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View Full Version : "Assessment" versus "Diagnosis": what are the differences?


mycrofft
02-09-2010, 01:44 PM
I know the classic divisions: techs can assess and consult, MD's and RN's* can diagnose and treat. Techs and nurses' medical treatment (other than basic safety and comfort measures and items outside medicine like mechanical extrication) stems from protocols or standardized procedures written and/or approved by MD's which specify objective findings leading to specific measures, and the qualification to attain before you can do these measures.

In the real world, do you personally feel the use of the word "diagnose" is bad in reference to the acts of evaluation then treatment without getting a case by case real time order from higher medical authority by EMT's of any level?

*"Nusing diagnosis" is a recognized term, has been organized and formalized, and is in use.

firecoins
02-09-2010, 02:29 PM
Its called a differential diagnosis. Using a limited assessment, littles knowledge and little ability to do a whole lot, we make a working guess on whats going on. You can it a differential diagnosis which will need to be confirmed by the MDs at the receiving facility.

A real diagnosis can not be made by EMTs. Not enough info or education.

Veneficus
02-09-2010, 02:44 PM
I don’t like the wording on the poll.

Diagnosis is using physical and history findings combined with knowledge of anatomy, physiology, pathology, and other basic sciences too numerous to list to come up with a likely "name" (aka explanation) about what is going on with a patient so one can formulate the best plan of treatment.

Some EMS providers diagnose, some just treat signs and symptoms following a cookbook. I am more fond of the former than the latter, but sadly I concede it is possible to be an EMT or Paramedic and never make a diagnosis in a career. Likewise one could diagnose every patient they ever see irrespective of title.

The more information you have, the more accurate a diagnosis can be. Certainly as a patient progresses through the levels of care more information can be gathered that help to better diagnose.

Some treatments can be effective for large time periods covering various pathologies. Some treatments have a very narrow range of time and pathologies they are effective in. Some treatments are needed to give the most accurate diagnosis. Diagnosis and treatment therefore are seemlessly connected. A truly proper treatment would require some level of diagnosis. As we know, there are many EMS providers (as well as other healthcare providers) who perform improper treatments trying to equate signs and symptoms alone. A good example is edema, there are many causes of pulmonary edema. Not all resulting from congestive heart failure. Not all respond well to loop diuretics. Sometimes the wrong treatment is harmful at some level, sometimes it does nothing, and sometimes can be effective to some level.

There are lots of qualifiers for diagnosing. “Initial diagnosis,” “working diagnosis,” “differential diagnosis,” They are simply various levels of the same behavior.

The cultures of some agencies are to be mindless laborers; in some agencies the culture is to be a critical thinking professional. About the only things both have in common is they call themselves the same title and they don’t like each other and vehemently defend their way as the one true faith.

mycrofft
02-09-2010, 04:05 PM
You too firecoins.

It is interesting to see the way agency protocols etc. can get twisted up versus state and county regulations, versus real world (good or bad real world).
In my experience "cookbooking" is the solid floor, and making a "working diagnosis", eval, assessment, wildarsed guess or epiphany based on solid education and experience is a bridge to selection and use of the proper protocol.

E.G.: three EMS walk up to a pt dispatched as "coughing up blood".

Nancy wants to urgently start a large bore IV, O2, C spine, and is considering MAST.

Betty spends twenty minutes doing a by the book workup with family hx and postural VS's including temp.

Annie takes VS, looks the pt over on approach and during VS, talks to him ab out whats happening/meds/etc. and looks down his throat, detects a mild retronasal bleed, finds out this is recurrent, and tells pt to go see MD if it doesn't stop in an hour. Total time: ten minutes from approach to code 4, 10-8, 10-19.

Who's right?

LondonMedic
02-09-2010, 04:22 PM
You can it a differential diagnosis which will need to be confirmed by the MDs at the receiving facility.Or pathologists. ^_^

I would suggest that in the absence of a definitive investigation result everyone goes on a differential, be they doctor, paramedic or first responder. As often as not that means doing an assessment, to a level of detail appropriate to the settingm forming a differential diagnosis appropriate to the setting and initiating 'best guess' treatment appropriate to the setting.

LondonMedic
02-09-2010, 04:32 PM
E.G.: three EMS walk up to a pt dispatched as "coughing up blood".

Nancy wants to urgently start a large bore IV, O2, C spine, and is considering MAST.

Betty spends twenty minutes doing a by the book workup with family hx and postural VS's including temp.

