ALS question to pt w/vomit/stool dark red blood

[socalmdx]

NO Doctors Diagnose...

is there anything in our drug boxes that will tell us why this women is bleeding? NO

We simply ask questions, fact find, look in our toolbox (a.k.a. Drug Box and Brain) and pull out what we THINK will fix the current problem! Then we will pass on any and all findings we have to a doctor so he can decide what the DIAGNOSIS is!

and we can play the what if game alllllll day!!! But you and I both know ULTIMATELY DOCTORS Diagnose! If you want to diagnose go to MED school and earn your degree and then YES you may DIAGNOSE!

 

[Lifeguards For Life]

NO Doctors Diagnose...

is there anything in our drug boxes that will tell us why this women is bleeding? NO

We simply ask questions, fact find, look in our toolbox (a.k.a. Drug Box and Brain) and pull out what we THINK will fix the current problem! Then we will pass on any and all findings we have to a doctor so he can decide what the DIAGNOSIS is!

and we can play the what if game alllllll day!!! But you and I both know ULTIMATELY DOCTORS Diagnose! If you want to diagnose go to MED school and earn your degree and then YES you may DIAGNOSE!

This argument has been made several times among varying members, and invariably always produces the same outcome. If you are so adamant that you do not diagnose, you may consider turning in your paramedic patch, resigning back to the old EMT patch, as paramedics have little business treating patients with minimally invasive procedures and pharmacological agents if they do not know why they are performing these interventions.

Why do you do perform a pleural decompression? Because you have "looked in your toolbox (a.k.a. Drug Box and Brain) and pull out what we THINK will fix the current problem! Then we will pass on any and all findings we have to a doctor so he can decide what the DIAGNOSIS is!"

You have made a diagnosis and initiated the proper treatment to correct the underlying cause.

I did recognize that this particular scenario is a purely academic pursuit, with no way to form an accurate and confirmed diagnosis in the field. however many illnesses, conditions and injuries can, and are diagnosed successfully, in the pre hospital environment every day.

 

[JPINFV]

So anaphylaxic shock, cardiogenic shock, and septic shock all get the same treatment from you? After all, all types of shock are equal, right?

Do you give Lasix to all patients with dyspnea, or only after "deciding" (read diagnosing) the patient with pulmonary edema secondary to heart failure and ruling out pneumonia.

 

[MrBrown]

One of my old lecturers use to refer to the acute abdomen as "tiger country" given there are an almost endless list of possible causes for pain, bleeding, urine/faecal issues etc. Looking for a diagnosis in this one seems like an academic exercise at best with no guarantee of getting it right.

Have you been hit in the head with Frank Archer's 4x2 with "brilliance" written on it too? Wow he's just friggin awesome!

I think that's what most of the job of an ambo is, unless it is horrendously obvious eg a cardiac arrest or a broken arm then there is little room for being a true diagnostician in the acute medical sense because the tools are not present that we need to make a confirmed diagnosis

Agreed that you should not be relying on electronic gizmo's for heart rate and I will go one further and sat even BP; I dislike using the NIBP on the Lifepack as much as possible!

dark red vomit, dark red stool, two syncope episodes, bp 84/p, pulse VERY weak and 55bpm on scene (done with pulse oximeter, probably incorrect) , SpO2 98%. Due to low b/p, the crew chief called for ALS intercept.

Your patient sounds pretty crook.

As an overseas operator I would certainly be interested to hear if your US Rx and assessment protocols differ from ours in such cases.

Can't speak to the US but ours would be lots of transport very quickly and maybe 500ml of fluid.

 

[mycrofft]

Five is four. Diagnose Schmiagnose, of course we do.

BRB out both ends at once?
The diverticulosis thing is a red herring. An acute case of diverticulitis presents as belly pain, it is the equivalent of a leaking appendix.
Bright red bleeding out both ends argues for two etiologies with one trigger. Examples could be: oral injury, esophageal varices (my pt survived by the way), posterior nasal bleed; the rectal arena could be rectal trauma, very lower GI trauma, including small penetrating injury to the bowel such as .22 cal. or stabbing. Meds could make for worse bleeding, such as coumadin, NSAIDs, as would some herbals and of course alcohol.
Vomitting? I want to see food in it or see the vomit ocurr. Most time it's spit up, not vomited. If it is vomited, mre likely esoph or bad stomch bleed (again, look for small penetraing wounds or blunt force trauma if scene suggests).
Oh, yeah....also cancer.
Or did someone beat up Granny?

NEVER heard of or saw a diverticulum cause a frank bleed.

 

[zmedic]

There's a big difference between saying "this is traumatic chest pain" or "this is chest pain from a likely cardiac source"

A real diagnosis would be to tell me exactly what is wrong with the heart. Is it an effusion, myocarditis, MI, valvular abnormality etc. They are treated differently at the hospital. Yes I'd agree that you shouldn't be blindly following algorythms, but at the same time it's good to keep some perspective on how much you can determine in the field. And it usually isn't worth the extra ten minutes on scene to really satisfy yourself that you've done a detailed history and physical to try to get the answer.

 

[mycrofft]

zmedic roger that

Nice to know later, though, for reference sake. We used to NEVER get the outcomes or definitve dx except through back channels.

 

[JPINFV]

A real diagnosis would be to tell me exactly what is wrong with the heart.

Not necessarily. A lot of times physicians in the hospital will only be able to narrow down a list of differential diagnoses until more test results come back. It's like saying EM physicians shouldn't diagnosis patients being admitted because the admitting diagnosis will often be different from the discharge diagnosis. I agree, and have stated, that transport shouldn't be delayed because a medic is wavering in his assessment (assessment, as in diagnosis. The A in SOAP) of what is going on. However there's a thought process difference between "I'm treating X protocol" and "I'm treating a patient with either A, B, or C who has the following acute problems (hypotension, etc)."

Yes, not every piece of the puzzle can be found in the field, however not every piece of the puzzle is going to be found in the ER.

 

[mycrofft]

Why not take the diagnosis versus assessment thing to a separate thread?

The OP was looking for a scenario response.