Can you diagnose in the field?

[Dustdevil]

This whole "WE DON'T DIAGNOSE!!" mantra is a tired old bag of dinosaur bones left over from the early 1970s, when no paramedics were educated to a level of competency where they could differentiate between one tummyache and another. When all dyspnea was the same. When we were merely the eyes and ears of the medical control physician, and nothing more. Although that culture persists in many regions today, we are finally starting to move solidly away from it towards an era of professional medical practise, where paramedics will be educated to do rudimentary diagnoses, as well as prescribing specific short-term treatment instead of just giving every tummyache an IV and oxygen.

Continuing to to parrot that old line doesn't ingratiate you to those of us who were here when it was true. And it certainly does not bode well for your potential to be a part of the future either. It is time to either get on board with the future of EMS or to get out altogether.

[jmac]

This is just my opinion but if we do not diagnose are we doing the best for our Pt's.

Is it not better to make a provisional diagnosis and be proved wrong then to come in with dust's "pain in the tummy", take a Pt that you have been called to for ? a CVA ( i am not going to use any ALS interventions for to show my point), you arrive and all the indicaters are there, but on your work-up you find that the Pt is in SVT (A-fib or flutter).

The Pt has no previous Hx of cerebral events or cardiac and has been feeling unwell for a number of days ending in collapse and LOC a number of hours ago, so you arrive at the ED with an obvious CVA Pt and a possible heading towards unstable SVT that you have a diagnosis for and evidence (ECG) and event Hx, so that you have a probable cause of the CVA (washing machine effect) that can be addressed straight away where the CVA has to be worked up (CT ect).

I know most here could look at this and say that this is a simple example, but hey this is pre-hosp diagnosis at its best, the obvious and the underlying, and because of the diagnosis the Pt's cause can be addressed there and then.

I hope this makes some sense, i have been up all night and this piqued my interest, our provisional diagnosis on the ground is the thing that actually directs the ED, regardless of your level towards a Pt's better clinical care, no staff in an ED is going to ignore or discard your diagnosis without investigation, so long as you have the facts.

[aussiephil]

I agree with jmac (for a change)

I think our role is to provisionally diagnose what we have indicated by the signs & symptoms presented to us.

That is what we then use our Protocols for.

The difference here is can we differentially diagnose in the field? In some cases, i believe yes we can, as has been sighted in some cases earlier.

But

let me question paramedic mike further on the question of a stroke patient. In essence there are a number of types of 'strokes' a person can have, but the main 2 are Ischaemic & haemhorragic. Will the patiernt not present to you clinically the same in the early stages & can you, without the use of a CT scan differentially diagnose the type of stroke the patient is having & what their likelihood of recovery is?

I think it is important to provisionally diagnose & initiate treatment, but, differential can really only be undertaken in hospital where there are full testing facilities to confirm or deny the provisional diagnosis.

Sorry, had to throm my bit in.

Phil

[AZCEP]

Echoing Rid and Dust, our diagnostic ability is limited by the educational level and the tools we have available. Consider that there was a time that doctors were diagnosing without CT/MRI/lab values. This is basically where we are now. Quite possibly the single most underused tool we have at our disposal is the thorough history and physical exam.

Can't diagnose, can't treat. Can't treat, why respond in the first place?

[zippyRN]

This whole "WE DON'T DIAGNOSE!!" mantra is a tired old bag of dinosaur bones left over from the early 1970s, when no paramedics were educated to a level of competency where they could differentiate between one tummyache and another. When all dyspnea was the same. When we were merely the eyes and ears of the medical control physician, and nothing more. Although that culture persists in many regions today, we are finally starting to move solidly away from it towards an era of professional medical practise, where paramedics will be educated to do rudimentary diagnoses, as well as prescribing specific short-term treatment instead of just giving every tummyache an IV and oxygen.

Continuing to to parrot that old line doesn't ingratiate you to those of us who were here when it was true. And it certainly does not bode well for your potential to be a part of the future either. It is time to either get on board with the future of EMS or to get out altogether.

Nursing diagnoses has come up in this discussion perhaps unsuprisingly , needless to say nursing diagnoses as an art form seems to be an particualery American art, although we i nthe Uk do do nursing diagnosis it;s not anal-ised to the point that NANDA seems to be

Of course none Medical Practitioner helathcare providers diagnose - what we don't often do is provide the final diagnosis everytime

[todd17ff]

I agree with the above post. I believe you have to diagnose specific problems to treat them properly. EMS is constantly moving forward. As paramedics and EMT's we have to stay on top of the game through education and training.

[Just Plain Ruff]

Excellent excellent replies

Now a follow up question

Since we all do diagnose, what if any training courses should we invest in or provide to our students/employees to aid them in their ability to diagnose someone and give the receiving ER or facility their best diagnosis.

[AZCEP]

Anything beyond the status quo initial education.

Nobody is coming out of their intial program knowing what the information is trying to tell them. More critical thinking, and pattern identification.

[aussiephil]

I think we can also add to that personal experience on top of education.

I know when I have had a patient with an unusual illness, I have researched it to find out more.

Education, while vital, and provides the grounding for everything we do, can never be replaced by hands on experience. This is something that as an industry we need to recognise & nurture. The more exposure one ets, the more accurate their provisional diagnostic skills become.

As AZCEP stated

Echoing Rid and Dust, our diagnostic ability is limited by the educational level and the tools we have available. Consider that there was a time that doctors were diagnosing without CT/MRI/lab values. This is basically where we are now. Quite possibly the single most underused tool we have at our disposal is the thorough history and physical exam.

we can only provsionally diagnose & exclude but difinitive requires further testing.

[jmac]

Excellent excellent replies

Now a follow up question

Since we all do diagnose, what if any training courses should we invest in or provide to our students/employees to aid them in their ability to diagnose someone and give the receiving ER or facility their best diagnosis.

Any course that will indicate to you as a professional possible problems and indicate to you possible underlying factors, ACLS, ATLS, PEPP, NEO-NAT, STABLE, anything, while academic courses that give you the piece of paper for your vast CV are well and good in my opinion workshops in individual fields are the best way to learn, to shadow another healthcare professional while they are doing their job can give you an insight into all sorts of diagnostic skills.

When i started i was taken aside and told that i will get a lot of facts and theorys, and to make a diagnosis i should try to make the theory fit the facts...not the otherway around, i may come up with a couple of things pre-hosp...suspicions and an old doctor said...a spade is a spade, the same way an MI is an MI regardless of what artery it is it is still treated the same way, if you have a 12 lead well and good, just give the info that you have, dent get pissed off because the first thing the ED does is another 12 lead, they are just confirming your findings, i have seen a lot of young newbies messed up because the think "I told them it was an MI" .

In my opinion never be afraid to follow up on a Pt..regardless of what level you are, and you never stop learning, and if there is not a piece of paper and the end of your course what the hell, its nice to have it but i am there to share the experience of those there trying to teach me, its a personal thing, i just want to do my job to the best of my ability..not paper a wall :wink: