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

[mycrofft]

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

Good thinking, well stated. See my comment above.

So diagnosis may be multilevel and defined by the measures you ache on hand?

Does this recognition help stop mistreatment of "non-emergency" cases such as endometriosis and cancer because we recognize that the diagnostic materials at hand lead the decisions to treat? Are field techs trained to perform and interpret MRI's, or even Lixiscope (handheld) fluoroscopy? Do labs in the ambulance?

 

[MrsMedic]

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.

The key words here are "provisional" and "differential". A lot of doctors in my area would still not count this a diagnosis, but maybe if we encouraged and incorporated more of these diagnosing terms here in the United States, our profession would be taken more seriously by the doctors.

 

[Medic Tim]

The key words here are "provisional" and "differential". A lot of doctors in my area would still not count this a diagnosis, but maybe if we encouraged and incorporated more of these diagnosing terms here in the United States, our profession would be taken more seriously by the doctors.

There are pts where it can take days or longer to nail down a diagnosis. Pts are also admitted with a provisional diagnosis from the ER on a daily basis. I am not saying this is the same thing we do, but want to point out that it is a fluid process. Throw whatever words you want in front of or behind it but we do diagnose. It is common here to hear the term paramedic diagnosis .

 

[KellyBracket]

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

Yes.

Or heck, call them BOTH "clinical impression," which is actually the name of the field I complete in my chart. Doesn't matter what we call it, we're all talking about the same process.

Interestingly, in day-to-day practice, I don't often hear physicians use "diagnose" as an active verb. I.e., you don't often hear a doctor say "I diagnosed the patient with pneumonia." Instead, they say something like "It looked like pneumonia, so I gave Zosyn," or "I found a pneumonia."

When the verb is used, it seems to usually be in the passive voice, and suggests some element of empiric skepticism. E.g., "The patient was diagnosed with CHF last year." It suggests some small element of doubt, as if to say "Some other doctor wrote this in the chart, but I haven't come to a conclusion myself."

 

[unleashedfury]

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"?

agreed as the chest pain can be related to Either CHF or Pneumonia as the respiratory difficulty warrants sore ribs, ECG findings normal per pt. due to cardiac condition.

Before I start treeing down a protocol list, You stated cough, what kind of cough Productive? if so what color mucous, Pink frothy, dark yellow, Green? Nocturnal dyspnea? Orthopnea?

Edema? Present not present? what about JVD (actually proven only prevalent in less that 20% of CHF cases)

While I agree that your gentlemen here presents with symptoms of both CHF or Pneumonia, and you stated afebrile it appears the provider couldve dug a little farther before treating CHF.

 

[Medic Tim]

agreed as the chest pain can be related to Either CHF or Pneumonia as the respiratory difficulty warrants sore ribs, ECG findings normal per pt. due to cardiac condition.



Before I start treeing down a protocol list, You stated cough, what kind of cough Productive? if so what color mucous, Pink frothy, dark yellow, Green? Nocturnal dyspnea? Orthopnea?



Edema? Present not present? what about JVD (actually proven only prevalent in less that 20% of CHF cases)



While I agree that your gentlemen here presents with symptoms of both CHF or Pneumonia, and you stated afebrile it appears the provider couldve dug a little farther before treating CHF.

Agreed

 

[unleashedfury]

Good thinking, well stated. See my comment above.

So diagnosis may be multilevel and defined by the measures you ache on hand?

Does this recognition help stop mistreatment of "non-emergency" cases such as endometriosis and cancer because we recognize that the diagnostic materials at hand lead the decisions to treat? Are field techs trained to perform and interpret MRI's, or even Lixiscope (handheld) fluoroscopy? Do labs in the ambulance?

the other dimension to the equation. you are 100% correct that recognition of an underlying disease may or may not prevail a correct treatment plan. It lies on the fact of developing a hypothesis based on the tools and diagnostic tests on hand to the provider.

Obviously non emergent cases of Endometriosis and cancer cannot be defined and treated in the field. Pt. would most likely present with pain present and a HPI related to that pain. If patient has history of a specific disease they may state they suspect a "acute illness" related to the medical history and Pre-hospital providers may treat the symptoms of the acute illness, I.E. if the patient has a history of endometriosis and is experiencing abdominal pain. thorough assessment rules out a bleed or constipation, the treatment plan would most likely include monitoring and pain management, (Proper positioning for most comfort, maybe some sort of analgesic depending on level of pain). I am sure if this is a new onset CT or xray reveals signs prevalent with the prognosis of a specific disease a ED physician may refer the patient to a specialist or his/her findings to a specialist for confirmation. I doubt a ED physician will hand a diagnosis of a malignant tumor based on his findings without conferring with a oncologist first.

