Ruling out MI - Pressing on Patient's Chest

[VFlutter]

I can just as thoroughly diagnose a patient as a doctor can, but the difference I see is that I just don't have the same tools to use to confirm the said diagnosis

No, no you can not. Why does this "I am just as good as the doctor" crap keep coming up. Are you better than a MD since you do the same :censored::censored::censored::censored: only in the back of a speeding ambulance without all them fancy tools?

 

[TheLocalMedic]

No, no you can not. Why does this "I am just as good as the doctor" crap keep coming up. Are you better than a MD since you do the same :censored::censored::censored::censored: only in the back of a speeding ambulance without all them fancy tools?

Don't be condescending. Are you telling me that you can't or won't diagnose a patient because you aren't good enough? As I said before, many diagnoses are fairly easy to come to, and I can make that diagnosis just as easily as a physician can. I don't argue that I'm "just as good as the doctor" because our jobs are inherently different both in the amount of training we require and the resources we have available to us. But that doesn't stop me from being a good practitioner and calling 'em as I sees 'em.

 

[MediMike]

Chase I think you're overreacting a bit here. There are certain obvious things that can be diagnosed the same as a doctor could. I doubt LocalMedic was saying he could offhand call nonketotic hyperosmolar hyperglycemia off a set of vitals and a monitor, but if you are telling me that you aren't able to identify a simple fx, STEMI, or hypoglycemia well enough to call it a "diagnosis", well I think we're just arguing semantics.

 

[VFlutter]

Don't be condescending. Are you telling me that you can't or won't diagnose a patient because you aren't good enough? As I said before, many diagnoses are fairly easy to come to, and I can make that diagnosis just as easily as a physician can. I don't argue that I'm "just as good as the doctor" because our jobs are inherently different both in the amount of training we require and the resources we have available to us. But that doesn't stop me from being a good practitioner and calling 'em as I sees 'em.

I would like to think I am very competent at diagnosing medical conditions in certain specific populations. Yes, it is fairly easy to diagnoses that small population of common acute and chronic conditions that makes up the majority of EMS calls. I am sure that you can diagnoses that typical MI patient just as easily as a physician can. But outside of that population many us, including me, would be totally out of our league unless the diagnosis slapped us in the face. It is that population with atypical or non specific symptoms, non textbook presentation, mimics, complex multisystem dysfunction, or rare disease processes that require a physician's advanced education and experience.

That is nothing against you as a practitioner. You are not expected to be a the level of a physician with a decade of education and I am sure you are very good at your job however when I read "I can diagnoses just as easily as a physician" I take that as you comparing yourself to them. Maybe I am just cynical.

 

[Akulahawk]

I would like to think I am very competent at diagnosing medical conditions in certain specific populations. Yes, it is fairly easy to diagnoses that small population of common acute and chronic conditions that makes up the majority of EMS calls. I am sure that you can diagnoses that typical MI patient just as easily as a physician can. But outside of that population many us, including me, would be totally out of our league unless the diagnosis slapped us in the face. It is that population with atypical or non specific symptoms, non textbook presentation, mimics, complex multisystem dysfunction, or rare disease processes that require a physician's advanced education and experience.

That is nothing against you as a practitioner. You are not expected to be a the level of a physician with a decade of education and I am sure you are very good at your job however when I read "I can diagnoses just as easily as a physician" I take that as you comparing yourself to them. Maybe I am just cynical.

When it comes to a certain narrow set of problems, I can diagnose as well as a physician. Outside of a certain set of problems, however, I'm well out of my depth, and I know it. There have been times that I've handed the diagnosis to the doc on a platter... just because the patient's problem fell within my narrow area of expertise. Those times have been rare though. Most of the time, I try to figure out what I can do for my patient and go from there, and let the Doc do the diagnosing.

 

[JPINFV]

I practice medicine and make diagnosis every time I'm on the truck. It may have some warm a d fuzzy "provisional", "field", "working" ect in front of it but it is a diagnosis. A LOT of patients get admitted from the ED doc with a diagnosis as vague as "short of breath".

Umm, how is a "working diagnosis" supposed to be warm and fuzzy? Even physicians work with a working diagnosis when there are differentials that haven't been cleared yet.

 

[JPINFV]

Generally speaking (and I know this view isn't popular) I do not believe that paramedics diagnose. We treat a "field diagnosis" at best. You could argue that every diagnosis is a "working diagnosis" subject to change based on new information but the reality is that a paramedic's education is not based on developing a differential diagnosis.

How is a diagnosis any different from a conclusion based on the facts at hand?

It's a technician education and while I wish it was different we just don't have enough education to "know what we don't know" unless we've done a huge amount of aftermarket education or self study. If we could really diagnose then we wouldn't see so many studies showing we can't even predict who needs to be seen in the emergency department and who can be left on scene safely (one of the most glaring failures of paramedic education in the United States).