Annie takes VS, looks the pt over on approach and during VS, talks to him ab out whats happening/meds/etc. and looks down his throat, detects a mild retronasal bleed, finds out this is recurrent, and tells pt to go see MD if it doesn't stop in an hour. Total time: ten minutes from approach to code 4, 10-8, 10-19.None is wrong (I presume that's your point).

Annie is the obvious 'right' answer here, but her course of action here are entirely inappropriate if she doesn't have the experience, knowledge and authority (not to mention insurance) to act in that way. That also presumes that she has the ability to be certain that she has the time to do that.

Veneficus
02-09-2010, 04:43 PM
Since all of the examples are correct treatment, I guess the question becomes who is providing the best treatment?

Lifeguards For Life
02-09-2010, 04:53 PM
Attached is an excerpt from an article written by David W. Powers, NREMT-P, BCETS, BCECR, last year.

While I do not agree with the underlying principle behind the article, he does bring up some valid points on paramedics diagnosing.

Physician assistants are healthcare professionals licensed to practice medicine with physician supervision…PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive healthcare, assist in surgery, and in virtually all states can write prescriptions. This definition comes from the Information About PAs and the PA Profession section at www.aapa.org. As I outline the comparisons, I think you’ll see that as far as two careers in the healthcare field go, we aren’t that different.

Paramedics are also healthcare professionals licensed or certified to practice medicine with physician supervision. I know some people say we don’t practice medicine, but we do. We practice medicine under our medical control physician’s license. We conduct physical exams, except we call them patient assessments.

We also diagnose and treat illnesses. I was taught in various EMS classes that paramedics do not diagnose. If that is true, then how do we know what to treat for? If I have a patient with pain, diaphoresis and ECG changes in all the right places, I’m going to diagnose a myocardial infarction and treat accordingly. The truth is that we diagnose illnesses and injuries every day we work on an ambulance.

Here’s one where we upstage the PAs: We don’t order and interpret tests; we choose the tests we run and interpret them ourselves. Regular-duty medics run ECGs every day and interpret the strips. We run fancy tests with names like pulse oximetry, capnography and blood glucose on a regular basis. Extended-practice medics test blood gases.

We also counsel on preventive healthcare. When we have long transports or the call isn’t an emergency, we often sit beside the stretcher and talk to our patients. I’ve spoken to patients about smoking and obesity. I’ve encouraged new mothers and young babysitters to attend infant/child CPR classes. Paramedics are usually the first line in preventive healthcare, although we seldom realize it.

While certainly regular-duty paramedics don’t assist in surgery, interns in paramedic school are frequently allowed to view surgeries. Some paramedics actually perform surgical procedures as part of their job. Surgical cricothyroidotomies, chest tubes, central catheters, postmortem cesarean sections and field amputations are only some of the surgical skills that many paramedics in the United States are authorized to perform.

PAs do not even have us on the prescription medicine issue. Webster’s Dictionary defines a medical prescription as a designation or order for the use of a treatment or medicine. We are prescribing every time we give aspirin, epinephrine, morphine and so on, are we not? While we may not write prescriptions to fill at a pharmacy, we do prescribe medicines.

What about the differences between medics and PAs? The two main ones I see are education and salary.

Physician assistants are trained using the same model as doctors. This model is used because PAs work closely with physicians and for all practical purposes act for physicians in many settings. The majority of educational programs require a bachelor’s degree prior to entering. Many pre-PA students take the same pre-medical courses as aspiring doctors. Once the student graduates PA school, he is awarded a master’s degree.

Although there are many variables that go into the reasoning behind the salary gap, I see two as having the most impact: education level and place of employment. Paramedics are not required to have a degree to be certified, whereas PAs must go through an accredited degree program, often a master’s degree program. Medics are often employed in private, nonprofit or government jobs. PAs are employed in the military as officers, in hospitals and in doctor’s offices.

JPINFV
02-09-2010, 05:13 PM
Nancy wants to urgently start a large bore IV, O2, C spine, and is considering MAST.

Betty spends twenty minutes doing a by the book workup with family hx and postural VS's including temp.

Annie takes VS, looks the pt over on approach and during VS, talks to him ab out whats happening/meds/etc. and looks down his throat, detects a mild retronasal bleed, finds out this is recurrent, and tells pt to go see MD if it doesn't stop in an hour. Total time: ten minutes from approach to code 4, 10-8, 10-19.

Who's right?


Nancy is wrong. There's no indication yet for any of those interventions. They all may be appropriate depending on the exam findings, but just because the patient is coughing up blood doesn't mean that it's a life threatening emergency. We just don't know yet.