 

[Brandon O]

I find the word used to be very immaterial. The question you're asking seems to be about whether we make decisions based on signs, symptoms, and other isolated findings (i.e. "give aspirin for chest pain"), or for more synthesized, interpreted analyses (i.e. "give aspirin for possible ACS").

The answer varies widely depending on your level, region, protocols, and personal approach. If you want, you can flip through the Mass protocols (http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1101.pdf) and compare the headings that sound like the former against those that sound like the latter. Both are present.

Note that even when one option is technically authorized or mandated, providers may often make the other type of decision based on their (perceived or real) understanding of the situation. But that can go in either direction. There are medics giving aspirin to aortic dissections and there are EMTs diverting to cath labs. Big world out there.

 

[TheLocalMedic]

Yes.

Or heck, call them BOTH "clinical impression," which is actually the name of the field I complete in my chart. Doesn't matter what we call it, we're all talking about the same process.

Interestingly, in day-to-day practice, I don't often hear physicians use "diagnose" as an active verb. I.e., you don't often hear a doctor say "I diagnosed the patient with pneumonia." Instead, they say something like "It looked like pneumonia, so I gave Zosyn," or "I found a pneumonia."

When the verb is used, it seems to usually be in the passive voice, and suggests some element of empiric skepticism. E.g., "The patient was diagnosed with CHF last year." It suggests some small element of doubt, as if to say "Some other doctor wrote this in the chart, but I haven't come to a conclusion myself."

Well put. I don't hear the word "diagnose" used very often either, and when I do, it's generally in the context of a patient's medical history. Perhaps some of this may stem from a hesitation to definitively announce that you have arrived at a conclusion, and that there is no possibility that your conclusion is wrong. Nobody wants to be wrong, after all, so leaving room for other possibilities by saying that you have formed a "clinical impression" rather than a "diagnosis" is a cheap and easy way to leave yourself an out in case you weren't on the money.

Sometimes I will say that I have a "working diagnosis", meaning that I'm fairly certain I know what's going on and am treating accordingly, but I'm also open to the possibility that there may be other factors in play or multiple disease processes at work.

 

[KellyBracket]

The question you're asking seems to be about whether we make decisions based on signs, symptoms, and other isolated findings (i.e. "give aspirin for chest pain"), or for more synthesized, interpreted analyses (i.e. "give aspirin for possible ACS").

What does it mean to establish a psychiatric diagnosis, versus an orthopedic diagnosis, versus a genetic diagnosis?

This question ("What do we mean by diagnosis?") is a deep philosophical question, with historical and scientific roots. It can be fun to delve into some of attempts to answer the question (e.g. http://www.tandfonline.com/doi/pdf/10.1080/03605310600860809), But I'll note one thing: I've never seen any scientist, philosopher, or historian write about who should or can diagnose, let alone based on professional designation.

 

[mycrofft]

What does it mean to establish a psychiatric diagnosis, versus an orthopedic diagnosis, versus a genetic diagnosis?

This question ("What do we mean by diagnosis?") is a deep philosophical question, with historical and scientific roots. It can be fun to delve into some of attempts to answer the question (e.g. http://www.tandfonline.com/doi/pdf/10.1080/03605310600860809), But I'll note one thing: I've never seen any scientist, philosopher, or historian write about who should or can diagnose, let alone based on professional designation.

What would you say when the district attorney or the grand jury asks you?

 

[KellyBracket]

What would you say when the district attorney or the grand jury asks you?

If the DA's office or grand jury is involved, it's a criminal matter, and is far more concerning than using the term "diagnosis" imprecisely.

OTOH, if it's a civil matter, then the plaintiff's attorney will be hammering me on 1) what tests I got, 2) what I did about them, and 3) what I did or didn't tell the patient. The issue of whether my chart says "diagnosis" or says "clinical impression" won't really matter if I told the AMI patient they "just have some indigestion!"

Why the concern about prosecution and/or litigation? Have you heard of a case where this came up?

 

[mycrofft]

Thanks for asking.

If the DA's office or grand jury is involved, it's a criminal matter, and is far more concerning than using the term "diagnosis" imprecisely.

OTOH, if it's a civil matter, then the plaintiff's attorney will be hammering me on 1) what tests I got, 2) what I did about them, and 3) what I did or didn't tell the patient. The issue of whether my chart says "diagnosis" or says "clinical impression" won't really matter if I told the AMI patient they "just have some indigestion!"

