Transferring Care and the "Field Impression"

[EpiEMS]

Do you share your field impression/field diagnosis/[pick your term] when you transfer care to the receiving facility? If so, how do you qualify it? Does how you explain what you think is going on differ by the type of patient (e.g. medical vs. trauma)?

I'm not clear on whether the appropriate term is "field impression," "field diagnosis", "diagnosis", "impression," etc., so any guidance is appreciated!

Technically, I'm fairly sure you could call what we do in assessment a diagnosis, but I want to qualify it, at least a bit.

 

[NysEms2117]

Do you share your field impression/field diagnosis/[pick your term] when you transfer care to the receiving facility? If so, how do you qualify it? Does how you explain what you think is going on differ by the type of patient (e.g. medical vs. trauma)?

I'm not clear on whether the appropriate term is "field impression," "field diagnosis", "diagnosis", "impression," etc., so any guidance is appreciated!

Technically, I'm fairly sure you could call what we do in assessment a diagnosis, but I want to qualify it, at least a bit.

I tend to notice my CC-medic says his impression or whatever you want to call it, when he radios in for initial contact with the hospital. Or has me call in his impression because he's doing some medic thing. This is obviously used in trauma quite a bit for resources reasons, (if the hospital needs to do something special, trauma team, anesthesia ect)

 

[EpiEMS]

I tend to notice my CC-medic says his impression or whatever you want to call it, when he radios in for initial contact with the hospital. Or has me call in his impression because he's doing some medic thing. This is obviously used in trauma quite a bit for resources reasons, (if the hospital needs to do something special, trauma team, anesthesia ect)

I think trauma and couching things in broad "syndromes," if you will, makes things easier than calls that are medical in nature, especially for a BLS provider. I'm much more comfortable saying that I suspect a humeral fracture, say, than I am saying that I suspect new onset pneumonia - but I'm as comfortable saying that I think this patient may be having a CVA (or that they're here to rule out CVA, if you will) as I am saying they have a long bone fracture of some kind.

 

[NysEms2117]

I think trauma and couching things in broad "syndromes," if you will, makes things easier than calls that are medical in nature, especially for a BLS provider. I'm much more comfortable saying that I suspect a humeral fracture, say, than I am saying that I suspect new onset pneumonia - but I'm as comfortable saying that I think this patient may be having a CVA (or that they're here to rule out CVA, if you will) as I am saying they have a long bone fracture of some kind.

I can't really speak because any calls that I'm "lead" on. Are taxi calls. And we only take them so I don't think I'm his slave(I am an assistant, I understood my job description he just feels bad) so all of his calls are pretty bad since we are a Cct rig. So he tells me "call it in say my impression is xyz, they probably have this, activate xyz" then we call back in route saying interventions ect.


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[NomadicMedic]

The majority of things that we see fall into pretty large buckets, and any diagnosis or impression that you would make and relay will probably be one from those all encompassing areas.

And really, If you're following the treatment pathway for a particular patient, your diagnosis has already been made, hasn't it?

 

[VentMonkey]

Pretty much what @DEmedic is saying. As far as me specifically? I am more inclined to activate strokes or STEMI's aggressively even if they don't meet "textbook" criteria, but I still feel something isn't quite right with the patients presentation.

The same could be said for septic patients. While we don't officially have a "sepsis protocol" as of now, I believe in pushing this thought processes along to the receiving ED if I suspect such. Most of the ED's locally where I am get to know the paramedics after they've been in our system long enough, and will trust their judgement...or not.

The same holds true for the opposite. Let's say we're hypothetically launched for a stroke and for whatever reason upon my assessment it just doesn't fit stroke alert criteria, be it they're s/s have resolved, or it's just too vague to clearly say this screams stroke alert. I wholeheartedly believe in calling in and telling the ED as such, that for example, they're not quite meeting criteria, but if they so choose to this may meet alert criteria on arrival.

Another good example is a flash pulmonary edema on a ground shift that may still be refractory to CPAP, and may actually require emergent induction--->intubation, when I don't have an RN with me for prehospital induction. Letting the receiving ED know in advance "Hey, have RT ready and prepare for such..." is something that can only benefit the patient and make transfer of care much more seamless (in theory).

The above examples are what (to me) separates a mediocre paramedic technician from a well trusted paramedic clinician.

As far as specifics for my hand offs, I try and keep it pertinent to the complaint at call time; the rest gets filtered through once we off load. Hope this helps some, Ep.

 

[StCEMT]

If it's something known, then yes. OD, asthma, stroke, etc. If it's something more general like abdominal pain then I just leave it at that.

 

[VentMonkey]

If it's something known, then yes. OD, asthma, stroke, etc. If it's something more general like abdominal pain then I just leave it at that...unless it's screaming acute abdomen.

I know exactly how you mean.

 

[NomadicMedic]

I've seen newer medics get so hung up in the specifics of a differential that they fail to recognize the overarching problem. In the case of something that may have a vast array of causes, like an altered mental status, with our limited diagnostic capability, its smart to rule out the immediately correctable things and then move down the list. Sugar? CVA? Cardiac? Intoxicants? Sepsis? And on and on... if you're clinician and not just a technician, you'll find a pathway that leads you down the road to discovery.

And there is nothing wrong with doing a great assessment, using all of your tools and skill and then walking in to the ED and saying, "Hi doc, I found this 24 year old guy* slightly confused and just a little off at a McDonalds and I just can't figure out what's goin' on..."

(*Turned out to be a bleed. A congenital defect that was later repaired)

 

[VentMonkey]

And there is nothing wrong with doing a great assessment, using all of your tools and skill and then walking in to the ED and saying, "Hi doc, I found this 24 year old guy* slightly confused and just a little off at a McDonalds and I just can't figure out what's goin' on..."