Betty represents the ideal course of action under the current education standards and EMS treatment theory, provided there isn't any critical exam findings like hypotension.

Annie represents the ideal course of action, but may be inappropriate (especially the treat and release) for the vast majority of paramedics in the US given the current education standards.

VentMedic
02-09-2010, 06:27 PM
Attached is an excerpt from an article written by David W. Powers, NREMT-P, BCETS, BCECR, last year.

While I do not agree with the underlying principle behind the article, he does bring up some valid points on paramedics diagnosing.

That article has described just about every health care professional from PT to RN when it comes to assessment and "prescribing" as the author is attempting to make his own interpretation. Giving medications from a protocol is not prescribing. A Paramedic does not write the order or protocol to give the medicine. The doctor has already written that for the Paramedic in the protocols. A Paramedic can not get a DEA number and does not need one any more than an RN or RRT.

Pulse oximetry is also not a definitive diagnostic tool used to make a definitive medical diagnosis.

Both PAs and NPs are true physician extenders and can make a "medical diagnosis" which a Paramedic can not. Paramedics and many other licensed professionals make a working diagnosis for treating certain signs and symptoms by protocols.

http://www.wapa.org/pdfs/np-pa_chart.pdf

While certainly regular-duty paramedics don’t assist in surgery, interns in paramedic school are frequently allowed to view surgeries. Some paramedics actually perform surgical procedures as part of their job. Surgical cricothyroidotomies, chest tubes, central catheters, postmortem cesarean sections and field amputations are only some of the surgical skills that many paramedics in the United States are authorized to perform.


I would emphasize the word "some" used at the beginning of that paragraph. Also, being allowed to "view a brain surgery" does not make one a neurosurgeon.

Although there are many variables that go into the reasoning behind the salary gap, I see two as having the most impact: education level and place of employment

He seriously missed on this one. PAs are certified providers for CMS or Medicaid and Medicare and generally receive favorable reimbursement from commercial payers. And of course the fact they do diagnose, can order many invasive tests and prescribe treatment as well as medication could be part of the salary difference. Until a Paramedic is recognized as a Physician Extender, the differences are many as is the education.

mycrofft
02-09-2010, 11:45 PM
What exactly, without legal def's, is a diagnosis?

Personally, I'm not hung up on the terminology as long as I know who did what and their qualifications. After the podiatrist put the young lady with a broken nose and neck pain into the back seat of a Mustang and we had to board her out, I'll take info from anyone whno knows what the heck they are about.

Lifeguards For Life
02-10-2010, 12:44 AM
What exactly, without legal def's, is a diagnosis?

Personally, I'm not hung up on the terminology as long as I know who did what and their qualifications. After the podiatrist put the young lady with a broken nose and neck pain into the back seat of a Mustang and we had to board her out, I'll take info from anyone whno knows what the heck they are about.

The process of considering the patient’s signs and symptoms, medical background and laboratory findings, to identify an underlying cause.

If you take your vehicle to a mechanic, does he diagnose mechanical problems? Does a veterinarian diagnose your pet?

Why are we taught the Cincinnati prehospital stroke scale, hunt and hess scale, the Los Angeles prehospital stroke screen, if not to aid in a rapid diagnosis of a stroke?

Is that 'diagnosis' likely to change? yes. though i am sure all of you perform the appropriate stroke screening test when warranted and transport to the appropriate facility. If you are taking a stroke patient to a stroke center, have you not 'diagnosed' a stroke?

MrBrown
02-10-2010, 01:19 AM
Ambo's make a provisional diagnosis; no more and almost certianly less depending upon the specific ambo

Veneficus
02-10-2010, 03:40 AM
The process of considering the patient’s signs and symptoms, medical background and laboratory findings, to identify an underlying cause.

I don't think labs are required to make every Dx.

JPINFV
02-10-2010, 03:53 AM
Of course, because EMS can't run the highest valued medical test possible...

http://www.youtube.com/watch?v=2BDd0XseGtU

Lifeguards For Life
02-10-2010, 07:16 AM
I don't think labs are required to make every Dx.

No, not by any means. But, if those values were available and the provider was capable of interpreting them, they may aid in a quick and accurate diagnosis. I also know full well that they will never be available in the prehospital setting.

MrBrown
02-10-2010, 07:56 AM
No, not by any means. But, if those values were available and the provider was capable of interpreting them, they may aid in a quick and accurate diagnosis. I also know full well that they will never be available in the prehospital setting.

