "tester".
> 
> You must not assume that a "good" response to GTN means it is cardiac chest pain as it might just be a placebo effect.
> 
> ...



My gripe was more with the lock-step protocol adherence I often see due to a lack of an education to make a better decision.



Clare said:


> Now as for putting in an IV, I was once told to put an IV into everybody I thought was having a cardiac event to save having to do it when they arrested.



Meh, I fall into the Palin camp on this one...Drill baby! Drill!


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## Clare (Nov 29, 2012)

Christopher said:


> Meh, I fall into the Palin camp on this one...Drill baby! Drill!



Given the progressive deemphasis of IV access and IV drugs in primary cardiac arrest (they are now a very low priority) I wouldn't be overly quick to put in an IO unless three IV attempts have failed, including the foot and external jugular.  

For somebody who has arrested due to asthma, anaphylaxis or hypovolaemia and needs adrenaline or fluid very promptly then yes I would be a bit quicker.


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## DrParasite (Nov 29, 2012)

Christopher said:


> And if it isn't Delta traffic chest pain it is 6-D-1 because they're having trouble breathing...because they're puking...


According to ProQA, it's not: it's a 6-C-1 or 2, because they are not breathing normally while puking..... 

when asked of the instructor, the response was "we would rather over dispatch than under dispatch."

As for the OP, check out these articles by reputable people:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC549654/

http://www.aafp.org/afp/2005/1115/p2012.html

http://jama.jamanetwork.com/article.aspx?articleid=201900

http://sfghed.ucsf.edu/Education/Lectures/Syllabus/ChestPain.pdf

I know many paramedics that still do the reproducible chest pain = not cardiac related, and have done it myself.  that being said, the studies show it isn't as accurate as the providers seem to think.


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## Shishkabob (Nov 29, 2012)

Clare said:


> You can make a provisional diagnosis of MI yes but such a diagnosis is subject to confirmation.



I make a diagnosis.  I don't make a 'provisional diagnosis'.  I don't make a 'working diagnosis'.  I don't make a 'field diagnosis'.  I may have a differential diagnosis to get to my decision, but I diagnose. 

Just because it may end up changing in the end doesn't make it any less of a diagnosis.  




You have a patient with an angulated piece of solid white material sticking out of their leg after an MVC.  Is it a compound fracture?  A patient's arm is separated from the rest of the body.  Is it an amputation?  CAREFUL!  That would be diagnosing something!


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## KellyBracket (Nov 29, 2012)

Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary? 

Google wasn't as helpful as it usually is!


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## Clare (Nov 29, 2012)

KellyBracket said:


> Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?
> 
> Google wasn't as helpful as it usually is!



I have no idea, I've never heard that.

A Physician makes a medical diagnosis,
A Nurse makes a nursing diagnosis,
A Paramedic makes a provisional diagnosis,
A Mechanic makes a mechanical diagnosis ... 

Each of those is a diagnosis but they may be different than each other depending upon the type of diagnosis being made; certainly a medical and nursing diagnosis differ but the Paramedics provisional diagnosis and the Physicians medical diagnosis may be the same or differ too depending on what is found but they are both for all intents and purposes a diagnosis.


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## Aidey (Nov 29, 2012)

KellyBracket said:


> Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?
> 
> Google wasn't as helpful as it usually is!



No idea, but some people will defend that myth until they hyperventilate themselves out.


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## RocketMedic (Nov 29, 2012)

KellyBracket said:


> Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?
> 
> Google wasn't as helpful as it usually is!



Poorly trained EMS leadership, doc. Poorly trained and undereducated leadership.


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## TomB (Nov 29, 2012)

KellyBracket said:


> Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?
> 
> Google wasn't as helpful as it usually is!



Generally speaking (and I know this view isn't popular) I do not believe that paramedics diagnose. We treat a "field diagnosis" at best. You could argue that every diagnosis is a "working diagnosis" subject to change based on new information but the reality is that a paramedic's education is not based on developing a differential diagnosis. It's a technician education and while I wish it was different we just don't have enough education to "know what we don't know" unless we've done a huge amount of aftermarket education or self study. If we could really diagnose then we wouldn't see so many studies showing we can't even predict who needs to be seen in the emergency department and who can be left on scene safely (one of the most glaring failures of paramedic education in the United States). After 15 years in the field full time and 17 years as a paramedic (including one year in a stepdown unit and experience working in 2 different emergency departments) there are some things I can diagnose but many other situations where I'm happy to leave the definitive diagnosis and treatment to physicians. It doesn't bruise my ego in the slightest. I really don't care if we're technicians. I just want us to be really good ones and do the right thing for the patient. I actually think you can be a technician who exercises sound clinical judgment (what should I do, what should I not do).


