Categorising chief complaints

[Sr Dingdong]

In an effort to become more systematic, I am trying to categorise the different complaints we get called to. I am not completely satisfied with any of the lists I have found in my paramedic books, although they have been of great help.
My goal is to make a list as comprehensive as possible to help me remember all possible causes of for example chest pain, and to be able to exclude as many possibilities as possible, at least of the critical causes. The list should include all possible critical conditions, and the most common ones that are not critical. That way I can easily see which conditions I need to learn more about or refresh my knowledge of.

So far I have come up with these main categories:
Unresponsive/unconscious (maybe these should be two separate categories?)
Respiratory/breathing problems
Chest pain
Abdominal pain
Back pain
Headache
Seizures
Vomit/diarrhoea
Reduced neurological function (not sure about this category, and it might not be the best translation from Norwegian)
Vision problems
Pregnant patients

If anybody is interested in helping me I can post the different causes I have come up with so far in the different categories. Eventually I want to expand it to include things like critical findings and important examinations under the different categories as well, but still try to keep it short and easy to read.

 

[hometownmedic5]

It sounds like you’re trying to memorize “Harrison’s”, cover to cover. I don’t know why you’d want to do that, but more power too you.

I follow the same basic diagnostic procedure for all my patients, adding things or subtracting things as appropriate. Vitals, EKG, 12ld, CBG, EtCO2, physical exam.

At the end of the road, I either have a diagnosis(STEMI, etc,) or I don’t. Fine tuning the diagnosis is the job of the hospital, mainly the doctor who went to medical school and made a concerted effort to memorize Harrison’s. We have a limited diagnostic ability, and most of the conditions you’re trying to memorize require assessment procedures you simply aren’t equipped to manage. Imaging, laboratory studies, advanced physical exams and so on.

My recommendation is too become an expert at your level before you try to nibble into the stuff outside your scope. Also, and I only mention this because it just happened to me last night, if it sounds like you’re trying to be a know it all based on an incomplete assessment, you might get some pushback from the hospital staff.

I brought a patient in last night, POD 3(cervical fusion), on opioids, hasn’t had a bowel movement or passed flatus in three days, gaseous distension, abd pain, nausea. Abd firm to palpation, tender. Poor PO intake, dry mucosa. That’s a dunker, right? The nurse says ‘what’s she in for?”. “?SBO”. She says, “ so, abdominal pain” with an attitude. That’s when the fight started.

Just keep it in mind. We’re still largely seen as ‘ambulance drivers’. If you show up spouting off your half baked diagnosis, it might not do you any favors...

 

[mgr22]

Sr Dingdong (I can't believe I'm addressing somebody that way), regarding your desire to "become more systematic," I think Hometownmedic5 is pointing you in a better direction by suggesting that being systematic has more to do with a consistent approach to assessment than constructing a very long list of critical conditions. Perhaps give some thought to what makes a condition critical, and how you might be able to begin making decisions based on those signs and symptoms.

 

[Sr Dingdong]

My point with it is not to come up with a diagnosis, I have worked long enough to know that is not significant, and often impossible. My goal is, as mentioned earlier, to be more systematic in my examination of the patients, and not miss out on clues to a critical condition, i.e. miss an aneurism in a patient with complaints of back pain because I didn't think of it as a possibility.
After having worked in a very unstructured way for several years as an EMT, I have come a long way to be more systematic in my primary and secondary assessment after I finished my paramedic class, but I still tend to approach a patient with a specific problem with too narrow of a focus. I tend to forget potential causes when dealing with a patient.
So my goal is to always have the most serious causes in the back of my mind, and as I go through the examination, find out which causes I can eliminate or at least put away as not likely. It will not be necessary for the majority of my calls, but once every blue moon there might be a patient that will get the right treatment in a more timely manner because of it.
If I have a list I can have a glance at for a few seconds on my way out to a patient, I will more likely be able to be more effective at narrowing down the possible causes.

