Cutting Clothes

medic417 said:
Then all meds including Oxygen must be removed from the ambulance. W/o at least a field or working diagnosis we can do nothing. Deciding which protocol to follow requires you to examine and diagnose. It may not be a definitive diagnosis but it is a working diagnosis. Honestly if we can not diagnose anything you could not even put a bandage on a laceration because you could not diagnose that the patient is bleeding. Its just ridiculous to say we do not diagnose.
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You don't give meds on your speculated diagnosis, you give meds based on the presentation and signs and symptoms of a patient. You don't treat CHF. You treat the fluid filling up in their lungs and the s.o.b.
 
Sasha said:
You don't give meds on your speculated diagnosis, you give meds based on the presentation and signs and symptoms of a patient. You don't treat CHF. You treat the fluid filling up in their lungs and the s.o.b.
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Nope fluid in the lungs is a diagnosis. So can't treat it as per you we can not diagnose. Heck I can't even splint the angulated leg because I can't even diagnos that it just aint right. Actually my protocols state for CHF do XXXX. So if I can't determine CHF I can't do XXXX. So yes I field diagnose CHF. For a fractured femur I do XXXXX, so guess what I field diagnose fractued femur and do XXXXX. For a STEMI I do XXXX, XXXX. and XXXXXXXXX. So I field diagnose STEMI and do XXXX, XXXX, and XXXXXXXXX.

Again maybe I'm just better than all other medics and allowed to diagnose but somehow I feel there are others out there that might even be better than me that diagnose also. :P
 
I'm with Medic417 on this one. A diagnosis is a decision as to what is wrong with the patient. In order to treat the patient we have to make a decision, and thus we are making a diagnosis.
 
You have a patient that is hot, flush, dry, and altered, what do you do?

I can think of at least two DDXs where patients can have those symptoms and, strangely enough, have essentially opposite treatments. Tell me how I can differentiate between, say CO poisoning (move to fresh air) and heat stroke (seek shelter), without choosing a DDX?

Debating if we call something a DDX or a 'working dx' or an impression or an assessment is just semantics.
 
medic417 said:
Then all meds including Oxygen must be removed from the ambulance. W/o at least a field or working diagnosis we can do nothing. Deciding which protocol to follow requires you to examine and diagnose. It may not be a definitive diagnosis but it is a working diagnosis. Honestly if we can not diagnose anything you could not even put a bandage on a laceration because you could not diagnose that the patient is bleeding. Its just ridiculous to say we do not diagnose.
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Read your scope of practice, we do not diagnose, we are not allowed to diagnose. Yes we may treat signs and symptoms, but we cannot legally diagnose, that's why it says Rule Out on your PCR.

You can treat a symptom without diagnosing the cause. Don't be silly.
 
BossyCow said:
Read your scope of practice, we do not diagnose, we are not allowed to diagnose. Yes we may treat signs and symptoms, but we cannot legally diagnose, that's why it says Rule Out on your PCR.

You can treat a symptom without diagnosing the cause. Don't be silly.
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My PCR does not say rule out. My scope of practice requires me to diagnose. I have to diagnose what type of cardiac problem so I can treat it. I have diagnose which respiratory problem so I can detremine whice one to treat. Sorry but we diagnose other wise all we would be is "ambulance drivers".
 
medic417 said:
Nope fluid in the lungs is a diagnosis. So can't treat it as per you we can not diagnose. Heck I can't even splint the angulated leg because I can't even diagnos that it just aint right. Actually my protocols state for CHF do XXXX. So if I can't determine CHF I can't do XXXX. So yes I field diagnose CHF. For a fractured femur I do XXXXX, so guess what I field diagnose fractued femur and do XXXXX. For a STEMI I do XXXX, XXXX. and XXXXXXXXX. So I field diagnose STEMI and do XXXX, XXXX, and XXXXXXXXX.

Again maybe I'm just better than all other medics and allowed to diagnose but somehow I feel there are others out there that might even be better than me that diagnose also. :P
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Fluid in the lungs is a sign/symptom.. CHF is a diagnosis. But the diagnosis of CHF was not made by you, but made by the pt's doctor and reported to you.

What about those greenstick fxs that aren't visibly angulated? Can you 'diagnose' that one? You can say you see signs of what might be a STEMI and treat what you see, but the dianosis of STEMI happens with the doc. Not even R.N.s diagnose.. look it up. Sorry, this isn't a judgement call, you are just plain wrong here.
 
Could be both actually. Hearing rales would be a sign while the congestion felt by the patient would be a symptom.
 
Ay, I disagree. We do "diagnose". For example, a de-compensating CHF patient with bilateral rales and obvious pitting edema in dependent areas. With a Hx of CHF we can create a working diagnosis of pulmonary edema, which we must do if we are to treat for it. Giving Lasix and Nirtro for purely for treating "primary rales" would show a great lack of critical thinking and would be cookbook medicine. Besides, pathophysiology of heart failure is learned at the medic level, why so if we cannot recognize and treat it (hence diagnose).