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## mycrofft (Nov 29, 2012)

*I skimmed the comments and many had merit, but I liked this one best*



Clare said:


> I have no idea, I've never heard that.
> 
> A Physician makes a medical diagnosis,
> A Nurse makes a nursing diagnosis,
> ...



And every one except the top one is based on a protocol rooted in the top one. ANy valid protocol below MD which starts with the name of a diagnosis instead of a sign or anatomic area (e.g., "MI", instead of "Chest Pain" or "Chest" or "Thorax") is also invalid as it presupposes the practitioner has already made a medical diagnosis.
===============================================
Back on track:

OP: any question which relates one s/s  as THE certain indicator of a condition, especially for protocol-driven practitioners, is invalid.

 Think of it as Venn diagrams (intersecting circles? Remember?). Each sign and symptom is a circle (list of s/s), and where most of them intersect indicates the likely diagnosis, or the applicable protocol/action. Remember it is not certain, and pts often have more than one problem, plus historians can influence histories.

OK, you're a day's hike from help at an expensive rental and your significant other c/o chest pain. You can instantly drop everything and carry them to help, or consider the following:

1. VS including rate, regularity and quality of apical and palpated pulses and respirations; plus chest auscultation.
2. Palpate costochondral areas firmly but not hard to elicit tenderness, malformation or crepitus; ditto thoracic spine . If you don't know what costochondral area is, skip it, and tend towards transport.
3. Observe for bruising, lumps, foreign objects, asymmetries, shifts. 
4. Observe for SOB, pallor or cyanosis, air hunger, guarding.
5. Observe for level of energy and affect (tired/discouraged/scared?).
6. Ask about hx of indigestion, belching, similar earlier episodes, any earlier dx. If so, do these episodes get better with eating, antacids, sitting up? Worse with swallowing? Worse or better with position of neck/head, arms? Worse with a deep breath?
7. ASK what the pain felt like: zipping, tearing, electric shock, sudden or slow onset, sudden or slow recession, or is it ongoing?

And some others. NO mention of a pulse ox, labs, ekg.

These presume you have the knowledge base (didactic and practical), the confidence to use your senses, and are not in a situation where you are bound by protocol to act in a certain manner.

And you could STILL have your loved one keel over and die in your arms.

Tenderness of the chest does not rule-out MI. Tenderness reproducing the exact sensation plus normal s/s and VS means it makes the picture look more optimistic. Follow your protocols and learn.:angry:

EDIT: Well, I thought of one; absence of breathing for over three minutes is presuptive for respiratory failure. The differential gets sticky, but safety, airway and BVM is indicated STAT.


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## Clare (Nov 29, 2012)

mycrofft said:


> And every one except the top one is based on a protocol rooted in the top one. ANy valid protocol below MD which starts with the name of a diagnosis instead of a sign or anatomic area (e.g., "MI", instead of "Chest Pain" or "Chest" or "Thorax") is also invalid as it presupposes the practitioner has already made a medical diagnosis.



This makes absolutely no sense to me whatsoever.

A medical diagnosis is made by a Doctor, a nursing diagnosis is made by a Nurse, a provisional is made by a Paramedic.  They are all inherently the same but inherently different and serve different purposes but are made after collecting a history, signs and symptoms, results of investigations etc and drawing upon a base of knowledge which may be anatomical, physiological, pathological, microbiological, psychological and/or a few others or likely all of them.

You cannot use a "protocol" to make a diagnosis.  

A Nurse does not need a Doctor to make a nursing diagnosis, a Doctor does not need a Nurse to make a medical diagnosis, a Paramedic does not need a Doctor to make a provisional diagnosis and a Mechanic does not need a Vet to make a mechanical diagnosis.  They are completely independent of one another.

To say that only a Doctor makes a diagnosis is very narrow minded.  If the patient is immediately referred to a Doctor then the Doctor will make his medical diagnosis however that has no bearing on what the provisional diagnosis of the Paramedic was or how or if the Paramedic will treat the patient, the two are for all intents and purposes totally separate.


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## VFlutter (Nov 29, 2012)

But what about PA/NP do they make semi medical diagnosis? lol


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## Aidey (Nov 29, 2012)

Clare said:


> This makes absolutely no sense to me whatsoever.
> 
> A medical diagnosis is made by a Doctor, a nursing diagnosis is made by a Nurse, a provisional is made by a Paramedic.  They are all inherently the same but inherently different and serve different purposes but are made after collecting a history, signs and symptoms, results of investigations etc and drawing upon a base of knowledge which may be anatomical, physiological, pathological, microbiological, psychological and/or a few others or likely all of them.
> 
> You cannot use a "protocol" to make a diagnosis.