(*Turned out to be a bleed. A congenital defect that was later repaired)

AVM?

 

[NomadicMedic]

AVM?

Yep. He had it clipped and had a completely uneventful recovery.

 

[VentMonkey]

Yep. He had it clipped and had a completely uneventful recovery.

Did he have a "thunderclap" headache?

They (AVM's) don't sound all that uncommon, and if caught in time, (i.e., in young and healthy adults) their neurological recovery seems quite remarkable.

 

[NomadicMedic]

I'll hijack this thread for a second;

Dispatched to a McD's for a sick person. Guy is sitting in a booth, had a bit of a flat affect, but answered all of my questions appropriately. His GF said he was just acting kind of funny. No complaints. No headache. No history. He just seemed "off". That was it. I talked him into going to the ED with us, he got a CT and a neuro consult. Got flown out shortly after.

 

[VentMonkey]

I'll hijack this thread for a second;

Dispatched to a McD's for a sick person. Guy is sitting in a booth, had a bit of a flat affect, but answered all of my questions appropriately. His GF said he was just acting kind of funny. No complaints. No headache. No history. He just seemed "off". That was it. I talked him into going to the ED with us, he got a CT and a neuro consult. Got flown out shortly after.

So I am going to go out on a limb here and say clinical insight and experience just sort of told you something just doesn't add up, or isn't quite right?

It's a great example and can be incredibly frustrating to see newer providers blow things off as such (not to mention quite dangerous), or Nurse Ratchett roll their eyes at your work up solely based on instincts.

The same rings true in telling you (generalized) when some seems to be yanking your chain, at least for me anyhow.

Again, technician meet clinician.

 

[NomadicMedic]

Yeah, that's basically it. I got his girlfriend away for a few minutes while fire and my partner got him to the truck. I was trying to find out what was really happening and she thought he was just acting funny. I'd never seen the guy before, but felt that he was just not really tracking appropriately when I was talking to him and it just raised my index of suspicion for an intoxicant, poison, electrolyte imbalance or a lesion/bleed. He just kept saying he was tired and wanted to go home. The fact that she noticed and was worried was what lead me to really push to transport him.

As an aside, my partner gave me a bit of grief about transporting him. He thought there wasn't anything wrong with the guy. I didn't gloat excessively when we found out about the bleed a few hours later.

 

[VentMonkey]

I think all to often the less experienced are lured by the "sexiness" of skills.

That is a technician, it doesn't take too long to master the limited skills given in a toolbox. If I was a physician, I would be more inclined to trust the clinician who stuck by their guns, and offered up proficient reasoning for their thought processes. The bilateral IV's on said patient should be treated much like your approach to your partner, @DEmedic; without excessive gloating.

It has nothing to do with being a badass IMO, but has everything to do with cutting down time on a critically ill or injured patient that you found to be based on your clinical assessment.

There are patients that I would deem critical, others may not, that got the full work up and were pushed straight to a resus bed even though others may have played it down, say, a legitimate polypharm OD. Again, you don't know what you don't know, and neither does your patient which is most important.

That's what gets me about people's lack of desire to further understand the typical pathologies we encounter in the field. Particularly when they've been doing it for some time. Monkey medicine isn't VentMonkey's medicine...

 

[NomadicMedic]

Right... and to circle all that back around to the OPs original question, I think there's a couple of important points to remember when you're presenting a patient to the ED:

You have to be honest in knowing what you don't know and/or stand up for yourself if you know something specific when you're making that bedside presentation.

You have to have a relationship with the docs and nurses before they'll trust anything you have to say.

You have to have your **** together when you present your patient to the ED. The staff is much more likely to actually listen if you present your patient in an orderly and organized manner. Tell them what's up, tell them what you did, hand them copies of relevant material, like serial 12 leads, asking they need anything else...

 

[StCEMT]

You have to be honest in knowing what you don't know and/or stand up for yourself if you know something specific when you're making that bedside presentation.

As a very, very green medic, I know I am only scraping the surface on what I know. Scenarios like the one you gave kinda of make me pause and think, but not sure that I have enough time and experience to have that gut feeling to push this guy to go with us instead of suggesting he check with a doc. There are a lot of things I am 100% confident in calling, this is one of those things I was talking about in the last post of "I got no idea what's going on, this is what I know" and list XYZ that I know.

 

[VentMonkey]

As a very, very green medic, I know I am only scraping the surface on what I know. Scenarios like the one you gave kinda of make me pause and think, but not sure that I have enough time and experience to have that gut feeling to push this guy to go with us instead of suggesting he check with a doc. There are a lot of things I am 100% confident in calling, this is one of those things I was talking about in the last post of "I got no idea what's going on, this is what I know" and list XYZ that I know.

I always, always, ALWAYS encouraged my interns to follow their instincts, even if they're not earth shatteringly correct, they most certainly have yielded me many a good nights sleep and guiltless conscience. As time passes you will get better at the "sick" vs. "not sick".

This is for all newer providers, I know you're a sharp guy.

 

[Carlos Danger]

As a very, very green medic, I know I am only scraping the surface on what I know. Scenarios like the one you gave kinda of make me pause and think, but not sure that I have enough time and experience to have that gut feeling to push this guy to go with us instead of suggesting he check with a doc. There are a lot of things I am 100% confident in calling, this is one of those things I was talking about in the last post of "I got no idea what's going on, this is what I know" and list XYZ that I know.

Fake it till you make it.

I used to hate that phrase but I've learned it really is a very useful technique.