While I agree completely with the 'this is where we're at, and I wish it was different' thought, if we were to take the technician education to it's logical conclusion, than paramedics should be expected to follow cookbook protocols without thought. How can any branch be taken based off of judgement if the paramedic isn't making a conclusion based off of the assessment? How is that conclusion anything but a diagnosis? Sure, the number of cards, to steal from a column from Kelly Grayson, that a paramedic and a physician has to choose from and the amount they are holding (i.e. number of differential diagnoses considered) might be different, but that doesn't change the fact that at it's core a diagnosis is a conclusion. Is a primary care physician less of a physician because his diagnosis might not be as complex or specific as a specialists?

I actually think you can be a technician who exercises sound clinical judgment (what should I do, what should I not do).

I think that the very nature of the difference between a technician and a professional makes the ability of a technician to do any meaningful judgement very limited.

 

[mycrofft]

I'm not commenting further because the OP is sidetracked into an EMT Black Hole.

Oh, what the heck.

OK nursing diagnosis : "Pt is experiencing a deficit in oxygenation as indicated by (S/S 1,2 3). Nursing interventions are X Y Z"(pt postiion of comfort, check oxygen delivery if any orders, check oxygenation meters if any, notify MD or some such).

Versus "CHF as indicated by rales, altered BP (criteria), c/o breathlessness, swelling of dependent extremities (ankles, feet). Start O2 at 3 LPM via NRB, IV SNS TKO, etc etc".

No specialty other than MD (and PA/ FNP working under overview of MD) can make a diagnosis of what disease process is active then make a plan and treat. Paramedics and other technicians (and nurses) when not executing direct MD orders are following protocols or standardized procedures which are written by MD-moderated bodies.

You can make any diagnosis you want or as many as you want, but as sure as 5=4*, your actions must reflect what you see as related to a protocol, unless you are stumped, then you are on your own. Most incident review boards will decide you failed to detect (for whatever reason) significant s/s which would have put you on the right protocol.
====================================

*To refresh EMTLIFE veterans, "5=4":

1. Spell any number ("twenty")
2. Count the letters (6)
3. Spell the number of letters (three)
Repeat until you work your way down to between one and ten, (except seven and eight, which require an extra step), and it always boils down to "four"/4.

Ergo, "5=4" means "Machs Nix", or "it all boils down to this again and again".

 

[JPINFV]

A medical diagnosis is made by a Doctor, a nursing diagnosis is made by a Nurse, a provisional is made by a Paramedic. They are all inherently the same but inherently different and serve different purposes but are made after collecting a history, signs and symptoms, results of investigations etc and drawing upon a base of knowledge which may be anatomical, physiological, pathological, microbiological, psychological and/or a few others or likely all of them.

A paramedic's diagnose and a physician's diagnosis is inherently similar. A nursing diagnosis bears no similarity to a physician's diagnosis.

 

[mycrofft]

Damned skippy.

 

[Clare]

You can make any diagnosis you want or as many as you want, but as sure as 5=4*, your actions must reflect what you see as related to a protocol, unless you are stumped, then you are on your own. Most incident review boards will decide you failed to detect (for whatever reason) significant s/s which would have put you on the right protocol.

This makes no sense to me.

A patient with enough signs and symptoms of X problem +/- a history of factors which may increase risk of, or are consistent with, X problem will get whatever the treatment for X problem is but surely you do not treat every patient you go to with some sort of procedural or drug intervention?

A paramedic's diagnose and a physician's diagnosis is inherently similar. A nursing diagnosis bears no similarity to a physician's diagnosis.

Allow me to clarify; all diagnoses are identification of problems based upon a set of symptoms or other such presentation and results of investigations so in that sense they are all the same.

 

[mycrofft]

Clare,

"A patient with enough signs and symptoms of X problem +/- a history of factors which may increase risk of, or are consistent with, X problem will get whatever the treatment for X problem is..."

YES, exactly, as dictated by a protocol/ st proc. A MD could do something (s)he read that morning in a journal, use a drug off-label, even decide the pt is a phony and chew them out all the way to the lobby. IF a technician violates the protocol, it had better be good. A MD treats based upon the diagnosis; the technician treats based upon the s/s because the decision step in diagnosing is denied techs/nurses due to the level of training leading to certification/licensure.

"... but surely you do not treat every patient you go to with some sort of procedural or drug intervention?"

Correct, no s/s=no tx.


You got it! I just bug people when I get on that soapbox.

Now, I remember tossing DX back and forth with receiving ED people, but when it came time to write the report, unless I had their dx in hand, my working dx (like a working hypothesis; we didn't have protocols when dinosaurs roamed the streets) stayed off the run report.