I'm pretty sure what he is saying is that in order to pick a protocol to follow you have to have come up with a diagnosis.


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## TheLocalMedic (Nov 29, 2012)

I personally feel that a lot of people get "hung up" on making a diagnosis on a call.  Often there's a lot of glaringly obvious evidence that points to a diagnosis, but even if there isn't, then so what?  I can just as thoroughly diagnose a patient as a doctor can, but the difference I see is that I just don't have the same tools to use to confirm the said diagnosis.  And I caution people about being too quick to try and diagnose, or to make symptoms try and fit what you are leaning towards.  Trying to diagnose everyone can quickly lead you to putting on blinders about other symptoms that might point to multiple problems or shift your entire diagnosis.  

But I digress...

As to the original question about palpating a chest to rule out MI:  I feel that, in general, if someone has a vague complaint of chest pain that's tender to palpation and there are no other symptoms or clinical findings that may indicate ischemia, then it's a pretty safe bet that what they are experiencing isn't an MI.  Granted, if you push hard enough you'll elicit a reaction in just about anyone, but a reasonable amount of pressure producing pain seems to almost certainly to rule the problem as musculoskeletal.


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## VFlutter (Nov 29, 2012)

TheLocalMedic said:


> I can just as thoroughly diagnose a patient as a doctor can, but the difference I see is that I just don't have the same tools to use to confirm the said diagnosis



No, no you can not. Why does this "I am just as good as the doctor" crap keep coming up. Are you better than a MD since you do the same :censored::censored::censored::censored: only in the back of a speeding ambulance without all them fancy tools?


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## TheLocalMedic (Nov 29, 2012)

ChaseZ33 said:


> No, no you can not. Why does this "I am just as good as the doctor" crap keep coming up. Are you better than a MD since you do the same :censored::censored::censored::censored: only in the back of a speeding ambulance without all them fancy tools?



Don't be condescending.  Are you telling me that you can't or won't diagnose a patient because you aren't good enough?  As I said before, many diagnoses are fairly easy to come to, and I can make that diagnosis just as easily as a physician can.  I don't argue that I'm "just as good as the doctor" because our jobs are inherently different both in the amount of training we require and the resources we have available to us.  But that doesn't stop me from being a good practitioner and calling 'em as I sees 'em.


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## MediMike (Nov 29, 2012)

Chase I think you're overreacting a bit here.  There are certain obvious things that can be diagnosed the same as a doctor could.  I doubt LocalMedic was saying he could offhand call nonketotic hyperosmolar hyperglycemia off a set of vitals and a monitor, but if you are telling me that you aren't able to identify a simple fx, STEMI, or hypoglycemia well enough to call it a "diagnosis", well I think we're just arguing semantics.


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## VFlutter (Nov 29, 2012)

TheLocalMedic said:


> Don't be condescending.  Are you telling me that you can't or won't diagnose a patient because you aren't good enough?  As I said before, many diagnoses are fairly easy to come to, and I can make that diagnosis just as easily as a physician can.  I don't argue that I'm "just as good as the doctor" because our jobs are inherently different both in the amount of training we require and the resources we have available to us.  But that doesn't stop me from being a good practitioner and calling 'em as I sees 'em.



I would like to think I am very competent at diagnosing medical conditions in certain specific populations. Yes, it is fairly easy to diagnoses that small population of common acute and chronic conditions that makes up the  majority of EMS calls. I am sure that you can diagnoses that typical MI patient just as easily as a physician can. But outside of that population many us, including me, would be totally out of our league unless the diagnosis slapped us in the face. It is that population with atypical or non specific symptoms, non textbook presentation, mimics,  complex multisystem dysfunction, or rare disease processes that require a physician's advanced education and experience. 

That is nothing against you as a practitioner. You are not expected to be a the level of a physician with a decade of education and I am sure you are very good at your job however when I read "I can diagnoses just as easily as a physician" I take that as you comparing yourself to them. Maybe I am just cynical.


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## Akulahawk (Nov 29, 2012)

ChaseZ33 said:


> I would like to think I am very competent at diagnosing medical conditions in certain specific populations. Yes, it is fairly easy to diagnoses that small population of common acute and chronic conditions that makes up the  majority of EMS calls. I am sure that you can diagnoses that typical MI patient just as easily as a physician can. But outside of that population many us, including me, would be totally out of our league unless the diagnosis slapped us in the face. It is that population with atypical or non specific symptoms, non textbook presentation, mimics,  complex multisystem dysfunction, or rare disease processes that require a physician's advanced education and experience.
> 
> That is nothing against you as a practitioner. You are not expected to be a the level of a physician with a decade of education and I am sure you are very good at your job however when I read "I can diagnoses just as easily as a physician" I take that as you comparing yourself to them. Maybe I am just cynical.



