"Assessment" versus "Diagnosis": what are the differences?

[mycrofft]

I know the classic divisions: techs can assess and consult, MD's and RN's* can diagnose and treat. Techs and nurses' medical treatment (other than basic safety and comfort measures and items outside medicine like mechanical extrication) stems from protocols or standardized procedures written and/or approved by MD's which specify objective findings leading to specific measures, and the qualification to attain before you can do these measures.

In the real world, do you personally feel the use of the word "diagnose" is bad in reference to the acts of evaluation then treatment without getting a case by case real time order from higher medical authority by EMT's of any level?

*"Nusing diagnosis" is a recognized term, has been organized and formalized, and is in use.

 

[firecoins]

Its called a differential diagnosis. Using a limited assessment, littles knowledge and little ability to do a whole lot, we make a working guess on whats going on. You can it a differential diagnosis which will need to be confirmed by the MDs at the receiving facility.

A real diagnosis can not be made by EMTs. Not enough info or education.

 

[Veneficus]

I don’t like the wording on the poll.

Diagnosis is using physical and history findings combined with knowledge of anatomy, physiology, pathology, and other basic sciences too numerous to list to come up with a likely "name" (aka explanation) about what is going on with a patient so one can formulate the best plan of treatment.

Some EMS providers diagnose, some just treat signs and symptoms following a cookbook. I am more fond of the former than the latter, but sadly I concede it is possible to be an EMT or Paramedic and never make a diagnosis in a career. Likewise one could diagnose every patient they ever see irrespective of title.

The more information you have, the more accurate a diagnosis can be. Certainly as a patient progresses through the levels of care more information can be gathered that help to better diagnose.

Some treatments can be effective for large time periods covering various pathologies. Some treatments have a very narrow range of time and pathologies they are effective in. Some treatments are needed to give the most accurate diagnosis. Diagnosis and treatment therefore are seemlessly connected. A truly proper treatment would require some level of diagnosis. As we know, there are many EMS providers (as well as other healthcare providers) who perform improper treatments trying to equate signs and symptoms alone. A good example is edema, there are many causes of pulmonary edema. Not all resulting from congestive heart failure. Not all respond well to loop diuretics. Sometimes the wrong treatment is harmful at some level, sometimes it does nothing, and sometimes can be effective to some level.

There are lots of qualifiers for diagnosing. “Initial diagnosis,” “working diagnosis,” “differential diagnosis,” They are simply various levels of the same behavior.

The cultures of some agencies are to be mindless laborers; in some agencies the culture is to be a critical thinking professional. About the only things both have in common is they call themselves the same title and they don’t like each other and vehemently defend their way as the one true faith.

 

[mycrofft]

I hear you Ven.

You too firecoins.

It is interesting to see the way agency protocols etc. can get twisted up versus state and county regulations, versus real world (good or bad real world).
In my experience "cookbooking" is the solid floor, and making a "working diagnosis", eval, assessment, wildarsed guess or epiphany based on solid education and experience is a bridge to selection and use of the proper protocol.

E.G.: three EMS walk up to a pt dispatched as "coughing up blood".

Nancy wants to urgently start a large bore IV, O2, C spine, and is considering MAST.

Betty spends twenty minutes doing a by the book workup with family hx and postural VS's including temp.

Annie takes VS, looks the pt over on approach and during VS, talks to him ab out whats happening/meds/etc. and looks down his throat, detects a mild retronasal bleed, finds out this is recurrent, and tells pt to go see MD if it doesn't stop in an hour. Total time: ten minutes from approach to code 4, 10-8, 10-19.

Who's right?

 

[LondonMedic]

You can it a differential diagnosis which will need to be confirmed by the MDs at the receiving facility.

Or pathologists. ^_^

I would suggest that in the absence of a definitive investigation result everyone goes on a differential, be they doctor, paramedic or first responder. As often as not that means doing an assessment, to a level of detail appropriate to the settingm forming a differential diagnosis appropriate to the setting and initiating 'best guess' treatment appropriate to the setting.

 

[LondonMedic]

E.G.: three EMS walk up to a pt dispatched as "coughing up blood".

Nancy wants to urgently start a large bore IV, O2, C spine, and is considering MAST.

Betty spends twenty minutes doing a by the book workup with family hx and postural VS's including temp.

Annie takes VS, looks the pt over on approach and during VS, talks to him ab out whats happening/meds/etc. and looks down his throat, detects a mild retronasal bleed, finds out this is recurrent, and tells pt to go see MD if it doesn't stop in an hour. Total time: ten minutes from approach to code 4, 10-8, 10-19.

