"DO Prehospital Emergency Medical Technicians Diagnose?" (References and citations)

[mycrofft]

OK, we've teased out the themes about driving fast, working under cover of arms, honoring DNRs and others, and discussed them at length and with proper citations.

Here'as one. I back out of a stalled discussion awhile back about whether prehoispital EMS (PEMS) technicians (EMT, Paramedics, first responders, first aid providers, and the assorted other titles and wrinkles (but NOT PA's or Nurse Practitioners) actually can diagnose.

It's still sticking in my craw.

So to avoid hijacking someone else's thread, here's my preposition:

"1. Since prehospital technicians (and paramedics are deemed technicians) are governed by strict protocols, they have a strictly limited sheaf of diagnoses to attribute their patients' perceived conditions to. (Split that infinitive didn't I?).

2. Likewise, they have a sharply delineated armamentarium of measures.

3. MDs on the other hand have a virtually unlimited armentarium of diagnoses, and measures to fit.

4. I will concede the concept of a "working" or "provisional diagnosis" only as a shorthand for the tech's hypothesis which is compared to the strictly limited protocols, which then dictate action. (This is comparable to the "Nursing Process's "VCP, or Verified Client Problem")."

So I see three new* tracks to follow, and please bring along proper citations:

A. LEGAL: What do state laws and EMSA regs say using the word "diagnosis" per se. ?

B. PROFESSIONAL: What do MDs, professional associations (other than EMT and Paramedic**) and administrators say about it? No "op ed" articles unless they are by heavyweights.

C. STRICT CONSTRUCTIONIST: Any definitions such as accredited Wikipedia articles, standard medical professional dictionaries or texts.

Bring your URL's.

* By "new", I mean we should be discounting the "Is not!", "Common sense says it is too!" school of argument.

**I say "other than EMT and Paramedic" because they and their professional associations leaders have personal and political issues to further apart from the legal and medico-professinal aspects, and thus may be tainted. Probably are).

 

[Medic Tim]

"DO we diagnose?" poll

Absolutely. If you aren't you aren't doing your job.

 

[ZombieEMT]

I was told in EMT school that we never diagnose, on the BLS level. To the extent that they want us to document as "possible." Personally sometimes I make a diagnosis based on obvious facts. A patient with their bone sticking out of the skin, is not a "possible" fracture it is a definite fracture. A patient with a BGL of 25 IS experiencing a diabetic emergency and hypoglycemia, regardless of whether or not something else is going on.


So are we supposed to? Maybe not. Do we? Absolutely.

 

[CodeBru1984]

I've always referred to diagnosing as a "working field impression."

 

[mycrofft]

Citations to support to refute?

 

[Medic Tim]

I think Kelly does a pretty good job of explaining it.

http://www.ems1.com/ems-products/education/articles/584425-Yes-We-Do-Diagnose/

 

[mycrofft]

Reading Mr Grayson's article was one impetus for this thread and the exclusion of partial sources in PEMS.

He has a strong personal stake in the politics and extended scope of practice for PEMS. While he has one citation from a good dictionary, he only concedes provisional diagnosis, but then stretches it without definition as to its limits.

 

[mycrofft]

I read through Calif title 22 section 9, which includes enabling and governance of paramedics.

It does not use the word "diagnosis" and limits actions to protocols, which can be very flexible as one as they are sanctioned by a medical controller. Despite a very wide sheaf of possible treatments, it is still "If you see symptoms A, F, and H, then you do Y, or maybe Z". Not "If the pt exhibits A,F, and H, then choose what you want to do…consistent with prudent practice".

 

[Medic Tim]

Auto technicians and mechanics diagnose. A diagnosis is not a term owned by physicians . You can easily google or look up the definition of diagnosis. From just about every source , what medics and for the most part EMT do fit those . Something else other people get hung up on is that a diagnosis is a fluid thing that is changing over time as more information becomes available. There are units with istats, there are units with ultrasound . While these can be in the minority they do exist in our playground.

Maybe it is jut different up here in Canada. We are not technicians we are all clinicians expected to make a paramedic diagnosis and differential diagnosis.

Just did a quick google search for paramedic job description diagnosis and got a lot of results with paramedic diagnosis and differential diagnosis in the job description.

 

[mycrofft]

Good.
Citations?

 

[unleashedfury]

In PA we use a "clinical impression" and are not allowed to diagnose, I know from dealing with a specific team of ER Physicians if you advise them of your thoughts, based on your impressions and clinical findings, They may or may not agree with you. A few docs I work with will ask hey "well what do you think?"