When it comes to a certain narrow set of problems, I can diagnose as well as a physician. Outside of a certain set of problems, however, I'm well out of my depth, and I know it. There have been times that I've handed the diagnosis to the doc on a platter... just because the patient's problem fell within my narrow area of expertise. Those times have been rare though. Most of the time, I try to figure out what I can do for my patient and go from there, and let the Doc do the diagnosing.


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## JPINFV (Nov 29, 2012)

usalsfyre said:


> I practice medicine and make diagnosis every time I'm on the truck. It may have some warm a d fuzzy "provisional", "field", "working" ect in front of it but it is a diagnosis. A LOT of patients get admitted from the ED doc with a diagnosis as vague as "short of breath".



Umm, how is a "working diagnosis" supposed to be warm and fuzzy? Even physicians work with a working diagnosis when there are differentials that haven't been cleared yet.


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## JPINFV (Nov 29, 2012)

TomB said:


> Generally speaking (and I know this view isn't popular) I do not believe that paramedics diagnose. We treat a "field diagnosis" at best. You could argue that every diagnosis is a "working diagnosis" subject to change based on new information but the reality is that a paramedic's education is not based on developing a differential diagnosis.


How is a diagnosis any different from a conclusion based on the facts at hand?



> It's a technician education and while I wish it was different we just don't have enough education to "know what we don't know" unless we've done a huge amount of aftermarket education or self study. If we could really diagnose then we wouldn't see so many studies showing we can't even predict who needs to be seen in the emergency department and who can be left on scene safely (one of the most glaring failures of paramedic education in the United States).



While I agree completely with the 'this is where we're at, and I wish it was different' thought, if we were to take the technician education to it's logical conclusion, than paramedics should be expected to follow cookbook protocols without thought. How can any branch be taken based off of judgement if the paramedic isn't making a conclusion based off of the assessment? How is that conclusion anything but a diagnosis? Sure, the number of cards, to steal from a column from Kelly Grayson, that a paramedic and a physician has to choose from and the amount they are holding (i.e. number of differential diagnoses considered) might be different, but that doesn't change the fact that at it's core a diagnosis is a conclusion. Is a primary care physician less of a physician because his diagnosis might not be as complex or specific as a specialists? 



> I actually think you can be a technician who exercises sound clinical judgment (what should I do, what should I not do).



I think that the very nature of the difference between a technician and a professional makes the ability of a technician to do any meaningful judgement very limited.


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## mycrofft (Nov 29, 2012)

I'm not commenting further because the OP is sidetracked into an EMT Black Hole.

Oh, what the heck. 

OK nursing diagnosis : "Pt is experiencing a *deficit in oxygenation* as indicated by (S/S 1,2 3). Nursing interventions are  X Y Z"(pt postiion of comfort, check oxygen delivery if any orders, check oxygenation meters if any, notify MD or some such).

Versus "*CHF* as indicated by rales, altered BP (criteria), c/o breathlessness, swelling of dependent extremities (ankles, feet). Start O2 at 3 LPM via NRB,  IV SNS TKO, etc etc".

No specialty other than MD (and PA/ FNP  working under overview of MD) can make a diagnosis of what disease process is active then make a plan and treat. Paramedics and other technicians (and nurses) when not executing direct MD orders are following protocols or standardized procedures  which are written by MD-moderated bodies. 

You can make _any_ diagnosis you want or _as many_ as you want, but as sure as 5=4*, your actions must reflect what you see as related to a_ protocol_, unless you are stumped, then you are on your own. Most incident review boards will decide you failed to detect (for whatever reason) significant s/s which would have put you on the right protocol.
====================================

*To refresh EMTLIFE veterans, "5=4": 

1. Spell any number  ("twenty")
2. Count the letters (6)
3. Spell the number of letters (three)
Repeat until you work your way down to between one and ten, (except seven and eight, which require an extra step), and it always boils down to "four"/4.

Ergo, "5=4" means "Machs Nix", or "it all boils down to this again and again".


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## JPINFV (Nov 29, 2012)

Clare said:


> A medical diagnosis is made by a Doctor, a nursing diagnosis is made by a Nurse, a provisional is made by a Paramedic.  They are all inherently the same but inherently different and serve different purposes but are made after collecting a history, signs and symptoms, results of investigations etc and drawing upon a base of knowledge which may be anatomical, physiological, pathological, microbiological, psychological and/or a few others or likely all of them.




A paramedic's diagnose and a physician's diagnosis is inherently similar. A nursing diagnosis bears no similarity to a physician's diagnosis.