 

[TomB]

But what about PA/NP do they make semi medical diagnosis? lol

I think they do, yes. But their training is completely different from a paramedic's education. Paramedics want all of the respect of being "clinicians" without any of the appropriate education and training. You can't have it both ways.

 

[medicsb]

It is interesting that X amount of MIs are reproducible as it doesn't make sense from a anatomic and physiologic stand-point. I've seen (read) it proposed that "reproducible" nature of CP in an MI patient may be due to poor communication either by the patient or the physician, poor interpretation of physical findings, or concomitant chest wall pain with MI. Obviously if you push hard enough on anyone's chest, it will hurt. The question to be asked very specifically is the pain felt upon palpation the same pain they have been feeling or is it different? Is there an underlying pain AND a chest wall pain? (Seen that; underlying pain resolved w/ NTG but not the chest wall pain.) Also, to be considered is leading the patient or the patient answering in a way they think cardiac chest pain may be like.

I did once have a patient with seemingly reproducible CP, it worsened with deep inspiration and arm movement (I do not remember if I assessed for chest wall tenderness) who apparently suffered a syncopal episode at the start of her night shift. Me and my partner were leaning towards it not being cardiac (possible malingering) except for the fact that she diaphoretic. 12 lead showed an Inferior STEMI w/ R ventricular involvement. She was relatively young, too.

Ultimately, the LR of reproducibility by palpation ranges from 0.21-0.41 based on 6 studies with sample sizes 492 to 7734. LR for pain related to breathing is 0.20 - 0.36 (3 studies encompassing >8200 patients). (See this recent meta-analysis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490454/)

Anyhow, I think it reasonable to triage to BLS for transport if the 12 lead is without STE or ischemic changes and the physical exam is otherwise benign. (I wouldn't deny transport.) At that point it becomes the job of a physician to determine a cause.

 

[zmedic]

Anyhow, I think it reasonable to triage to BLS for transport if the 12 lead is without STE or ischemic changes and the physical exam is otherwise benign. (I wouldn't deny transport.) At that point it becomes the job of a physician to determine a cause.

Not sure if I agree with this. Half of the point of ALS if for those patients who don't need an immediate ALS intervention, but have a decent probability of needing an intervention enroute to the hospital. I'd say patients with chest pain generally should be transported by ALS, even with a normal ECG. What is an EMT going to do if the patient's chest pain worsens enroute to the hospital? A medic could do another 12 lead and think about giving some nitro. What if the patient start having arrythmias? I'd rather a medic be in back with the patient on monitor.

Sure there are exceptions. You might say a 21 yo with no risks factors and no cocaine use who has some chest pain might not need ALS. But generally if someone was suspicious enough of this chest pain to either dispatch ALS in the first place or call for an intercept, you have to be really careful downgrading it to BLS. What's the worst that happens if ALS takes it in and it was nothing? You are out of service for a bit. But if you turff it to BLS and something happens....just doesn't look very good.

Keep in mind ECG changes can take awhile to develop. A normal ECG that you get 15 minutes after the patient starts having pain doesn't reassure me a whole lot.

 

[KellyBracket]

Observation and a suggestion:

First, the issue of who can diagnose is not quite as thorny and confusing as what a diagnosis is.

In all seriousness, there are a number of people interested in the "philosophy of medicine," and the topic of what constitutes a diagnosis is a healthy area of discussion. Even ER doctors discuss this. Historians of medicine are also quick to point out the shifting uses of the term over the centuries, as well as shifting bases for diagnosing. One thing I haven't heard stated, however, is that "only physicians can diagnose." On the contrary...

[A]lthough diagnosis ordinarily has medical connotations, this is not essential, for the term involves activities by no means unique to medicine. Although we may think of diagnosis as the identification of disease, such usage is far too narrow. Lester S. King

I.e. diagnosis is a human process, and should not be thought of as limited to the mythical scientist-physician. Instead, it is an act of pattern recognition, and active evidence collection, based in innumerable cultural and conceptual biases. And just like a lot of things that all humans do, it's often messy, and we don't talk about the process in public much!

So here is my proposal - stop using the words diagnosis/diagnosing/diagnostic. Instead, simply say what is going on!

With this method, controversial statements are avoided, and clarity is supported. For example, instead of "I diagnosed an MI," instead say "He was complaining of chest pain, and the ECG showed a STEMI-pattern." Or instead of "I diagnosed CHF," instead state "He was hypoxic, and my initial exam found rales and pronounced JVD." Both of these statements could be made by a medic or doctor, and both contain far more information if the root "diagnos-" is avoided.

Forgive me an additional extended quotation, but I particularly like this one. Understand that Dr King is a pathologist interested in the the medical philospohy of the 1700s and early 1800s. Why, then, does it seem to apply so well to this discussion?

