Transferring Care and the "Field Impression"

[VentMonkey]

Fake it till you make it.

I think the caveat to me with this phrase includes never, ever stop learning.

Cheesy? Perhaps, but pick brains, read journals, blogs, podcasts, whatever. Eventually it will help you "make it" that much sooner.

 

[hometownmedic5]

Unless my clinical findings have eliminated all other possibilities(had an angulated humerous Fx last week, and of course something like ST elevation with reciprocal depressions and the like); I refrain from presenting a specific diagnosis per se. While some things are within the purview of field providers to diagnose accurately, others are not and the line is not always clear. Also, when you're wrong, you look foolish. I work in a system that, with few exceptions, is a single point of entry system, so I see the same nurses and doctors day in and day out. Not looking foolish becomes more of an issue than ego. When I need to call in and get orders to do weird stuff, I need the doctors to know my name and respect my clinical judgement. If I arrogantly stroll in time after time with a CHF pt and call it PNA or vice versa or try and make diagnoses beyond my scope because I read one journal article about it(but not the other ten that refute the first one); my name is going to ring out in my ED for sure, but not in a good way.

I tell them what I found and what I thought based on those finding only in the capacity of justifying why I did or didn't do this or that. I don't do their job and I don't let them tell me how to do mine. Its a system that works for me in the system I work in, which doesn't make it right or wrong.

 

[CALEMT]

Fake it till you make it.

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

And when in doubt VOMIT. Vitals, oxygen, monitor, IV, and transport.
They say for test taking that your first initial answer "gut answer" is typically correct. When you second guess yourself is when you start checking the wrong answers. I guess you can say the same can be applied here.

 

[VentMonkey]

Welp, I am going to add I am not blatantly pointing out diagnoses. I am in no way a doctor and long gone are the days of the "paragod" IMO.

I will more than like say something to the effect of "it looks like it may be...", or "I'm thinking it's 'x' instead of 'y'". This leads it open to both dialogue and a teachable moment between myself and the EM physicians.

 

[CALEMT]

Welp, I am going to add I am not blatantly pointing out diagnoses.

But if it looks like a duck, quacks like a duck, and walks like a duck one would be inclined to say that it is in fact a duck. Unless you're one of those people that thinks its a squirrel...

 

[StCEMT]

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.

This is one of those cases, I don't really know what instinct would say on the sick or not sick scale. I for sure would have the "somethings off" feeling, but my suggestion to be checked would be from my uncertainty rather than my sense of urgency. I have yet to have the experience of having to rely on my gut and not have a senior person to refer to, so definitely a work in progress. Throw in a little newbie mental second guessing for good measure. But I don't mind walking in to a place and saying I don't know, I actually had that happen a few weeks ago with a dude me and my partner brought in. We couldn't find anything definitive so the doc went down the stroke until proven otherwise path.

Fake it till you make it.

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

Grew up hearing my grandma say that. Pretty much sums up my life, most of the time I just figure life out as I go. Use this philosophy a lot at work, just with people abusing 911 or nursing home staff, not those that need it immediately. Good saying to work with though at the appropriate times.

 

[EpiEMS]

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.

Mr. @DEmedic, sir, you're welcome to hijack my car if you so wish - this is a very useful digression!

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...

I feel like this is the kind of direction I never had gotten explicitly enough before - this all makes very good sense to me.

Welp, I am going to add I am not blatantly pointing out diagnoses. I am in no way a doctor and long gone are the days of the "paragod" IMO.

I will more than like say something to the effect of "it looks like it may be...", or "I'm thinking it's 'x' instead of 'y'". This leads it open to both dialogue and a teachable moment between myself and the EM physicians.

I've generally seen my favorite medics take this tack, and it looks good to me. Most of the time, for an ALS call, I'm not the one giving report, just helping to transfer the patient, and with my BLS calls that I give report on, they generally are something a bit vaguer, less acute complaints (or obvious traumatic injury) so I am hoping for the chance to be able to give report on an ALS call some time...

 

[zzyzx]

It may be easier for you, when giving a report on the radio, to just state the patient's chief complaint and a few of their relevant symptoms. You can't go wrong with that.
I.e., "A 70 y/o female who is complaining of L arm numbness since waking up this morning 6 hours ago. She has no weakness in that arm or her other extremities. No facial droop, no slurred speech."

On the other hand, when the diagnosis is obvious, you don't have to be afraid to state it.
I.e., "A 70 y/o female who looks to be having stroke. She has left arm weakness, slurred speech, and facial droop."

 

[EpiEMS]

It may be easier for you, when giving a report on the radio, to just state the patient's chief complaint and a few of their relevant symptoms. You can't go wrong with that.

I like this approach - it also ties in nicely to broader "activations", like a trauma alert/stroke alert/sepsis alert!