Protocol V. On-Scene Judgement Calls

Miss Xina

Forum Lieutenant
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Wow, ok, whatever. I'm going to stop now before I get banned. I like this place a lot and plan on sticking my uneducated arse around for quite a while.

I wasn't saying anything bad about you, Jeez, you really are sensitive today. I was saying that I know people here who have been medics for 13 years for example.

They could just probably run off the textbook list and stuff they learned from experience.

I find I learn more from people that have been around the block a few times than I ever would from a book, or even a class!
 

Sasha

Forum Chief
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How the heck can you treat something without a working diagnosis?
 

Sasha

Forum Chief
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*shrugs*

beats me!!

Then why advocate not diagnosing? I used to be ignorant as well and thought that you didn't diagnose.. but you HAVE to to treat something effectively. Symptoms are treated differently according to what you think is going on.

now that is not to say you go around telling someone their chest pain is GERD and they don't need to go to a doctor, but you always form a working diagnosis and go from there.
 

Miss Xina

Forum Lieutenant
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Then why advocate not diagnosing? I used to be ignorant as well and thought that you didn't diagnose.. but you HAVE to to treat something effectively. Symptoms are treated differently according to what you think is going on.

now that is not to say you go around telling someone their chest pain is GERD and they don't need to go to a doctor, but you always form a working diagnosis and go from there.

I'm not advocating not diagnosing. I was merely pointing out WHY in class we were not taught every cause for every symptom.

What erked me, was in role-playing, we had a patient who was having an asthma attack. I said that we needed to administer Epi. My teacher demanded to know why I think that, and cos I knew why, but couldn't quite put it into words, he said if I were a medic student then I would have not gotten marks for that call.

Seeing as we weren't taught that in class, I just happened to know it from experience, I thought he would have been impressed!

It was really early on in the course so I didn't really have the medical knowledge to explain it.

We had this huge debate in class why we don't diagnose yet they expect us to differentiate between an allergic reaction and an asthma attack.

We didn't get a good response.

Just because I am telling you what we were taught in class, does not mean I advocate anything!

We're taught to call medical direction for EVERYTHING.. except administer o2.

Another example, role playing. The patient is having a heart attack. I say this and my teacher says 'no, you don't say that, you're say "chest pains with radiating pain down the arm and shortness of breath"

Again, I asked why not.
 

Jon

Administrator
Community Leader
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... Big lesson - we are not drs, we do not diagnose

Incorrect. A long-held fallacy of EMS.

We may not call it a diagnosis - but guess what - we diagnose many of our patients.

To treat something, we NEED to at least have a differential diagnosis. We may call it something else to not interfere with the great medical hierarchy, but we diagnose.
 

Miss Xina

Forum Lieutenant
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Incorrect. A long-held fallacy of EMS.

We may not call it a diagnosis - but guess what - we diagnose many of our patients.

To treat something, we NEED to at least have a differential diagnosis. We may call it something else to not interfere with the great medical hierarchy, but we diagnose.

Yeah, I know. I was merely pointing out WHY we weren't taught the causation of many symptoms. Which sucks.
 

zaboomafoozarg

Forum Crew Member
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To those whom it may concern,

Lay off of Xina, folks.

Not sure how long it's been since many of you went through EMT school, but either it never happened to you or you forgot how HARD they pound into you that you never diagnose a patient.

The fact is, the textbooks' main goal and theme by and large seems to be 1. cover your butt, 2. don't do anything wrong, and 3. work only according to protocols like a mindless pawn, THEN treat the patient after meeting goals 1, 2 and 3!

Sure, common sense tells us this is all wrong. You have to have at least an idea on the backburner of your mind as to what is going on with the patient so that you can begin to treat and provide ongoing care as well. (Not to mention watching for deterioration

Now that doesn't mean you tell the head-ache patient, "Hey, you have an aneurysm in the brain" or anything like that. But rather you consider it a possibility and watch for signs of stroke, among other things, right? Right.