But I believe this is a double edge sword. If the patient presents a specific way and your clinical findings prove a specific disease process what is it? Our protocol books state nothing of the sort of the word diagnosis, But the algorithms speak otherwise.

Some Examples:

Pt. presents Pulseless and apniec, CPR in progress Do You call this a "possible cardiac arrest"? I am sure if you told the doc that whilst doing pushy and puffies they may think that you might have to go back to school

Pt. Presents with a suspected Opiod Overdose, Yet responds to Narcan. Is a possible overdose?

You perform a 12 lead ECG with findings that show a STEMI is it a possible STEMI? or a possible cardiac event? or did your findings present to show a confirmed Infarct? and you are treating said infarct.

Open fractures with protruding bones?

In the end of the day EMT's and Paramedics do Diagnose, its just that we use less tools to confirm the diagnosis. Obviously we don't have the capabilities to check Troponin levels. Or Xray machines to verify which way and how a bone is broken. a Multi Million dollar lab to perform ABG's CMP's , a CT machine to verify intercranial hemorrhages

 

[Medic Tim]

This is from a Paramedic textbook

http://books.google.ca/books?id=sGZ...wBDgK#v=onepage&q=paramedic diagnosis&f=false


from the national association of ems educators
http://www.naemse.org/Educator-Update/397689/


this is from one of our (Canadian ) paramedic programs. Near the bottom you can click the link for the course EMTP-222 Emergency diagnosis and treatment. This school is in Alberta. AB is the only province to use the old EMT and EMT-P titles. The difference is EMT stands for Emergency Medical Technologist.

http://www.portagecollege.ca/Programs/Emergency_Medical_Technologist_-_Paramedic.htm


For a Paramedic to work in Ontario they need to pass a base hospital course.
http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/002-CriticalDecisionMaking11-06.pdf

 

[Eddie2170]

In PA we use a "clinical impression" and are not allowed to diagnose, I know from dealing with a specific team of ER Physicians if you advise them of your thoughts, based on your impressions and clinical findings, They may or may not agree with you. A few docs I work with will ask hey "well what do you think?"

But I believe this is a double edge sword. If the patient presents a specific way and your clinical findings prove a specific disease process what is it? Our protocol books state nothing of the sort of the word diagnosis, But the algorithms speak otherwise.

Some Examples:

Pt. presents Pulseless and apniec, CPR in progress Do You call this a "possible cardiac arrest"? I am sure if you told the doc that whilst doing pushy and puffies they may think that you might have to go back to school

Pt. Presents with a suspected Opiod Overdose, Yet responds to Narcan. Is a possible overdose?

You perform a 12 lead ECG with findings that show a STEMI is it a possible STEMI? or a possible cardiac event? or did your findings present to show a confirmed Infarct? and you are treating said infarct.

Open fractures with protruding bones?

In the end of the day EMT's and Paramedics do Diagnose, its just that we use less tools to confirm the diagnosis. Obviously we don't have the capabilities to check Troponin levels. Or Xray machines to verify which way and how a bone is broken. a Multi Million dollar lab to perform ABG's CMP's , a CT machine to verify intercranial hemorrhages

I agree with this, i'm in NY and in class we were taught you are not definitively diagnosing (this is at the BLS level however paramedics are a certification also not a license so id assume its the same), but my paramedic partner I think said it the best, to provide an appropriate treatment you have to clinically diagnose at least to an extent.

You arent just throwing interventions and drugs at patients and seeing what improves them, you are assessing them, using whatever skills tools & knowledge you have and diagnosing the patient & providing an appropriate treatment from your findings. Your proof in the prehospital setting is exactly what unleashedfury said, if your 'diagnosis' is correct, based on your interventions the patient should improve accordingly.

The best examples of this are narcan for opiate OD, d10/d50 & hypoglycemia, respiratory distress for CHF vs for pneumonia or asthma, especially when the wrong diagnosis will call for the wrong treatment especially one that will adversely effect the pt.

But this only goes so far, i.e. I cannot diagnose a UTI or similar prehospitally however for things like this I will definitely share my impression with a receiving Nurse/MD in my report especially if its a nurse or Dr i trust& see everyday at work and actually want & care about a report from EMS

 

[usalsfyre]

I guess you can say legally no but functionally yes.

I suppose if we really wanted to be laughing stocks could shoot for ridiculous pseudo-diagnoses like some professions have...

 

[Handsome Robb]

"DO Prehospital Emergency Medical Technicians Diagnose?" (References and cita...

The definition of diagnosis, according to Merriam-Webster online is, "the art or act of identifying a disease from its signs and symptoms."