"Scientific medicine lies not in formidable apparatus nor the myriads of available tests, nor in overflowing libraries, but in that stil small voice that I call critical judgment. This voice asks the important questions: 'Do you see a pattern clearly? How good is your evidence? How sound is your reasoning? Can you support your inferences with the means at your disposal? What are the alternatives? What hangs on your decision?' This voice, I believe, goes to the heart of scientific medicine. It has been speaking throughout the ages, but physicians do not always listen. And those who do not listen are empirics, regardless of the technical facilities at their command." Lester S. King

(N.B. "empirics" is another way to say "technician.)

 

[medicsb]

Not sure if I agree with this. Half of the point of ALS if for those patients who don't need an immediate ALS intervention, but have a decent probability of needing an intervention enroute to the hospital. I'd say patients with chest pain generally should be transported by ALS, even with a normal ECG. What is an EMT going to do if the patient's chest pain worsens enroute to the hospital? A medic could do another 12 lead and think about giving some nitro. What if the patient start having arrythmias? I'd rather a medic be in back with the patient on monitor.

But, what is the "decent probability" of a CP patient with reproducible CP or CP with respiration needing ALS intervention during transport? I'd bet that it is <1%. I've transported hundreds of isolated CP patients, and even counting the ones I treated with (M)ONA, I can count on one hand the number that required immediate intervention due to a sudden deterioration aside from fluid bolus for hypotension s/p NTG.

Sure there are exceptions. You might say a 21 yo with no risks factors and no cocaine use who has some chest pain might not need ALS. But generally if someone was suspicious enough of this chest pain to either dispatch ALS in the first place or call for an intercept, you have to be really careful downgrading it to BLS.

I haven't said you don't need to be careful, but I'd say that generally speaking, the sort of CP being discussed it largely low risk. I'm not saying that there is no need for ALS to ride with patients based on "what if", but shouldn't we have some sort of idea which patients those are, based on something other than a hunch?

What's the worst that happens if ALS takes it in and it was nothing? You are out of service for a bit. But if you turff it to BLS and something happens....just doesn't look very good.

Well, the worst is that the patient receives an unnecessary IV and develops septic thrombophlebitis and dies. Far fetched, but it is not outside the realm of possibility. Other possibility is that in a system with few ALS resources a patient that does need ALS intervention has to wait longer for it because ALS is riding in a a low risk patient because of some distant "what if" scenario. And then there is the cumulative healthcare cost associated wide-spread practice of ALSing patients needlessly (EMS should start policing itself, because the govt soon will - already heard of EMS' getting audited and questioned why so many patients are receiving IVs). Anyhow, anything can look "bad". Doesn't mean anything wrong was done. As an EM doc, I'm sure you know that all too well. I'm not convinced based on that argument.

Keep in mind ECG changes can take awhile to develop. A normal ECG that you get 15 minutes after the patient starts having pain doesn't reassure me a whole lot.

I'm well aware, which is why you would do another 12 lead when the patient arrives and then 3-4 hours later if negative. Had you seen the patient when EMS did, would you be doing a 12 lead every 5 minutes just in case?

 

[medic417]

And the obvious solution is all ambulances be staffed by Paramedics only.

 

[zmedic]

But, what is the "decent probability" of a CP patient with reproducible CP or CP with respiration needing ALS intervention during transport? I'd bet that it is <1%. I've transported hundreds of isolated CP patients, and even counting the ones I treated with (M)ONA, I can count on one hand the number that required immediate intervention due to a sudden deterioration aside from fluid bolus for hypotension s/p NTG.

By this argument anyone who doesn't get ALS interventions on scene probably can be taken to the hospital by BLS. The vast majority of ALS calls don't get actual ALS treatment (ie meds or fluids or intubation), but as a system we say "patient's with x complaint are still ALS even if all we do is monitor them."

I'm just saying you've got to be careful downgrading patients to BLS. And if someone actually has an ALS type complaint (chest pain, altered mental status, GI bleeding) they should generally be transported by an ALS provider. If you've been able to risk stratify them in a very clear way by all means downgrade them. But that shouldn't be done just based on a normal ECG. It should be someone that you could stand in front of your medical director and say "this patient did not need continuous ECG monitoring, there was almost no chance of needing IV medications, and based on our protocols I felt safe having BLS transport."

Note the last part of the statement. It's very based on your system. Some systems say "all chest pain gets a medic to ride with them." Others give you more leeway. Do what's right for the patient and you'll never get in trouble. So be sure in your mind that it's not in a given patient's best interest to have a medic bring them in.

 

[KellyBracket]

And the obvious solution is all ambulances be staffed by Paramedics only.

Well, that's the direction taken by some services. Or even physician only, as with the SAMU system in France.

Zmedic, I would only point out one thing: Medics can diagnose, but OEC? I'm not so sure!