There's a difference between being mindful of a POSSIBLE and/or PROBABLE diagnosis, and making your own definitive diagnosis which you're not qualified at all to do. Correct me if I'm wrong, Xina, but I believe you were talking about the latter, here?


To lash out at Xina and treat her like an imbecile because she echoed what most students have been taught is counter intuitive. Clearly what she said came off wrong and not entirely what she meant. So give some helpful advice instead of freaking out.

That's all I'm going to say. If this rebuke applies to you, well... you know who you are.


 
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JPINFV

Gadfly
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Now that doesn't mean you tell the head-ache patient, "Hey, you have an aneurysm in the brain" or anything like that. But rather you consider it a possibility and watch for signs of stroke, among other things, right? Right.


There's a difference between being mindful of a POSSIBLE and/or PROBABLE diagnosis, and making your own definitive diagnosis which you're not qualified at all to do. Correct me if I'm wrong, Xina, but I believe you were talking about the latter, here?

...which is pretty much what everyone is saying. No one is saying that a EMS providers make a definitive diagnosis. This is why the qualifying terms "differential" or "field" is being thrown around in front of "diagnosis."
 

firecoins

IFT Puppet
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Protocol is get vitals on every patient, poor on scene judgement is "This guy is just a drunk, we don't need no stinkin vitals"

vitals are apart of assessment. I guess they arpart of protocols but I usually refer to what I am suppossed to do once the assessment has been done.
 

Sasha

Forum Chief
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vitals are apart of assessment. I guess they arpart of protocols but I usually refer to what I am suppossed to do once the assessment has been done.

But why do you do your assesment? Because protocols tell you too :p Just nod and agree.
 

Onceamedic

Forum Asst. Chief
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not one person told me any causes for bloody vomit LOL

Fair enough! Following is the differential diagnosis of hematemesis, or as you say, the causes for bloody vomit.

*

Trauma Causes
o Benign mucosal tear/esophagus
o Esophageal trauma

*

Electromagnetic, Physics, trauma, Radiation Causes
o Esophageal burn
o Esophageal radiation

*

Iatrogenic, Self Induced Disorders
o Nasogastric suction

*

Surgical, Procedure Complication
o Gastroscopy complication/effect
o Ulcer, anastomotic/stomal/post surgery

*

Infectious Disorders (Specific Agent)
o Leptospirosis/severe (Weils) type
o Ebola virus disease
o Yellow fever
o Aspergillosis
o Esophageal candidiasis
o Intestinal anthrax
o African hemorrhagic (Marburg) virus disease

*

Infected organ, Abscesses
o Stomach abscess

*

Neoplastic Disorders
o Leukemia, acute
o Zollinger-Ellison syndrome/gastrinoma
o Adenocarcinoma, gastric
o Carcinoma, esophageal
o Esophageal tumor
o Gastric adenoma (polyp)
o Stomach leiomyosarcoma
o Stomach, carcinoma, scirrhous
o Stomach lymphosarcoma
o Stomach, leiomyoma
o Gastrontestinal Stromal/Mesenchymal Tumor (GIST)

*

Allergic, Collagen, Auto-Immune Disorders
o Duodenal Crohn's disease
o Esophageal Crohn's disease
o Milk protein allergy/diarrhea
o Watermelon stomach/GAVE Scleroderma

*

Congenital, Developmental Disorders
o Arteriovenous malformations
o Generalized essential telangiectasia
o Intestinal telangiectasia

*

Hereditary, Familial, Genetic Disorders
o Telangiectasia,hereditary hemorrhagic
o Hereditary coagulopathies

*

Relational, Mental, Psychiatric Disorders
o Bulimia and purging/eating disorder

*

Anatomic, Foreign Body, Structural Disorders
o Gastrointestinal bleeding
o Gastric ulcer
o Penetrating duodenal ulcer
o Peptic ulcer hemorrhage
o Pulmonary hemorrhage/bleeding
o Stomach, perforation
o Upper GI bleeding
o Channel pyloric ulcer
o Epistaxis/nose bleed
o Esophageal ulceration
o Varices, esophageal
o Fistula, Aorticoduodenal (Aorticoenteric)
o Mallory Weiss syndrome(esophageal tear)
o Gastric varices
o Dieulafoy's Ulcer Lesion
o Hemosuccus Pancreatitis