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## mycrofft (Nov 29, 2012)

Damned skippy.


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## Clare (Nov 29, 2012)

mycrofft said:


> You can make _any_ diagnosis you want or _as many_ as you want, but as sure as 5=4*, your actions must reflect what you see as related to a_ protocol_, unless you are stumped, then you are on your own. Most incident review boards will decide you failed to detect (for whatever reason) significant s/s which would have put you on the right protocol.



This makes no sense to me.  

A patient with enough signs and symptoms of X problem +/- a history of factors which may increase risk of, or are consistent with, X problem will get whatever the treatment for X problem is but surely you do not treat every patient you go to with some sort of procedural or drug intervention?



JPINFV said:


> A paramedic's diagnose and a physician's diagnosis is inherently similar. A nursing diagnosis bears no similarity to a physician's diagnosis.



Allow me to clarify; all diagnoses are identification of problems based upon a set of symptoms or other such presentation and results of investigations so in that sense they are all the same.


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## mycrofft (Nov 29, 2012)

Clare,

"A patient with enough signs and symptoms of X problem +/- a history of factors which may increase risk of, or are consistent with, X problem will get whatever the treatment for X problem is..."

_YES_, exactly, _as dictated by a protocol/ st proc_. A MD could do something (s)he read that morning in a journal, use a drug off-label, even decide the pt is a phony and chew them out all the way to the lobby. IF a technician violates the protocol, it had better be _good_. A MD treats based upon the _diagnosis_; the technician treats based upon the _s/s _because the decision step in diagnosing is denied techs/nurses due to the level of training leading to certification/licensure.

"... but surely you do not treat every patient you go to with some sort of procedural or drug intervention?"

Correct, no s/s=no tx.


You got it! I just bug people when I get on that soapbox.

Now, I remember tossing DX back and forth with receiving ED people, but when it came time to write the report, unless I had their dx in hand, my working dx (like a working hypothesis; we didn't have protocols when dinosaurs roamed the streets) stayed off the run report.


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## TomB (Nov 30, 2012)

ChaseZ33 said:


> But what about PA/NP do they make semi medical diagnosis? lol



I think they do, yes. But their training is completely different from a paramedic's education. Paramedics want all of the respect of being "clinicians" without any of the appropriate education and training. You can't have it both ways.


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## medicsb (Nov 30, 2012)

It is interesting that X amount of MIs are reproducible as it doesn't make sense from a anatomic and physiologic stand-point.  I've seen (read) it proposed that "reproducible" nature of CP in an MI patient may be due to poor communication either by the patient or the physician, poor interpretation of physical findings, or concomitant chest wall pain with MI.  Obviously if you push hard enough on anyone's chest, it will hurt.  The question to be asked very specifically is the pain felt upon palpation the same pain they have been feeling or is it different?  Is there an underlying pain AND a chest wall pain?  (Seen that; underlying pain resolved w/ NTG but not the chest wall pain.)  Also, to be considered is leading the patient or the patient answering in a way they think cardiac chest pain may be like.  

I did once have a patient with seemingly reproducible CP, it worsened with deep inspiration and arm movement (I do not remember if I assessed for chest wall tenderness) who apparently suffered a syncopal episode at the start of her night shift.  Me and my partner were leaning towards it not being cardiac (possible malingering) except for the fact that she diaphoretic.  12 lead showed an Inferior STEMI w/ R ventricular involvement.  She was relatively young, too.  

Ultimately, the LR of reproducibility by palpation ranges from 0.21-0.41 based on 6 studies with sample sizes 492 to 7734.  LR for pain related to breathing is 0.20 - 0.36 (3 studies encompassing >8200 patients).   (See this recent meta-analysis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490454/)

Anyhow, I think it reasonable to triage to BLS for transport if the 12 lead is without STE or ischemic changes and the physical exam is otherwise benign.  (I wouldn't deny transport.)  At that point it becomes the job of a physician to determine a cause.


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## zmedic (Nov 30, 2012)

medicsb; said:
			
		

> Anyhow, I think it reasonable to triage to BLS for transport if the 12 lead is without STE or ischemic changes and the physical exam is otherwise benign.  (I wouldn't deny transport.)  At that point it becomes the job of a physician to determine a cause.



Not sure if I agree with this. Half of the point of ALS if for those patients who don't need an immediate ALS intervention, but have a decent probability of needing an intervention enroute to the hospital. I'd say patients with chest pain generally should be transported by ALS, even with a normal ECG. What is an EMT going to do if the patient's chest pain worsens enroute to the hospital? A medic could do another 12 lead and think about giving some nitro. What if the patient start having arrythmias? I'd rather a medic be in back with the patient on monitor. 

