Scenario

[resqparamedic]

ateup25-I would like to see any publications on the use of beta-blockers and cardiac tamponade. I think it is an interesting thought and I can see where it could possibly help with the symptoms of a tamponade.

As far as EMS diagnosing I say bullshit I worked in EMS for many years and now have work as a PA. I treat patients that are having signs and symptoms in an acute settingl. After ordering rad, labs, or whatever else I need, I get those back and then I formulate a diagnosis with all the information that I have before me. Paramedics are good at impressions. How can you diagnose a NSTEMI from UA in an Ambulance? You can't. Alot of systems still only use 3 lead EKGs, what can you diagnose with that? How do you diagnose a PE in the field?

I disagree. A provider on every level comes to a diagnosis by using all the information they have available to themselves at the time. As a patient progresses up the medical food chain the diagnosis is more specific due to the more comprehensive testing available.

[Phulano]

I havent commented on this yet because I have training, but no experience, but I was curious..

What about like tension pneumos and stuff. It seems to me that is something you would diagnose and treat on the spot with a needle drill. I know its not a difinitive treatment, but youve at least diagnosed it and bought time.

I agree with the whole AMI thing though, but you really arnt trying to diagnose anything so much as youre trying to treat the symptoms right?
or PSVT's.. You see it on the monitor.. you identify the rythm.. isnt that a diagnosis? even if you cant ID the underlying issue?

This is a good thread. lots of good info here.

[91W]

I disagree. A provider on every level comes to a diagnosis by using all the information they have available to themselves at the time. As a patient progresses up the medical food chain the diagnosis is more specific due to the more comprehensive testing available.

I would agree. I know that as an EMT, I "could tell" if someone was probably suffering an MI. But, as a critical care provider and through the progression of education, technology and equipment such as 12-leads, rapid troponin tests, etc, I knew when someone was having an MI and was provided the tools to begin treating it.

It's all a matter of training and toys.

Check Six,
Doc

OK then tell me how you diagnose and treat a NSTEMI in the field. I have never seen cardiac ensymes done in the field.

A medic may know what they are treating when it comes to an MI but my SO says what and how I treat. TNKase can be used for ST elevation greater than 2mm with recriprical depression 1mm or greater. If those signs are not there i cannot treat. Does that mean I cannot tell they are having a heart attack? No, I have almost 12 years in EMS to know that they are. However I treat signs and symptoms so I do not make the diagnosis.

Sometimes it sucks but a Medic cannot deviate from SO and Protocol and keep a cert very long. We may know beyond a shadow of a doubt what is going on with this pt and be right in hindsight but if a diagnosis is made and a treatment is given that does not follow Standing Orders or Medical Direction then we are guilty of negligence. That does not mean that Medics are incompetent by any means, I work with some that are just as good as an ER Doc, It all comes back to scope of practice.

That being said one thing I hate is a Cookbook Medic, and yes I know I sound like one. That is the "rules" and they suck. I will be the first to pressure and pester on line med control for treatment if I cannot treat under Standing Orders. That is where the ability to make a Differential Diagnosis and build a trust with your Docs comes in. But I am also letting the Doc make the call. Just my .02 on the subject.

[Thursday]

You can call it what you will, but if a paramedic in the field makes a decision and treats it, that is a diagnosis. It is a necessary thing to do. How do you treat something with out making a decision? Like Doc said, when you see someone that is sweating heavily, difficulty breathing, complaining of chest pain radiating into their arm with accompaning nausea and possibly vomiting, well, then, I would be willing to bet that they are having an MI. A paramedic in the field, at least a good one, is going to treat them with MONA, and hopefully give a good report on telemtry stating this so that the CCL can be put on standby for angioplasty.

91W, you said that you don't want to be a cookbook bedic, well, then, don't be one. Being a paramedic is an extremely easy job, but then again, it can be extremely difficult. You have to be able to think and make decisions very fastly. If someone is complainging of chest pain, but they were just hit in the chest with a base ball bat, you aren't going to treat them with your cardiac SMO, are you, because I have seen cases where that has been done. Granted that is a pretty easy case to see it was the wrong treatment, but then again, what do you do when someone has a sudden onset of acute respiratory distress? Is it a PE, Pnuemo, ARDS, chf or copd exacerbation?