Sssssh, don't tell Novia Scotia or Alberta who are doing field cardiac enzymes :o

VentMedic
02-10-2010, 07:59 AM
If you take your vehicle to a mechanic, does he diagnose mechanical problems? Does a veterinarian diagnose your pet?

I hope you are not comparing a car to the complex systems of the human body.

I also expect my veterinarian to run whatever tests necessary to provide proper treatment for my pet.



Why are we taught the Cincinnati prehospital stroke scale, hunt and hess scale, the Los Angeles prehospital stroke screen, if not to aid in a rapid diagnosis of a stroke?

Is that 'diagnosis' likely to change? yes. though i am sure all of you perform the appropriate stroke screening test when warranted and transport to the appropriate facility. If you are taking a stroke patient to a stroke center, have you not 'diagnosed' a stroke?

The use of a scale is great to identify the possibility of a stroke to initiate some care that can be very broad for many neuro problems and not just a stroke. Hopefully it does get the patient to the appropriate center but that scale is merely the very beginning of a long process and sometimes it may not be a "stroke" at all. However, for a Stroke Center to be a Primary, it must be able to do diagnostic testing 24/7. It must also have the ability to place the patient in an appropriate unit setting even if that means sending the patient to another facility. Of course the best facility would be one that is a full service neuro center just like the best hospital for an MI would be one that can also do cardiac surgery and not just a cath lab procedure.

Stroke Center Criteria...if you are interested.
http://www.strokeassociation.org/downloadable/stroke/1148590175166ASTP_Program_Capacity_Assessment_Tool _05.2006.doc

The chest pain protocol can also be an example. It may look like an MI but there are many, many other causes that can also present with the same symptoms. Generally the initial treatment of "MI" symptoms are broad enough where they can be applied with some benefit and may not do more harm. We could also use CHF vs PNA. These two are difficult since they can actually both be present. There are also many patients that even the physicians will be working from their preliminary diagnoses (yes more than one) for many days or weeks until a definitive one is made. Some patients will generally have more than one problem as well. Without the availability of some diagnostics, it is difficult to just go by "what you see is what you got". It would really be great if all the medical problems a patient could possibly have are just the few learned in EMT or
Paramedic.

I don't think labs are required to make every Dx.
But the Paramedic's training and education does not provide enough knowledge to know if more testing is needed. If you make the obvious dx of an arm fx on a young person, would the Paramedic be able to recognize other signs and symptoms to where there might be a more serious cause for a brittle bone? If you give morphine and the pain goes away, does that mean you have fixed the MI? If you apply CPAP to a "CHF" patient and they breathe better, have you fixed the CHF? If you give albuterol to an asthmatic patient and they breathe better, have you fixed them and no more treatment or testing is required? Too often some Paramedics, I hope not that many, are led to believe if the symptoms go away with the treatments they provide in the prehospital setting, they have fixed the patient and are providing the same level of care as a physician. However, the knowledge base of the Physician will be much more extensive to know when and when not to do more testing or that alleviating a "symptom" does not fix the problem. The Paramedic also has no ability to keep that symptom from reoccurring by prescribing ongoing treatment. That is also another difference between a PA and a Paramedic.

I know it sounds like I am down on Paramedics but one should realize their limitations from the education they have gotten in a Paramedic program. If not, something can also be missed when a Paramedic attempts to place all patients within just their few "working diagnoses". It is also okay to say you don't know which protocol to initiate for some things which is why you have access to med control for advice.

Veneficus
02-10-2010, 08:20 AM
But the Paramedic's training and education does not provide enough knowledge to know if more testing is needed. If you make the obvious dx of an arm fx on a young person, would the Paramedic be able to recognize other signs and symptoms to where there might be a more serious cause for a brittle bone?.

I do not think a paramedic has enough education to know if/when further testing is required, I was stipulating that not all Dx require lab work. Some do, others don't.


If you give morphine and the pain goes away, does that mean you have fixed the MI? If you apply CPAP to a "CHF" patient and they breathe better, have you fixed the CHF? If you give albuterol to an asthmatic patient and they breathe better, have you fixed them and no more treatment or testing is required? Too often some Paramedics, I hope not that many, are led to believe if the symptoms go away with the treatments they provide in the prehospital setting, they have fixed the patient and are providing the same level of care as a physician. However, the knowledge base of the Physician will be much more extensive to know when and when not to do more testing or that alleviating a "symptom" does not fix the problem. The Paramedic also has no ability to keep that symptom from reoccurring by prescribing ongoing treatment. That is also another difference between a PA and a Paramedic.