*

Arteriosclerotic, Vascular, Venous Disorders
o Gastric infarct

*

Functional, Physiologic Variant Disorders
o Malingering
o Vomiting

*

Vegetative, Autonomic, Endocrine Disorders
o Esophageal free reflux/GERD syndrome
o Gastric retention, acute
o Cushing/gastric stress ulcer
o Portal hypertension
o Hypergastrinemia

*

Reference to Organ System
o Gastritis, acute
o Duodenal ulcer
o Disseminated intravascular coagulopathy
o Gastritis
o Gastritis, stress, erosive
o Cirrhosis
o Esophagitis
o Peptic ulcer disease
o Thrombocytopenia
o Peptic esophagitis, chronic
o Telangiectasia
o Renal Failure Chronic
o Barrett's esophagus syndrome

*

Eponymic, Esoteric Disorders
o Blue rubber bleb nevus syndrome

*

Pathophysiologic
o Bleeding diathesis

*

Heirarchical Major Groups
o Gastric disorders
o Esophagus disorders

*

Drugs
o Aspirin (Acetylsalicylic acid) Administration/Toxicity
o Non-steroidal anti-inflammatory drug
o Corticosteroid Administration/Toxicity
o Aspirin gastritis
o Iron intoxication, acute
o Salicylate intoxication/overdose
o Drug induced Gastritis.
o Warfarin (Coumadin) Administration/Toxicity
o Chemotherapy, cancer (anti-neoplastic)
o Heparin Administration/Toxicity

*

Poisoning (Specific Agent)
o Baneberry (Actaea) intake/poisoning
o Puff adder snakebite. (Bitis)
o Alcohol gastritis
o Cuckcoopint/Arum/Wake-Robin plant
o Alkali corrosive/ingestion
o Caustic agent ingestion
o Corrosive agent ingestion
o Corrosive esophagitis
o Isopropyl alcohol ingestion/poisoning
o Mercury salts/bichloride acute toxicity
o Mushroom/Amanita Phalloides poisoning
o Thallium poisoning
o Alkali Ingestion/Poisoning

*

Organ Poisoning (Intoxication)
o Corrosive gastritis
o Gastritis, erosive/corrosive
o Toxic gastritis/poison
o Jejunal ulcer/stenosis from K tabs



PS.. when looking for causes of things, google "differential diagnosis" . That is what will tell you the possible causes of the symptom you are interested in.
 

Chimpie

Site Administrator
Community Leader
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EMTLife.com Community Guidelines: The basic ground rules for discussions on our forum are simple: be polite....
Let's keep it civil.
 

daedalus

Forum Deputy Chief
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Well, an EMT cannot preform an effective differential diagnosis if they are only using what they learn in EMT class. They would need a much greater foundation in normal physiology and altered physiology than is taught to them intially, which really is an argument for continuing to learn all you can or curthering your medical education.
 

mycrofft

Still crazy but elsewhere
11,322
48
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Protocols versus on the scene calls...

we are far afield.

Imagine yourself as an administrator trying to make sure a group of energetic partially (versus a doctor, or a paramedic) trained technicians are not over or maltreating the public. Required by law I might add. NOW think about how you would try to make this work.
This will teach you some of why there are protocols and why people who will not follow them need to go somewhere else. Like football and rugby; you want to plat rough, play rugby, because in football you will be benched then thrown out.

PS: The "if the shoe fits wear it" routine is an example of "shooting the choir"; since you can't find or face the culprit who raided the collection plate, you shoot the choir. EVERYONE takes rants to heart*, the the caveat "Only get excited about this if it applies to you" is a sloppy excuse for not emailing or naming folks you have a bone to pick with.



*Unless they are like me and don't really care a lot of the time.
;)
 
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mycrofft

Still crazy but elsewhere
11,322
48
48
Kaisu!!

Wow, ZEBRA FARM!!B)
 
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