It is in no way an attempt to make my own personal ICD-10 or something like that And definitely not for showing off my diagnostic skills to the doctors and nurses in the ER.

 

[mgr22]

My point with it is not to come up with a diagnosis, I have worked long enough to know that is not significant, and often impossible. My goal is, as mentioned earlier, to be more systematic in my examination of the patients, and not miss out on clues to a critical condition, i.e. miss an aneurism in a patient with complaints of back pain because I didn't think of it as a possibility.

After having worked in a very unstructured way for several years as an EMT, I have come a long way to be more systematic in my primary and secondary assessment after I finished my paramedic class, but I still tend to approach a patient with a specific problem with too narrow of a focus. I tend to forget potential causes when dealing with a patient...

Coming up with a diagnosis "is not significant" and "often impossible"? That sounds like you're one of those EMS-doesn't-diagnose folks who thinks your job is merely to document signs and symptoms. Good luck with that as a paramedic.

Your second paragraph makes more sense to me. It's not unusual for clinicians -- even experienced ones -- to have "too narrow a focus," as you say. One way to combat that is to ask yourself these questions after you've assessed and, yes, diagnosed your patient: (1) What doesn't fit? (2) What else could it be? (3) Could it be more than one thing? I didn't invent those; Dr. Jerome Groopman did, and wrote about it in "How Doctors Think."

 

[Sr Dingdong]

I brought a patient in last night, POD 3(cervical fusion), on opioids, hasn’t had a bowel movement or passed flatus in three days, gaseous distension, abd pain, nausea. Abd firm to palpation, tender. Poor PO intake, dry mucosa. That’s a dunker, right? The nurse says ‘what’s she in for?”. “?SBO”. She says, “ so, abdominal pain” with an attitude. That’s when the fight started.

I'm noticing my English is deteriorating so I apologise if I make myself unclear.

To try to give an example of my thinking to your case:
I assume when you got the call, the chief complaint was something like abdominal pain, maybe also with obstipation. That would probably be the case in my service at least.

Now, on my way out, I would look at the list, try to memorise all the serious/potential serious causes, e.g. heart attack, abdominal aneurysm, ileus, appendicitis, ectopic pregnancy (don't know if that is the correct term) if its a woman. And the causes that are not critical, but more or less common. Like obstipation, food poisoning, chiruosis of the liver, hepatitis, menstrual pain, kidney stone, gallstone (is that correct?).

When I get to the patient, I do my primary exam, to find out quickly if the patient is critical, potentially critical or not critical. If the patient is critical, prepare for evacuation and get the patient to hospital, as he/she is most likely to need surgery, and do more examinations and ask questions on the way to the hospital.
In the case you mentioned, it probably was clear pretty early that it wasn't critical relatively quick. Maybe initially it could appear critical if the patient is pale and sweaty from the pain, and
Then do examinations and ask questions more specifically to exclude the most serious causes. Heart attack would probably be excluded pretty quickly. Aneurysm as well, when hearing the events prior to illness. Ileus, appendicitis and ectopic pregnancy would require some more questioning to exclude or count as not likely, but going through the physical exam, SAMPLER and OPQRST I assume it would be likely to exclude those as probable causes.
As the list of serious causes in most cases can be narrowed down pretty quickly, I think it would be a very effective way to work, at the same time that I would minimise the risk of missing any serious conditions. Where I work, we rarely get critical patients, and a lot of the cases are the same, so being able to keep a broad approach to the patients is important.

Of course, it takes a lot of will power and dedication to stick to this routine, at least for me, but I want to try it out for a while and see if I become more effective with it, both because my patients would benefit from it, and I have something to aim for as I continue my paramedic career.

 

[Sr Dingdong]

Coming up with a diagnosis "is not significant" and "often impossible"? That sounds like you're one of those EMS-doesn't-diagnose folks who thinks your job is merely to document signs and symptoms. Good luck with that as a paramedic.