None is wrong (I presume that's your point).

Annie is the obvious 'right' answer here, but her course of action here are entirely inappropriate if she doesn't have the experience, knowledge and authority (not to mention insurance) to act in that way. That also presumes that she has the ability to be certain that she has the time to do that.

 

[Veneficus]

Since all of the examples are correct treatment, I guess the question becomes who is providing the best treatment?

 

[Lifeguards For Life]

Attached is an excerpt from an article written by David W. Powers, NREMT-P, BCETS, BCECR, last year.

While I do not agree with the underlying principle behind the article, he does bring up some valid points on paramedics diagnosing.

Physician assistants are healthcare professionals licensed to practice medicine with physician supervision…PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive healthcare, assist in surgery, and in virtually all states can write prescriptions. This definition comes from the Information About PAs and the PA Profession section at www.aapa.org. As I outline the comparisons, I think you’ll see that as far as two careers in the healthcare field go, we aren’t that different.

Paramedics are also healthcare professionals licensed or certified to practice medicine with physician supervision. I know some people say we don’t practice medicine, but we do. We practice medicine under our medical control physician’s license. We conduct physical exams, except we call them patient assessments.

We also diagnose and treat illnesses. I was taught in various EMS classes that paramedics do not diagnose. If that is true, then how do we know what to treat for? If I have a patient with pain, diaphoresis and ECG changes in all the right places, I’m going to diagnose a myocardial infarction and treat accordingly. The truth is that we diagnose illnesses and injuries every day we work on an ambulance.

Here’s one where we upstage the PAs: We don’t order and interpret tests; we choose the tests we run and interpret them ourselves. Regular-duty medics run ECGs every day and interpret the strips. We run fancy tests with names like pulse oximetry, capnography and blood glucose on a regular basis. Extended-practice medics test blood gases.

We also counsel on preventive healthcare. When we have long transports or the call isn’t an emergency, we often sit beside the stretcher and talk to our patients. I’ve spoken to patients about smoking and obesity. I’ve encouraged new mothers and young babysitters to attend infant/child CPR classes. Paramedics are usually the first line in preventive healthcare, although we seldom realize it.

While certainly regular-duty paramedics don’t assist in surgery, interns in paramedic school are frequently allowed to view surgeries. Some paramedics actually perform surgical procedures as part of their job. Surgical cricothyroidotomies, chest tubes, central catheters, postmortem cesarean sections and field amputations are only some of the surgical skills that many paramedics in the United States are authorized to perform.

PAs do not even have us on the prescription medicine issue. Webster’s Dictionary defines a medical prescription as a designation or order for the use of a treatment or medicine. We are prescribing every time we give aspirin, epinephrine, morphine and so on, are we not? While we may not write prescriptions to fill at a pharmacy, we do prescribe medicines.

What about the differences between medics and PAs? The two main ones I see are education and salary.

Physician assistants are trained using the same model as doctors. This model is used because PAs work closely with physicians and for all practical purposes act for physicians in many settings. The majority of educational programs require a bachelor’s degree prior to entering. Many pre-PA students take the same pre-medical courses as aspiring doctors. Once the student graduates PA school, he is awarded a master’s degree.

Although there are many variables that go into the reasoning behind the salary gap, I see two as having the most impact: education level and place of employment. Paramedics are not required to have a degree to be certified, whereas PAs must go through an accredited degree program, often a master’s degree program. Medics are often employed in private, nonprofit or government jobs. PAs are employed in the military as officers, in hospitals and in doctor’s offices.

 

[JPINFV]

Nancy wants to urgently start a large bore IV, O2, C spine, and is considering MAST.

Betty spends twenty minutes doing a by the book workup with family hx and postural VS's including temp.

Annie takes VS, looks the pt over on approach and during VS, talks to him ab out whats happening/meds/etc. and looks down his throat, detects a mild retronasal bleed, finds out this is recurrent, and tells pt to go see MD if it doesn't stop in an hour. Total time: ten minutes from approach to code 4, 10-8, 10-19.

Who's right?

Nancy is wrong. There's no indication yet for any of those interventions. They all may be appropriate depending on the exam findings, but just because the patient is coughing up blood doesn't mean that it's a life threatening emergency. We just don't know yet.

Betty represents the ideal course of action under the current education standards and EMS treatment theory, provided there isn't any critical exam findings like hypotension.

Annie represents the ideal course of action, but may be inappropriate (especially the treat and release) for the vast majority of paramedics in the US given the current education standards.

 

[VentMedic]

Attached is an excerpt from an article written by David W. Powers, NREMT-P, BCETS, BCECR, last year.