This is what seperates the good medics from poor ones. You have to find out what is going on. You need to do a damn good history and physical to figure out that the teenager that you are treating fits into the guidlines for spontaneous pnuemo's, or that the grandma that you pulled out of a car has been sitting in a car for the past 2 days on a road trip and has a cast around her ankle from when she broke it 1 week ago. You cant just look at it as say: difficulty breathing - give her oxygen and decompress bilaterally, because that will make for one really mad granny and an even more mad ER when you drop off the pt and she now has 2 open pnuemos on top of her PE that she threw.

And if you get to the ER, and they are giving you shit about what you did, stand up for yourself. I have had nurses tell me that the pt. that i brought in wasn't having a stroke because she didnt meet all 3 criteria for the Cincinatti stroke scale. Well, unknown to her, you only need to meet one part of the criteria for it to be a positive finding on the CSS. Have faith in yourself and even more, have faith in what treatments you do. Don't be afraid to stand up and say, "I treated the pt in the best way I possibly could have". Act as a pt advocate and you will never have to worry about someone comming down on you for treating or not treating a pt. in a certin way.

[91W]

I like "What ifs"

You can call it what you will, but if a paramedic in the field makes a decision and treats it, that is a diagnosis. It is a necessary thing to do. How do you treat something with out making a decision? Like Doc said, when you see someone that is sweating heavily, difficulty breathing, complaining of chest pain radiating into their arm with accompaning nausea and possibly vomiting, well, then, I would be willing to bet that they are having an MI. A paramedic in the field, at least a good one, is going to treat them with MONA, and hopefully give a good report on telemtry stating this so that the CCL can be put on standby for angioplasty.

What if it is a Synicopol Episode? Are you going to do your "Work up" and history. Using a 12 lead and after finding nothing write your report and state "Pt had a syncopal episode of unknown origin and was told to follow up with their family Phys. next week"? Then go back when they go back into A-Fib or Flutter? Or go back when they throw a PE because of the clot? You described S/S of a classic Cardiac problem. What if they do not have those S/S. Do you tell them they are fine?

91W, you said that you don't want to be a cookbook bedic, well, then, don't be one. Being a paramedic is an extremely easy job, but then again, it can be extremely difficult. You have to be able to think and make decisions very fastly. If someone is complainging of chest pain, but they were just hit in the chest with a base ball bat, you aren't going to treat them with your cardiac SMO, are you, because I have seen cases where that has been done. Granted that is a pretty easy case to see it was the wrong treatment, but then again, what do you do when someone has a sudden onset of acute respiratory distress? Is it a PE, Pnuemo, ARDS, chf or copd exacerbation?

So a blow to the chest cannot cause a disrythrimia? I said I hate a cookbook medic. As far as an acut onset of resp. distress, what are the signs, you gave the symptoms. Breath sounds in all fields? Equall breath sounds? Equal rise and fall bilat.? You will treat the signs. Tell me how you make an absolute diagnosis of a PE in the field. And if so what do you do for it beyond O2 and airway control? You may know what you are treating but you are reacting to the S/S you are presented with.

This is what seperates the good medics from poor ones. You have to find out what is going on. You need to do a damn good history and physical to figure out that the teenager that you are treating fits into the guidlines for spontaneous pnuemo's, or that the grandma that you pulled out of a car has been sitting in a car for the past 2 days on a road trip and has a cast around her ankle from when she broke it 1 week ago. You cant just look at it as say: difficulty breathing - give her oxygen and decompress bilaterally, because that will make for one really mad granny and an even more mad ER when you drop off the pt and she now has 2 open pnuemos on top of her PE that she threw.

Spontanoeus pneumo, S/S again. You have absent lung sounds or you do not. PE is S/S and history but you have not made the diagnosis.