Ok sorry, let me clarify. That was a bit exaggerated. In my experience some of my colleagues are very fast at jumping to a diagnosis, sometimes almost even before they see the patient. They are very determined to say that this or that is the problem, when in my view, they have a very uncertain basis for saying that. And like hometownmedic5 said, a lot of the patients need a specific test to be properly diagnosed.

Your second paragraph makes more sense to me. It's not unusual for clinicians -- even experienced ones -- to have "too narrow a focus," as you say. One way to combat that is to ask yourself these questions after you've assessed and, yes, diagnosed your patient: (1) What doesn't fit? (2) What else could it be? (3) Could it be more than one thing? I didn't invent those; Dr. Jerome Groopman did, and wrote about it in "How Doctors Think."

And why wouldn't a list of possible causes be a good thing to have in this case? I still believe that having a simple, quick and easy to read list of possible causes would be a good way to help me remember everything. However, I would like to approach it from a different angle, by excluding critical conditions as early as possible.
Plus, it will help me keep track of the subjects I need to freshen up on after a while whenever I look at the list.

 

[mgr22]

And why wouldn't a list of possible causes be a good thing to have in this case? I still believe that having a simple, quick and easy to read list of possible causes would be a good way to help me remember everything. However, I would like to approach it from a different angle, by excluding critical conditions as early as possible.
Plus, it will help me keep track of the subjects I need to freshen up on after a while whenever I look at the list.

The things that worry me about your approach are (1) relying on a list you have to carry with you and (2) feeling you have to "remember everything." Look, I'm an engineer, which means I'm one of the more anal people on the planet, and am constantly making lists of things to do. I also understand, though, that lists aren't substitutes for knowing how to do important, repetitive, hard-to-interrupt tasks. Think about driving a car, for example: You need to be good enough at that to do it without constantly referring to a list, but no one expects you to remember every obscure traffic law -- e.g., when you have to put on your headlights, how far in advance you have to signal a turn, etc. You learn the important things about driving mostly through practice.

Have you considered trying some mental simulation of field scenarios? When I was a new medic, I used to think a lot about calls I might have, and how I'd try to handle them. I also found that the more real calls I did, the less I had to actively remember what I was supposed to do. It sounds to me like you're expecting lists to substitute for your inexperience, but it's not as simple as that.

 

[Sr Dingdong]

I see your point, however I think you misunderstand the role the list will play in my patient assessment.
Im not gonna pull out a long and comprehensive list in front of the patient and go over it step by step. It is meant as a quick reminder of the most important things I can encounter to keep me from getting too caught up in the things I usually meet.
Of course it is not optimal to have to rely on a list, but if I use it on my way out to every call, it is likely to gradually stick more and more, hopefully to the point that I only need to repeat it every now and then. I don't see how it will compromise the way I already work, so why not give it a try? The difference from how I now work will be that instead of trying to remember possible diagnosis's on my way to the patient, I have a list I'll take a quick look at on the way, and my questions and exams (after the primary assessment) will be more directed towards eliminating the critical conditions I haven't yet ruled out than jumping around from point to point on the SAMPLE and OPQRST.

I don't know how it is in your EMS service, but where I work probably 90% of the calls consists of 10% of the subjects covered during paramedic class. Things like aneurysms, (tension) pneumothorax, ectopic prengancies, appencitis and loads of other conditions are very few and far between, and I'll probably never encounter a lot of it, so I need a reminder that those things do exists. Its not unusual that I go weeks without having a single critical patient. And I am working in one of the busiest EMS services in the country. If I don't repeat those subjects from time to time I am likely to have forgotten a lot about it the day I encounter it.
I have been a pretty unstructured EMT for several years without killing a patient, and I can very well keep working the way I do now and I probably won't have killed anyone by the time I retire due to not having recognised that the patient in front of me had appendicitis or an aneurysm, as long as I am able to recognise a critical patient. But I would like to be more efficient at recognising the critical conditions that I am not familiar with.