While I do not agree with the underlying principle behind the article, he does bring up some valid points on paramedics diagnosing.

That article has described just about every health care professional from PT to RN when it comes to assessment and "prescribing" as the author is attempting to make his own interpretation. Giving medications from a protocol is not prescribing. A Paramedic does not write the order or protocol to give the medicine. The doctor has already written that for the Paramedic in the protocols. A Paramedic can not get a DEA number and does not need one any more than an RN or RRT.

Pulse oximetry is also not a definitive diagnostic tool used to make a definitive medical diagnosis.

Both PAs and NPs are true physician extenders and can make a "medical diagnosis" which a Paramedic can not. Paramedics and many other licensed professionals make a working diagnosis for treating certain signs and symptoms by protocols.

http://www.wapa.org/pdfs/np-pa_chart.pdf

While certainly regular-duty paramedics don’t assist in surgery, interns in paramedic school are frequently allowed to view surgeries. Some paramedics actually perform surgical procedures as part of their job. Surgical cricothyroidotomies, chest tubes, central catheters, postmortem cesarean sections and field amputations are only some of the surgical skills that many paramedics in the United States are authorized to perform.

I would emphasize the word "some" used at the beginning of that paragraph. Also, being allowed to "view a brain surgery" does not make one a neurosurgeon.

Although there are many variables that go into the reasoning behind the salary gap, I see two as having the most impact: education level and place of employment

He seriously missed on this one. PAs are certified providers for CMS or Medicaid and Medicare and generally receive favorable reimbursement from commercial payers. And of course the fact they do diagnose, can order many invasive tests and prescribe treatment as well as medication could be part of the salary difference. Until a Paramedic is recognized as a Physician Extender, the differences are many as is the education.

 

[mycrofft]

OK forget the three girls for a minute, they were just thought-fodder.


What exactly, without legal def's, is a diagnosis?

Personally, I'm not hung up on the terminology as long as I know who did what and their qualifications. After the podiatrist put the young lady with a broken nose and neck pain into the back seat of a Mustang and we had to board her out, I'll take info from anyone whno knows what the heck they are about.

 

[Lifeguards For Life]

What exactly, without legal def's, is a diagnosis?

Personally, I'm not hung up on the terminology as long as I know who did what and their qualifications. After the podiatrist put the young lady with a broken nose and neck pain into the back seat of a Mustang and we had to board her out, I'll take info from anyone whno knows what the heck they are about.

The process of considering the patient’s signs and symptoms, medical background and laboratory findings, to identify an underlying cause.

If you take your vehicle to a mechanic, does he diagnose mechanical problems? Does a veterinarian diagnose your pet?

Why are we taught the Cincinnati prehospital stroke scale, hunt and hess scale, the Los Angeles prehospital stroke screen, if not to aid in a rapid diagnosis of a stroke?

Is that 'diagnosis' likely to change? yes. though i am sure all of you perform the appropriate stroke screening test when warranted and transport to the appropriate facility. If you are taking a stroke patient to a stroke center, have you not 'diagnosed' a stroke?

 

[MrBrown]

Ambo's make a provisional diagnosis; no more and almost certianly less depending upon the specific ambo

 

[Veneficus]

The process of considering the patient’s signs and symptoms, medical background and laboratory findings, to identify an underlying cause.

I don't think labs are required to make every Dx.

 

[JPINFV]

Of course, because EMS can't run the highest valued medical test possible...

[youtube]http://www.youtube.com/watch?v=2BDd0XseGtU[/youtube]

 

[Lifeguards For Life]

I don't think labs are required to make every Dx.

No, not by any means. But, if those values were available and the provider was capable of interpreting them, they may aid in a quick and accurate diagnosis. I also know full well that they will never be available in the prehospital setting.

 

[MrBrown]

No, not by any means. But, if those values were available and the provider was capable of interpreting them, they may aid in a quick and accurate diagnosis. I also know full well that they will never be available in the prehospital setting.

Sssssh, don't tell Novia Scotia or Alberta who are doing field cardiac enzymes

 

[VentMedic]

If you take your vehicle to a mechanic, does he diagnose mechanical problems? Does a veterinarian diagnose your pet?

I hope you are not comparing a car to the complex systems of the human body.

I also expect my veterinarian to run whatever tests necessary to provide proper treatment for my pet.

Why are we taught the Cincinnati prehospital stroke scale, hunt and hess scale, the Los Angeles prehospital stroke screen, if not to aid in a rapid diagnosis of a stroke?