And if you get to the ER, and they are giving you shit about what you did, stand up for yourself. I have had nurses tell me that the pt. that i brought in wasn't having a stroke because she didnt meet all 3 criteria for the Cincinatti stroke scale. Well, unknown to her, you only need to meet one part of the criteria for it to be a positive finding on the CSS. Have faith in yourself and even more, have faith in what treatments you do. Don't be afraid to stand up and say, "I treated the pt in the best way I possibly could have". Act as a pt advocate and you will never have to worry about someone comming down on you for treating or not treating a pt. in a certin way.

This is a touchy subject around here. If you are given shit do not say a word. Document, Document, Document. If you treated the pt. according to SO and Protocol, asked on line med control for "any further questions or orders", and did everything you could do there is no reason to say a word to a nurse. We do not work for nurses. I have learned the hard way to walk away and write a chart that leaves no room for questions. Treat every pt. as a family member and you will never have a problem. I was taught that by a medic that has 27 years of service.

I still say that I may know what is going on but I have not made a diagnosis. I have formulated a plan based on all S/S and history in order to anticipate what i might have to do, but I still treat signs and symptoms as they present. A good example is moderate chest pain and ST depression on the EKG. Could be ischemia, however it could be as my pt. the other night and be Pericarditis. I could have speculated to the pt. that they would be going to a cath lab and freaked them out for nothing. There are way too many variables to diagnose in the field. I would love to have an iStat machine and UltraSound in the truck. Could help make a diagnosis possible for for some conditions but we do not have that yet. As Ranger Fish, stated a diagnosis is made after all resources have been used at the hospital. Untill then we treat S/S and stabilize acute life threatening conditions when possible.

[resqparamedic]

I still say that I may know what is going on but I have not made a diagnosis. I have formulated a plan based on all S/S and history in order to anticipate what i might have to do, but I still treat signs and symptoms as they present. A good example is moderate chest pain and ST depression on the EKG. Could be ischemia, however it could be as my pt. the other night and be Pericarditis. I could have speculated to the pt. that they would be going to a cath lab and freaked them out for nothing. There are way too many variables to diagnose in the field. I would love to have an iStat machine and UltraSound in the truck. Could help make a diagnosis possible for for some conditions but we do not have that yet. As Ranger Fish, stated a diagnosis is made after all resources have been used at the hospital. Untill then we treat S/S and stabilize acute life threatening conditions when possible.

I don't agree with you. I think everyone makes a diagnosis with whatever information they have on hand. As more in depth answers and results present themselves a more exact diagnosis is made. However, maybe you can clarify something for me though. At what point is a diagnosis is made? Is it after a specific number of tests? Is a diagnosis made only when a certain level of care giver is involved?

[91W]

I still say that I may know what is going on but I have not made a diagnosis. I have formulated a plan based on all S/S and history in order to anticipate what i might have to do, but I still treat signs and symptoms as they present. A good example is moderate chest pain and ST depression on the EKG. Could be ischemia, however it could be as my pt. the other night and be Pericarditis. I could have speculated to the pt. that they would be going to a cath lab and freaked them out for nothing. There are way too many variables to diagnose in the field. I would love to have an iStat machine and UltraSound in the truck. Could help make a diagnosis possible for for some conditions but we do not have that yet. As Ranger Fish, stated a diagnosis is made after all resources have been used at the hospital. Untill then we treat S/S and stabilize acute life threatening conditions when possible.

I don't agree with you. I think everyone makes a diagnosis with whatever information they have on hand. As more in depth answers and results present themselves a more exact diagnosis is made. However, maybe you can clarify something for me though. At what point is a diagnosis is made? Is it after a specific number of tests? Is a diagnosis made only when a certain level of care giver is involved?

Ranger resqparamedic,

My personal Opinion is that a diagnosis is made after a combination of blood work, X-ray, CAT scan, Ultrasound, etc is done. I can treat a Disrythmia with drugs in a truck but cannot diagnose the problem. A SVT pt may have to have an ablasion(sp?) done, that, is after a diagnosis has been made. I may do a twelve lead and see all the classic S/S of an MI but as stated earlier cannot treat under Standing Orders. That is where a GOOD report and goor repore with Dr's is vital. I have made a Diagnosis of sorts however sinced I am not allowed to I cannot treat.

Medics do not diagnose FXs in the field but treat them as one. Sure I have learned alot of "tricks" through the years to have a pretty damn good idea that there is a FX but cannot diagnose without X-rays unless it is obvious.