Why the concern about prosecution and/or litigation? Have you heard of a case where this came up?

I have some personal yardsticks to help keep me from screwing the pooch:
1. Would I want this done to me?
2. Would I want to see this does to my wife, or Mom, or Granny?
3. Would I have trouble watching a video of myself defending this action if on the stand under oath?

I have been called as a witness in suits and criminal cases concerning my former place of work (happily, not my personal actions). While the legal system is not a medical one, they can cut through our self-absorbed fogs (see armchair medical expert threads) by applying logic and precedent. I also was involved in writing standardized procedures (SP's) for nurses under the supervision of people who had experience, and the final product was inspected by the Calif Medical Association in their accreditation process.

The concept of the unique nature of a medical (MD) diagnosis, versus the decision-making involved in using protocols and SP's, was drummed home. For instance, organization; the original format which was discarded had the SP's organized by diagnosis (e.g., gonorreah), when the proper format was to list s/s under a symptom or region ("Genitourinary", or "Urethral discharge"). Ditto shortness of breath=> wheezing (asthma), stridor (airway embarrassment versus disease), vital signs suggesting cardiac involvement (CHF), etc.

The reason the original SP's were clumped and presented by diagnosis was it was faster and easier to write that way. It also presumed the nurse could tell the difference in cases where a higher degree of diagnostic skill and equipment was needed…as is the case in an ambulance or someone's front room. Or by some road at 2 AM in the rain.

It was not for us to tell the patient a diagnosis. If we were wrong, the MD had a lot of 'splaining to do. I'd say something like "Your blood pressure's low and your pulse is irregular, we need to get you to the doc asap, and I will" Now we're going to do XYZ". Not "You have CHF".

I see the point of the patient being properly informed, but telling them "In your condition, we are allowed to do XYZ" and doing them should meet that as it is the truth and within scope of practice.

I was seeing up to 53 pts a day (eight hr day with a couple hrs prep on either end and a 1/2 hr lunch, forget breaks) and while I was sometimes wrong, I was rarely wrong to the point a patient suffered and had no successful suits against my actions.

PS: when the problem was obvious I'd confirm the pt's suspicion (Yep, looks broke to me too").

 

[KellyBracket]

...
1. Would I want this done to me?
2. Would I want to see this does to my wife, or Mom, or Granny?
3. Would I have trouble watching a video of myself defending this action if on the stand under oath?
...

I think we're essentially on the same page. Good advice for all.

 

[johnrsemt]

Look at it from the Doctor end of it:

I have been discharged from the emergency department for "Undiagnosed chest pain", and for "possible allergic reaction", and for "possible asthma".

EMS people diagnose patients all the time, up to the scope of their training. It is not a diagnosis that will stand up in court, or maybe even to some doctors. But we do it.
I know I have never looked at a woman delivering a baby and stated "she maybe pregnant, but I can't say for sure cause I am not a doctor". LOL

 

[mycrofft]

Ever asked a woman "Oh, when's your due date" and got scowled at?:unsure:

KellyBracket, 10-4 agreed.

 

[unleashedfury]

Ever asked a woman "Oh, when's your due date" and got scowled at?:unsure:

KellyBracket, 10-4 agreed.

Yes, I've learned never assume a women is pregnant, if she dosen't say so, I do ask about last menstrual cycle though and it may lead down that road.

 

[mycrofft]

Yes, I've learned never assume a women is pregnant, if she dosen't say so, I do ask about last menstrual cycle though and it may lead down that road.

Haha, I hear you.

Wonder if there are any equivalent male questions?

Disregard that.:blush:

 

[unleashedfury]

Haha, I hear you.

Wonder if there are any equivalent male questions?

Disregard that.:blush:

I saw a episode of untold stories of the ER where a patient was receiving black market botox injections. Looked,sounded,and presented like a woman, Until the doc went to do a exam and prep a urinary cath.. Turns out she had some appendages that changed things up a little. I wish I could be a fly on the wall when a transgender is asked about meunstral cycles or pregnancy

 

[mycrofft]

A whole 'nother world about patient sensitivity. Had occasional transgender patients at my old job (ALL male to female), and always a struggle to find out properly how they wanted to be addressed.

But anyway, Can it be said then that the word "diagnosis" seems to be sort of loosey-goosey? Medical diagnosis, psychiatric diagnosis (DSM), nursing diagnosis (Marjorie Gordon).