We Diagnosis Acute MI all the time. Based on Hx, FamHx, signs and symptoms, and a EKG, we remotely activate the cath lab and bypass all hospitals without one.
 
apologies to the OP for my tangents!

daedalus said:
Ay, I disagree. We do "diagnose". For example, a de-compensating CHF patient with bilateral rales and obvious pitting edema in dependent areas. With a Hx of CHF we can create a working diagnosis of pulmonary edema, which we must do if we are to treat for it. Giving Lasix and Nirtro for purely for treating "primary rales" would show a great lack of critical thinking and would be cookbook medicine. Besides, pathophysiology of heart failure is learned at the medic level, why so if we cannot recognize and treat it (hence diagnose).

We Diagnosis Acute MI all the time. Based on Hx, FamHx, signs and symptoms, and a EKG, we remotely activate the cath lab and bypass all hospitals without one.
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I like your phrase "working diagnosis". Fits the bill nicely for either debating side. Guess the only debate is whether or not our working diagnosis should be official, except of course for all the field interpretations performed by Doctor Ambulance..

Officially speaking, it's possibly good habit to NOT tell pts any definitive answer as to an exact etiology of their illness. Sure, that is a bit of hypocrisy with that, because times I've had someone who is/has been febrile, has rhonchi present and a productive cough, and said to the pt "Looks like ya might have pneumonia." And I've been wrong.

As far as us (EMS) diagnosing AMI, we should make it our business to never be the ones to inform the pt with CP that they're not having an AMI. Offer treatment and reassurance, give them honest answers, but probably best to avoid definitive statements like "you're not having a heart attack".
Unless you have a means to obtain lab values and your service is licensed to diagnose said labs, we have no right to tell the pt they aren't having an AMI based solely on our field/working diagnosis and ecg findings. Even services with licensed Istat use/diagnosis/whatever, will NOT have the transport time to recheck troponin to completely rule out an AMI.
 
I agree with the working diagnosis bit. I will never tell a patient definitively what is wrong with them and generally try to avoid the subject as a whole but I do come up with something in my head based on their presentation that I use to treat.

If a patient does ask me I will generalize as much as possible and make certain that they understand I cannot officially diagnose them and the doctor will require more information before he can.
 
vquintessence said:
I like your phrase "working diagnosis". Fits the bill nicely for either debating side. Guess the only debate is whether or not our working diagnosis should be official, except of course for all the field interpretations performed by Doctor Ambulance..

Officially speaking, it's possibly good habit to NOT tell pts any definitive answer as to an exact etiology of their illness. Sure, that is a bit of hypocrisy with that, because times I've had someone who is/has been febrile, has rhonchi present and a productive cough, and said to the pt "Looks like ya might have pneumonia." And I've been wrong.

As far as us (EMS) diagnosing AMI, we should make it our business to never be the ones to inform the pt with CP that they're not having an AMI. Offer treatment and reassurance, give them honest answers, but probably best to avoid definitive statements like "you're not having a heart attack".
Unless you have a means to obtain lab values and your service is licensed to diagnose said labs, we have no right to tell the pt they aren't having an AMI based solely on our field/working diagnosis and ecg findings. Even services with licensed Istat use/diagnosis/whatever, will NOT have the transport time to recheck troponin to completely rule out an AMI.
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In Ventura County in California, if we find ST elevation with s/s of MI we are to tell he patient " According to the EKG, you may be having a heart attack. We are going to bring you to Los Robles Hospital in another city for emergency heart treatment"

Of course, a field EKG cannot rule out an MI. That is what serial cardiac enzymes and EKGs at the hospital are for. We absolutely cannot tell them they are not having an MI.
 
I've had someone who is/has been febrile, has rhonchi present and a productive cough, and said to the pt "Looks like ya might have pneumonia." And I've been wrong.
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Aint it cool how many different things can cause the same set of symptoms? I have great respect for the clinicians in the hospital who sort out everything.
 
daedalus said:
Aint it cool how many different things can cause the same set of symptoms? I have great respect for the clinicians in the hospital who sort out everything.
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Yeah definately. See horses, expect horses, treat them as horses, you can be right much of the time, but then crap, it was a zebra.
 
On the PCR forms we fill out here, I have a box that says "Assessment". This is my opportunity to state what my differential Diagnosis is. Even with an angulated fracture, the Dr will take an x-ray (not available on my rig). Like Sasha said, we treat the symptoms presented to us. We don't officially diagnose a particular illness. If it's something I can see, it's a sign. If it's something the pt feels, it's a symptom.
 
vquintessence said:
Yeah definately. See horses, expect horses, treat them as horses, you can be right much of the time, but then crap, it was a zebra.
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...but how often do you see sea horses?
 
If you must, cut a down coat outside, if you didn't think they would be pissed for cutting it in the first place, enjoy that ride in.

Cut what you must, but try to keep the pt's dignity intact if possible. If they refuse, document document document.
 
If I cut your clothes off, rest assured they needed to come off. It probably wont be along the seams either for that I apologise, but im sure you can understand my haste in accessing your possibly life-threatning injury.

Having a multi-system trauma pt disrobe is probably not a good idea, it will usually compromise the integrity of your immobilization.

If a pt can physically disrobe themselves then their injury is usually not signifigant enough to warrent it.
 
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