I have done some mental simulation actually, mostly "post calls" to find ways to improve, but also for what to do in cardiac arrests, anaphylaxis, and the most critical calls I might encounter, as well as specific procedures and of the tactical part of incident management. I find it harder harder to do with a fictional patient interview however.

 

[mgr22]

I have been a pretty unstructured EMT for several years without killing a patient, and I can very well keep working the way I do now and I probably won't have killed anyone by the time I retire due to not having recognised that the patient in front of me had appendicitis or an aneurysm, as long as I am able to recognise a critical patient.

Got it -- you won't be including appendicitis or aneurysms on your list of critical conditions.

 

[Sr Dingdong]

Got it -- you won't be including appendicitis or aneurysms on your list of critical conditions.

I give up......

Anyways, if anybody else who does think making a list as mentioned in the first post sounds like a good idea and are willing to help me out, feel free to comment or send me a PM. If you think its a bad idea, please don't bother commenting.

 

[Akulahawk]

While I applaud your idea of making a list of common problems that we see, one of the problems with doing that is that there's a danger of falling into the trap of looking primarily at those and eventually neglecting the differentials that can also be dangerous. I've practiced this way for years and nursing school only further reinforced this method: do your assessments in a standardized manner, the same approach every time. You'll pick up more data and then you let the data drive the diagnosis. As you go through Paramedic school, you'll be presented with various field diagnoses and how to manage those. Trust that you'll know and remember that stuff. You really don't need to delve too far into formal medical diagnosing because that requires a lot more data than what we're going to have available to us in the field and sometimes more data than what's available to us in the ED. Being able to do that also requires that you have a LOT more background knowledge to draw from that you'll get from Paramedic school or Nursing school (I've done both...)

Focus on just doing assessments in a standardized way and you'll end up (often) with a field diagnosis that will yield a treatment plan that "covers" the majority of emergent problems associated with what a patient complains about.

A little while ago I had a patient in my ED that was having non-radiating chest pain that wasn't relieved by rest. The patient wasn't short of breath. Physical findings showed there was no change in the pain with deep inspiration nor with palpation, AP compression was negative, the upper extremities were cool and lower extremities were warm, and this patient was hypertensive. No nausea, vomiting, diarrhea, no history of GERD. The patient's 12-lead was fairly unremarkable.

The diagnosis is pretty much a slam-dunk from there and imaging was very definitive with this one. By keeping some differentials in your head, you might have thought of this one as a potential cause of this patient's pain and might not suggest a hospital that doesn't have cardiovascular or thoracic surgery or a cath lab available...

I had another patient that had non-radiating substernal chest pain that has been ongoing for a few hours. The onset was shortly after going to bed. Rest didn't relieve the pain, but sitting up helped some. There was no shortness of breath, no change with inspiration, palpation or AP compression testing. Skin temperature was normal in all extremities, normal pulses noted. No nausea/vomiting/diarrhea. No abdominal pain was elicited. Vitals and 12-lead were unremarkable. The patient stated that Tums helped but not for long.

The reason I bring these two cases up is that if you think about what I'm looking at and looking for while doing my exam, you'll realize that I'm doing my exams in basically the same way and I'm getting different results that are starting to point me toward fewer and fewer likely causes of chest pain (in these instances). As I get these results, I'm following their lead (so to speak) and seeing where the data takes me.

Don't worry about making lists of differentials. The education you receive will provide you with those and what you need to do about them. Focus on doing assessments in the same way every time and you'll pick up on more things that will help guide you toward appropriate field treatment.

Some people use SAMPLE. I use HIPS or HOPS. Think of this acronym as History, Inspection/Observation, Palpation, Special Test. I ask about allergies and meds as part of gathering the history. I've been doing things this way for a long time so I often do history gathering, physical exam (inspection/observation, palpation) and application of special tests (like attaching the monitor or doing a 12-lead) at nearly the same time.

Oh, and my assessment begins the moment I see the patient, even from across the room... you'd be amazed what patients do when they don't think you're looking at them or assessing them...