Is that 'diagnosis' likely to change? yes. though i am sure all of you perform the appropriate stroke screening test when warranted and transport to the appropriate facility. If you are taking a stroke patient to a stroke center, have you not 'diagnosed' a stroke?

The use of a scale is great to identify the possibility of a stroke to initiate some care that can be very broad for many neuro problems and not just a stroke. Hopefully it does get the patient to the appropriate center but that scale is merely the very beginning of a long process and sometimes it may not be a "stroke" at all. However, for a Stroke Center to be a Primary, it must be able to do diagnostic testing 24/7. It must also have the ability to place the patient in an appropriate unit setting even if that means sending the patient to another facility. Of course the best facility would be one that is a full service neuro center just like the best hospital for an MI would be one that can also do cardiac surgery and not just a cath lab procedure.

Stroke Center Criteria...if you are interested.
http://www.strokeassociation.org/do..._Program_Capacity_Assessment_Tool_05.2006.doc

The chest pain protocol can also be an example. It may look like an MI but there are many, many other causes that can also present with the same symptoms. Generally the initial treatment of "MI" symptoms are broad enough where they can be applied with some benefit and may not do more harm. We could also use CHF vs PNA. These two are difficult since they can actually both be present. There are also many patients that even the physicians will be working from their preliminary diagnoses (yes more than one) for many days or weeks until a definitive one is made. Some patients will generally have more than one problem as well. Without the availability of some diagnostics, it is difficult to just go by "what you see is what you got". It would really be great if all the medical problems a patient could possibly have are just the few learned in EMT or
Paramedic.

I don't think labs are required to make every Dx.

But the Paramedic's training and education does not provide enough knowledge to know if more testing is needed. If you make the obvious dx of an arm fx on a young person, would the Paramedic be able to recognize other signs and symptoms to where there might be a more serious cause for a brittle bone? If you give morphine and the pain goes away, does that mean you have fixed the MI? If you apply CPAP to a "CHF" patient and they breathe better, have you fixed the CHF? If you give albuterol to an asthmatic patient and they breathe better, have you fixed them and no more treatment or testing is required? Too often some Paramedics, I hope not that many, are led to believe if the symptoms go away with the treatments they provide in the prehospital setting, they have fixed the patient and are providing the same level of care as a physician. However, the knowledge base of the Physician will be much more extensive to know when and when not to do more testing or that alleviating a "symptom" does not fix the problem. The Paramedic also has no ability to keep that symptom from reoccurring by prescribing ongoing treatment. That is also another difference between a PA and a Paramedic.

I know it sounds like I am down on Paramedics but one should realize their limitations from the education they have gotten in a Paramedic program. If not, something can also be missed when a Paramedic attempts to place all patients within just their few "working diagnoses". It is also okay to say you don't know which protocol to initiate for some things which is why you have access to med control for advice.

 

[Veneficus]

But the Paramedic's training and education does not provide enough knowledge to know if more testing is needed. If you make the obvious dx of an arm fx on a young person, would the Paramedic be able to recognize other signs and symptoms to where there might be a more serious cause for a brittle bone?.

I do not think a paramedic has enough education to know if/when further testing is required, I was stipulating that not all Dx require lab work. Some do, others don't.

If you give morphine and the pain goes away, does that mean you have fixed the MI? If you apply CPAP to a "CHF" patient and they breathe better, have you fixed the CHF? If you give albuterol to an asthmatic patient and they breathe better, have you fixed them and no more treatment or testing is required? Too often some Paramedics, I hope not that many, are led to believe if the symptoms go away with the treatments they provide in the prehospital setting, they have fixed the patient and are providing the same level of care as a physician. However, the knowledge base of the Physician will be much more extensive to know when and when not to do more testing or that alleviating a "symptom" does not fix the problem. The Paramedic also has no ability to keep that symptom from reoccurring by prescribing ongoing treatment. That is also another difference between a PA and a Paramedic.

These are treatments to conditions, I do not see what this has to do with Dx. unless you are using the treatment to imply the Dx which in most cases is not the accepted practice for any provider.

 

[VentMedic]

These are treatments to conditions, I do not see what this has to do with Dx. unless you are using the treatment to imply the Dx which in most cases is not the accepted practice for any provider.

Actually they are treatments for the symptoms of the disease process. The CHF patient may need more diagnostics to determine the cause. The asthmatic may need steroids and/or antibiotics to treat the exacerbation. The "MI" patient will need more diagnostics to determine if it is an MI or something with very similar symptoms. Of course, since only half of ALS EMS services have 12-Lead ECG capability, that leaves out one valuable tool. Then there are a few services which do have the 12-Lead that rely solely on machine interpretation for the diagnosis.