Sure there are exceptions. You might say a 21 yo with no risks factors and no cocaine use who has some chest pain might not need ALS. But generally if someone was suspicious enough of this chest pain to either dispatch ALS in the first place or call for an intercept, you have to be really careful downgrading it to BLS. What's the worst that happens if ALS takes it in and it was nothing? You are out of service for a bit. But if you turff it to BLS and something happens....just doesn't look very good. 

Keep in mind ECG changes can take awhile to develop. A normal ECG that you get 15 minutes after the patient starts having pain doesn't reassure me a whole lot.


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## KellyBracket (Nov 30, 2012)

Observation and a suggestion:

First, the issue of _who_ can diagnose is not quite as thorny and confusing as _what_ a diagnosis is. 

In all seriousness, there are a number of people interested in the "philosophy of medicine," and the topic of what constitutes a diagnosis is a healthy area of discussion. Even *ER doctors *discuss this. Historians of medicine are also quick to point out the shifting uses of the term over the centuries, as well as shifting bases for diagnosing. One thing I _haven't_ heard stated, however, is that "only physicians can diagnose." On the contrary...



> [A]lthough diagnosis ordinarily has medical connotations, this is not essential, for the term involves activities by no means unique to medicine. Although we may think of diagnosis as the identification of disease, such usage is far too narrow. *Lester S. King*



I.e. diagnosis is a human process, and should not be thought of as limited to the mythical scientist-physician. Instead, it is an act of pattern recognition, and active evidence collection, based in innumerable cultural and conceptual biases. And just like a lot of things that all humans do, it's often messy, and we don't talk about the process in public much! 

So here is my proposal - *stop using the words diagnosis/diagnosing/diagnostic*. Instead, simply say what is going on! 

With this method, controversial statements are avoided, and clarity is supported. For example, instead of "I diagnosed an MI," instead say "He was complaining of chest pain, and the ECG showed a STEMI-pattern." Or instead of "I diagnosed CHF," instead state "He was hypoxic, and my initial exam found rales and pronounced JVD."  Both of these statements could be made by a medic or doctor, and both contain far more information if the root "diagnos-" is avoided.

Forgive me an additional extended quotation, but I particularly like this one. Understand that Dr King is a pathologist interested in the the medical philospohy of the 1700s and early 1800s. Why, then, does it seem to apply so well to this discussion? 



> "Scientific medicine lies not in formidable apparatus nor the myriads of available tests, nor in overflowing libraries, but in that stil small voice that I call critical judgment. This voice asks the important questions: 'Do you see a pattern clearly? How good is your evidence? How sound is your reasoning? Can you support your inferences with the means at your disposal? What are the alternatives? What hangs on your decision?' This voice, I believe, goes to the heart of scientific medicine. It has been speaking throughout the ages, but physicians do not always listen. And those who do not listen are empirics, regardless of the technical facilities at their command." *Lester S. King*


(N.B. "empirics" is another way to say "technician.)


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## medicsb (Nov 30, 2012)

zmedic said:


> Not sure if I agree with this. Half of the point of ALS if for those patients who don't need an immediate ALS intervention, but have a decent probability of needing an intervention enroute to the hospital. I'd say patients with chest pain generally should be transported by ALS, even with a normal ECG. What is an EMT going to do if the patient's chest pain worsens enroute to the hospital? A medic could do another 12 lead and think about giving some nitro. What if the patient start having arrythmias? I'd rather a medic be in back with the patient on monitor.



But, what is the "decent probability" of a CP patient with reproducible CP or CP with respiration needing ALS intervention during transport?  I'd bet that it is <1%.  I've transported hundreds of isolated CP patients, and even counting the ones I treated with (M)ONA, I can count on one hand the number that required immediate intervention due to a sudden deterioration  aside from fluid bolus for hypotension s/p NTG.  



> Sure there are exceptions. You might say a 21 yo with no risks factors and no cocaine use who has some chest pain might not need ALS. But generally if someone was suspicious enough of this chest pain to either dispatch ALS in the first place or call for an intercept, you have to be really careful downgrading it to BLS.



I haven't said you don't need to be careful, but I'd say that generally speaking, the sort of CP being discussed it largely low risk.  I'm not saying that there is no need for ALS to ride with patients based on "what if", but shouldn't we have some sort of idea which patients those are, based on something other than a hunch? 



> What's the worst that happens if ALS takes it in and it was nothing? You are out of service for a bit. But if you turff it to BLS and something happens....just doesn't look very good.