I do see your point but have learned to spell out the Signs and symptoms on a chart the hard way. "The pt had a rapid ventricular rate with no discernable P wave" for A-Fib. That keeps you away from the legalities of diagnosing and being wrong. I have seen enough people drug through the legal system over the years to learn to watch your back. If you do your job correctly you will come out on top every time but speculating a diagnosis can make it rough.

This means in no way that i am not aggresive with my pt care. Every medical and trauma pt i treat is treated with a plan in order to try to anticipate what if and what next. I have been wrong in my thought process and have learned over time that it is impossible to diagnose in the field. But that is part of the learning process.

HIPPA took alot of the learning away in order to more accurately have a diagnosis in the field buy not being able to follow up on pts after a run. Which I think will make it more difficult to new medics comming in to formulate a plan for treatment. That is my thought process and it may be we are just phrasing things differently. One of my favorite sayings is "EMS does not save lives, It postpones the inevitable", that is because we cannot diagnose the root of the issue and correct it. That is the MD's job.

[resqparamedic]

I still say that I may know what is going on but I have not made a diagnosis. I have formulated a plan based on all S/S and history in order to anticipate what i might have to do, but I still treat signs and symptoms as they present. A good example is moderate chest pain and ST depression on the EKG. Could be ischemia, however it could be as my pt. the other night and be Pericarditis. I could have speculated to the pt. that they would be going to a cath lab and freaked them out for nothing. There are way too many variables to diagnose in the field. I would love to have an iStat machine and UltraSound in the truck. Could help make a diagnosis possible for for some conditions but we do not have that yet. As Ranger Fish, stated a diagnosis is made after all resources have been used at the hospital. Untill then we treat S/S and stabilize acute life threatening conditions when possible.

I don't agree with you. I think everyone makes a diagnosis with whatever information they have on hand. As more in depth answers and results present themselves a more exact diagnosis is made. However, maybe you can clarify something for me though. At what point is a diagnosis is made? Is it after a specific number of tests? Is a diagnosis made only when a certain level of care giver is involved?

Ranger resqparamedic,

My personal Opinion is that a diagnosis is made after a combination of blood work, X-ray, CAT scan, Ultrasound, etc is done. I can treat a Disrythmia with drugs in a truck but cannot diagnose the problem. A SVT pt may have to have an ablasion(sp?) done, that, is after a diagnosis has been made. I may do a twelve lead and see all the classic S/S of an MI but as stated earlier cannot treat under Standing Orders. That is where a GOOD report and goor repore with Dr's is vital. I have made a Diagnosis of sorts however sinced I am not allowed to I cannot treat.

Medics do not diagnose FXs in the field but treat them as one. Sure I have learned alot of "tricks" through the years to have a pretty damn good idea that there is a FX but cannot diagnose without X-rays unless it is obvious.

I do see your point but have learned to spell out the Signs and symptoms on a chart the hard way. "The pt had a rapid ventricular rate with no discernable P wave" for A-Fib. That keeps you away from the legalities of diagnosing and being wrong. I have seen enough people drug through the legal system over the years to learn to watch your back. If you do your job correctly you will come out on top every time but speculating a diagnosis can make it rough.

This means in no way that i am not aggresive with my pt care. Every medical and trauma pt i treat is treated with a plan in order to try to anticipate what if and what next. I have been wrong in my thought process and have learned over time that it is impossible to diagnose in the field. But that is part of the learning process.

HIPPA took alot of the learning away in order to more accurately have a diagnosis in the field buy not being able to follow up on pts after a run. Which I think will make it more difficult to new medics comming in to formulate a plan for treatment. That is my thought process and it may be we are just phrasing things differently. One of my favorite sayings is "EMS does not save lives, It postpones the inevitable", that is because we cannot diagnose the root of the issue and correct it. That is the MD's job.

I've had this disagreement with others in the past. At one time I was on your side of this whole deal and understand where you are coming from, but like I said earlier I disagree. Quite often before heading overseas as a contractor I used differential diagnosis due to some of your points. It seemed to work well and kept us out of the exact diagnosis arena.