 

[Aprz]

I am assuming you are in the US? The NREMT patient assessment skill sheet is already a pretty systematic way to assess people. Why not just go off that? As for life threats, you always stop the assessment to treat immediate life threats. We can only really treat what's in front of us. For example, you mentioned considering the possibility of a ruptured aortic aneurysm in a back pain call, right? If you consider it, what difference does it make? There is nothing a paramedic can do for an aortic dissection other than get them to the hospital. In many cases, we don't know what is going on, and we can only treat the signs and symptoms to a limited extent. It's great to think beyond, think of different possibilities, but I think they are pretty low yield in treating patients prehospitally.

Medical Priority Dispatching System already categorizes calls too, so if you want to continue what you are doing, maybe use that?

1. Abdominal Pain/Problems
2. Allergies (Reactions)/ Envenomations (Stings, Bites)
3. Animal Bites/Attacks
4. Assault/Sexual
5. Back Pain (Non-Traumatic/Non-Recent)
6. Breathing Problems
7. Burns (Scalds) /Explosions
8. Carbon Monoxide/Inhalation/HAZMAT/CBRN
9. Cardiac or Respiratory Arrest/Death
10. Chest Pain
11. Choking
12. Convulsions/Seizures
13. Diabetic Problems
14. Drowning/Diving/SCUBA Accident
15. Electrocution/Lightning
16. Eye Problems/Injuries
17. Falls
18. Headache
19. Heart Problems/A.I.C.D.
20. Heat/Cold Exposure
21. Hemorrhage/Lacerations
22. Inaccessible Incident/Entrapments
23. Overdose/Poisoning (Ingestion)
24. Pregnancy/Childbirth/Miscarriage
25. Psychiatric/Suicide Attempt
26. Sick Person
27. Stab/Gunshot/Penetrating Trauma
28. Stroke (CVA)/Transient Ischemic Attack (TIA)
29. Traffic/Transportation Incidents
30. Traumatic Injuries
31. Unconscious/Fainting(Near)
32. Unknown Problem (Man Down)
33. Inter-Facility Transfer/Palliative Care
34. Automatic Crash Notification (A.C.N.)
35. HCP (Health-Care Practitioner) Referral (United Kingdom only)
36. Flu-Like Symptoms (Possible H1N1)
37. Inter-Facility Transfer specific to medically trained callers

 

[Gurby]

There is nothing a paramedic can do for an aortic dissection other than get them to the hospital.

You could withhold ASA I guess.

 

[Akulahawk]

For example, you mentioned considering the possibility of a ruptured aortic aneurysm in a back pain call, right? If you consider it, what difference does it make? There is nothing a paramedic can do for an aortic dissection other than get them to the hospital.

Actually, the appropriate treatment for that if you're at the point where you think that's what you're dealing with is to get the patient to a hospital that has vascular surgery or at least an OR that is either "hot" or can be opened up very quickly.

It's great to think beyond, think of different possibilities, but I think they are pretty low yield in treating patients prehospitally.

Knowing the different possibilities is a good thing. While you might not be able to do much for many of those "other" possibilities, if the evidence is leaning toward some of those differentials that a given hospital isn't able to easily provide good care for, changing the destination to a facility that can is a treatment of sorts.

 

[Gurby]

Actually, the appropriate treatment for that if you're at the point where you think that's what you're dealing with is to get the patient to a hospital that has vascular surgery or at least an OR that is either "hot" or can be opened up very quickly.

I think I've posted this here before at least twice, but one of my preceptors has a haiku that I love:

I present again
Now you must decide again
Can you trust in me?

If you have a pretty good idea of what's going on and you can convey it well in your radio patch, you have a much better chance of getting the patient straight to CT / OR / having the surgeon meet you at the door / etc. If you have no idea what's going on and you sound like an idiot over the radio, results may vary.

I guess even if you "aren't doing anything" for these patients, having that knowledge can still guide your actions to a great extent and can make a difference in outcome.