Well, the worst is that the patient receives an unnecessary IV and develops septic thrombophlebitis and dies.  Far fetched, but it is not outside the realm of possibility.  Other possibility is that in a system with few ALS resources a patient that does need ALS intervention has to wait longer for it because ALS is riding in a a low risk patient because of some distant "what if" scenario.  And then there is the cumulative healthcare cost associated wide-spread practice of ALSing patients needlessly (EMS should start policing itself, because the govt soon will - already heard of EMS' getting audited and questioned why so many patients are receiving IVs).  Anyhow, anything can look "bad".  Doesn't mean anything wrong was done. As an EM doc, I'm sure you know that all too well.  I'm not convinced based on that argument.



> Keep in mind ECG changes can take awhile to develop. A normal ECG that you get 15 minutes after the patient starts having pain doesn't reassure me a whole lot.



I'm well aware, which is why you would do another 12 lead when the patient arrives and then 3-4 hours later if negative.  Had you seen the patient when EMS did, would you be doing a 12 lead every 5 minutes just in case?


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## medic417 (Nov 30, 2012)

And the obvious solution is all ambulances be staffed by Paramedics only.


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## zmedic (Nov 30, 2012)

medicsb; said:
			
		

> But, what is the "decent probability" of a CP patient with reproducible CP or CP with respiration needing ALS intervention during transport?  I'd bet that it is <1%.  I've transported hundreds of isolated CP patients, and even counting the ones I treated with (M)ONA, I can count on one hand the number that required immediate intervention due to a sudden deterioration  aside from fluid bolus for hypotension s/p NTG.



By this argument anyone who doesn't get ALS interventions on scene probably can be taken to the hospital by BLS. The vast majority of ALS calls don't get actual ALS treatment (ie meds or fluids or intubation), but as a system we say "patient's with x complaint are still ALS even if all we do is monitor them."

I'm just saying you've got to be careful downgrading patients to BLS. And if someone actually has an ALS type complaint (chest pain, altered mental status, GI bleeding) they should generally be transported by an ALS provider. If you've been able to risk stratify them in a very clear way by all means downgrade them. But that shouldn't be done just based on a normal ECG.  It should be someone that you could stand in front of your medical director and say "this patient did not need continuous ECG monitoring, there was almost no chance of needing IV medications, and based on our protocols I felt safe having BLS transport." 

Note the last part of the statement. It's very based on your system. Some systems say "all chest pain gets a medic to ride with them." Others give you more leeway. Do what's right for the patient and you'll never get in trouble. So be sure in your mind that it's not in a given patient's best interest to have a medic bring them in.


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## KellyBracket (Nov 30, 2012)

medic417 said:


> And the obvious solution is all ambulances be staffed by Paramedics only.



Well, that's the direction taken by some services. Or even physician only, as with the SAMU system in France.

*Zmedic*, I would only point out one thing: Medics can diagnose, but OEC? I'm not so sure!


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## medicsb (Nov 30, 2012)

medic417 said:


> And the obvious solution is all ambulances be staffed by Paramedics only.



Not really.


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## medicsb (Nov 30, 2012)

zmedic said:


> By this argument anyone who doesn't get ALS interventions on scene probably can be taken to the hospital by BLS. The vast majority of ALS calls don't get actual ALS treatment (ie meds or fluids or intubation), but as a system we say "patient's with x complaint are still ALS even if all we do is monitor them."



Truthfully, most probably can be taken by BLS if no ALS intervention is found to be warranted by ALS on scene.  But, I know that some do develop a need enroute, so there is a degree of over triage to ALS that is warranted, but I think the way it is typically done is not reasonable.  It's funny how only about 1 in 5 patients transported actually get any ALS intervention besides VOMIT (vitals, O2, monitor, IV, transport), yet we have ALS sent to every patient in most systems and some others are lining over 50%.  Imagine if every CP in your department was sent a cardiologist or every headache, a neurologist, and on and on.  That would be even sillier than sending a medic to every call.  Why not use the money that would be otherwise used for upgrading every ambulance to ALS for research?  Sending a medic to every call and then requiring them to ride in patients with a certain complaint regardless of the assessment shows poor trust of the medics and EMTs and is also incredibly lazy of the medical director (and EMS system in general).



> I'm just saying you've got to be careful downgrading patients to BLS. And if someone actually has an ALS type complaint (chest pain, altered mental status, GI bleeding) they should generally be transported by an ALS provider.



Heh, I'd argue that many (maybe the majority) AMS and GI bleeds are totally BLS.  For certain, most "strokes" are BLS.  But, I'll save those arguments for another thread.



> If you've been able to risk stratify them in a very clear way by all means downgrade them. But that shouldn't be done just based on a normal ECG.  It should be someone that you could stand in front of your medical director and say "this patient did not need continuous ECG monitoring, there was almost no chance of needing IV medications, and based on our protocols I felt safe having BLS transport."