Definition if diagnose from the same source: "to recognize (as a disease) by signs and symptoms"

So I'd say we diagnose. Just my interpretation of what we do, though. We preform a physical assessment and collect a history of present illness as well as pertinent past medical history, form a clinical impression, or diagnosis, of what is wrong, and treat, or withhold treatments based on that diagnosis.


http://i.word.com/idictionary/Diagnosis

http://i.word.com/idictionary/diagnose

 

[mycrofft]

This is from a Paramedic textbook

http://books.google.ca/books?id=sGZ...wBDgK#v=onepage&q=paramedic diagnosis&f=false


from the national association of ems educators
http://www.naemse.org/Educator-Update/397689/


this is from one of our (Canadian ) paramedic programs. Near the bottom you can click the link for the course EMTP-222 Emergency diagnosis and treatment. This school is in Alberta. AB is the only province to use the old EMT and EMT-P titles. The difference is EMT stands for Emergency Medical Technologist.

http://www.portagecollege.ca/Programs/Emergency_Medical_Technologist_-_Paramedic.htm


For a Paramedic to work in Ontario they need to pass a base hospital course.
http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/002-CriticalDecisionMaking11-06.pdf

Excellent!

 

[mycrofft]

the definition of diagnosis, according to merriam-webster online is, "the art or act of identifying a disease from its signs and symptoms."

definition if diagnose from the same source: "to recognize (as a disease) by signs and symptoms"

so i'd say we diagnose. Just my interpretation of what we do, though. We preform a physical assessment and collect a history of present illness as well as pertinent past medical history, form a clinical impression, or diagnosis, of what is wrong, and treat, or withhold treatments based on that diagnosis.


http://i.word.com/idictionary/diagnosis

http://i.word.com/idictionary/diagnose

ok!

 

[MrsMedic]

We were always taught that we don't "diagnose" in the field in sense that we can't for sure tell if someone has pneumonia, or a kidney stone, or a UTI without the definitive diagnostic tools that a doctors office or a hospital has at their disposal. We don't give that "clinical diagnosis" that Kelly talks about in his article.
We do provide a differential diagnosis based on signs, symptoms, and the basic diagnostic tools we have.

An example could be a hypoglycemic patient. Do we diagnose diabetes? No. That is a clinical dx reserved for primary care provides. Hypoglycemia is the symptom, not a dx.

On the other hand, Kelly brought up dx fractures and obvious things. Well, yeah. So we can make a physical dx. The patient still needs further testing to determine if surgery is needed, or how bad the damage really is.

The service I work for encourages a differential dx to be made at the end of all narratives i.e. "Rule out: sepsis" or "rule out kidney stones"

So DO we Diagnose? Sometimes. Sort of.

 

[mycrofft]

An example

A hypothetical:

79 y/o frail male with known cardiac history. Three day worsening hx of ℅ chest heaviness, dyspnea, orthostatic near-syncope, languor (tired all the time), some cough. NO fever.

Exam includes abnormal EKG consistent with his ongoing cardiac condition; absent or diminished lower lobe breath sounds and rhonci bilat; normal temp by palp (or by thermometer if you like).

Exam suggests CHF. Protocol says do XYZ meds, O2, transport.

Diagnosis in the ED: pneumonia. Field meds DC'ed, pt placed on IV broad spectrum antibiotics, cautious rehydration, possibly parenteral nutrition, and sputum exam (micro for bugs and tissues, culture and sensitivity).

The field protocols were met consistent with the info derived from hx and dx, but the case treatment was not helpful and could be harmful (diuretics) because the necessary chain of discovery to treatment was not in the protocols (and likely absent from the field techs' education/certification).

So, does restriction to set protocols (which yields the best outcome for the majority of cases in the field) allow best treatment for all, or can even be potentially harmful for outliers like our man whose lack of fever (not uncommon in the very elderly) potentially shut off consideration of the path to discovering the true problem? Or would a freewheeling approach, requiring years of clinical experience and perception, be required to safely do that, sorting the zebras from the horses and donkeys?

Or is the stumbling block the decision to place one condition in the emergency category, and another in the non-emergent category and hence not in the protocols?

Or are these BOTH diagnoses, but one is simply "MD Diagnosis", the other "Paramedic Diagnosis"?

 

[Medic Tim]

From the NOCP...our national scope of practice.

4.3.a
http://paramedic.ca/nocp/nocp_assessmentdiagnostic/

"infer a provisional diagnosis"

it is a huge document and further on in it there is mention of a differential diagnosis.