I've never said anything about basing it solely on a normal ECG.  Otherwise, I agree.


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## mycrofft (Nov 30, 2012)

Haha, nothing says a cardiac pt can't have thoracic outlet syndrome or cervical plexus issues. I did, told the MD (new MD) but was ordered to the ED, which blew an afternoon and cost me nearly a grand for neck-originated pain as well as chronic a-fib.


And nothing  says a person with chronic or recurrent spinal issues/thoracic outlet syndrome can't have a heart attack.


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## DrParasite (Nov 30, 2012)

medicsb said:


> Sending a medic to every call and then requiring them to ride in patients with a certain complaint regardless of the assessment shows poor trust of the medics and EMTs and is also incredibly lazy of the medical director (and EMS system in general).


When you finish med school, can this be the title of your first published paper?





medicsb said:


> Heh, I'd argue that many (maybe the majority) AMS and GI bleeds are totally BLS.  For certain, most "strokes" are BLS.  But, I'll save those arguments for another thread.


heh, i'd argue that once a BGL is normal on an AMS person, you would be right.  ditto a GI bleed that isn't hypotensive.  And stokes (without airway compromise) are def BLS.


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## KellyBracket (Nov 30, 2012)

Well, if you go too far down that line of thinking, you end up with the "taxi-cab" model of EMS.

Just an *April Fool's* joke? Or a *serious proposal*?


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## DrParasite (Nov 30, 2012)

KellyBracket said:


> Well, if you go too far down that line of thinking, you end up with the "taxi-cab" model of EMS.


The truth of the matter is that many people who call 911 requesting an ambulance can go to the ER in a cab with no negative effects.

using the ProQA dispatch criteria, Alpha dispatches are ambulatory, and Bravos are non-ambulatory but not life threatening (or unknown statuses that can be ambulatory).  And since we know dispatchers are always 100% accurate :rofl:, we also know that just because it is dispatched as a Charlie or Delta response, doesn't mean it doesn't turn out to be a Alpha patient.

My personal experience (of urban EMS systems) would say that 60% of all EMS calls are either ambulatory, no transports (RMA or cancels), or would suffer no ill effects if they went by POV or taxi to the ER (or their PMD).  Another 25% are unable to ambulate to the POV or taxi, but once they are carried out to the ambulance, no intervention is needed until arrival at the ER.  The other 15% are either life critical calls or will require ALS interventions, or else the patient will suffer negative consequences.  Suburban calls might have a higher percentage of more serious calls due to greater accessibly to doctors offices and high percentage of insured people.

and as for the original topic, just because you have chest pain, doesn't mean you are having an MI, nor are you having ACS.  Esp if you are under 35 and showing no other symptoms.


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## JPINFV (Nov 30, 2012)

TomB said:


> I think they do, yes. But their training is completely different from a paramedic's education. Paramedics want all of the respect of being "clinicians" without any of the appropriate education and training. You can't have it both ways.


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## VFlutter (Dec 1, 2012)

jpinfv said:


>



+100000


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## usalsfyre (Dec 1, 2012)

ChaseZ33 said:


> +100000


I would SERIOUSLY refrain from commenting considering what nursing is trying to do with DNPs.

Glass houses....


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## VFlutter (Dec 1, 2012)

usalsfyre said:


> I would SERIOUSLY refrain from commenting considering what nursing is trying to do with DNPs.
> 
> Glass houses....



I don't really want to derail this thread but I am inclined to comment. So you want to compare an RN with multiple years of beside experience who has accumulated 8 years of education (4 BSN 2 MSN 2 DNP) trying to advance their clinical scope (along with a profession that as a whole is continuing to advocate increasing education standards) to a medic ,a non degree technician, wanting to be considered a "clinician" with no personal advancement in education and a profession who has little to no interest in raising educational standards? I can loosely see the comparison. 

IMHO That RN "playing doctor" has a lot more ground to stand on then the medic.  

Regardless, I do not see any reason to "SERIOUSLY refrain from commenting". Does pointing out the supposed flaws in my profession somehow change the facts or discredit my personal opinion? No matter what your opinion is of the DNP moment it does not negate truth of  the comment I was agreeing with.

I'll just sit back and continue to throw rocks in my glass house


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## NomadicMedic (Dec 1, 2012)

I'm very close to moving all of these posts and issuing some "thread jacking" infractions. This is the only warning. 

This is a "chest pain on palpation" thread. Please keep it on topic and if you choose to discuss nursing, DNP or other items, please start a new thread.


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## JPINFV (Dec 1, 2012)

[redacted]


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