These are treatments to conditions, I do not see what this has to do with Dx. unless you are using the treatment to imply the Dx which in most cases is not the accepted practice for any provider.

VentMedic
02-10-2010, 08:27 AM
These are treatments to conditions, I do not see what this has to do with Dx. unless you are using the treatment to imply the Dx which in most cases is not the accepted practice for any provider.

Actually they are treatments for the symptoms of the disease process. The CHF patient may need more diagnostics to determine the cause. The asthmatic may need steroids and/or antibiotics to treat the exacerbation. The "MI" patient will need more diagnostics to determine if it is an MI or something with very similar symptoms. Of course, since only half of ALS EMS services have 12-Lead ECG capability, that leaves out one valuable tool. Then there are a few services which do have the 12-Lead that rely solely on machine interpretation for the diagnosis.

Veneficus
02-10-2010, 10:51 AM
Might as well lock this thread up too.

LondonMedic
02-10-2010, 02:34 PM
Sssssh, don't tell Novia Scotia or Alberta who are doing field cardiac enzymes :oAre they holding the pt in the back of the ambo for twelve hours?! :o

I know travel times can be long, but seriously...

VentMedic
02-10-2010, 02:46 PM
Are they holding the pt in the back of the ambo for twelve hours?! :o

I know travel times can be long, but seriously...

Why would you hold a patient for 12 hours?

POC testing can generally give a troponin (protein) level in about 15 minutes. It can at least be used to determine destination if travel distance is great or used to initiate treatment based on clinical assessment and a 12-Lead ECG.

LondonMedic
02-10-2010, 03:01 PM
Why would you hold a patient for 12 hours?

POC testing can generally give a troponin (protein) level in about 15 minutes. It can at least be used to determine destination if travel distance is great or used to initiate treatment based on clinical assessment and a 12-Lead ECG.I know, I use these machines regularly, they are both a blessing and the bane of my life.

The key question questions here; what is the significance of an immediate troponin?

Do you not do serial (6hr and 12hr) trops? Immediate trops are usually -ve and often misleading. Even +ve trops are often misinterpreted.

VentMedic
02-10-2010, 03:17 PM
I know, I use these machines regularly, they are both a blessing and the bane of my life.

The key question questions here; what is the significance of an immediate troponin?

Do you not do serial (6hr and 12hr) trops? Immediate trops are usually -ve and often misleading. Even +ve trops are often misinterpreted.

Let me repeat my post:


POC testing can generally give a troponin (protein) level in about 15 minutes. It can at least be used to determine destination if travel distance is great or used to initiate treatment based on clinical assessment and a 12-Lead ECG.

If we have a positive tropinin on a symptomatic patient, we may still transport to a facility that has a cath lab regardless of the ECG since an ECG can be nonspecific. Waiting 24 hours for ECG changes might cost heart muscle. Remember, no one should ever rely on just one test and clinical correlation is a necessity.

While one would more than likely transport to a cath lab center, that may not always be the case depending on local protocols. As well, if you have a LONG transport time, there is a good chance the cath lab team members may have a long drive time when activated if not in house 24/7.

But, these machines are not on all EMS trucks and are generally reserved for a few Flight, CCT and Specialty transport teams.

mycrofft
02-10-2010, 08:16 PM
It seems to me then , by looking at the poll, that we can provisionally agree that for all intents and purposes field EMS does "diagnose" , if not by that name. Then the depth and quality is affected by practice limits/protocols and practicality (time factor from scene to hospital).

dave3189
02-11-2010, 06:39 PM
Diagnose: to determine the identity of (a disease, illness, etc.) by a medical examination. to ascertain the cause or nature of (a disorder, malfunction, problem, etc.) from the symptoms

I can't believe we are still having this age old discussion? I always find that the nay sayers of this debate are often the medics that are worried about protecting their "turf". Bottom line, to diagnose something does not mean it is a complicated procedure that requires an advanced and/or invasive protocol?

As an EMT-B, how can it be logically or rationally deemed "not a diagnosis" when I arrive at a scene and see an 8 year old child in respiratory distress, with a peanut butter cookie sitting next to her with Mom saying she is allergic to peanuts. BP shows her hypotensive, she has red/rashy skin. Hmmm, my medical assessment along with a history points to Anaphylaxis treated with Sub Q Epi and an ALS response. Remind me again how that isn't a diagnosis???

How about a more simple example... I arrive at a call of a teenager who wiped out on his skateboard. Upon assessment I see an open Tib fracture. Protocol is for me to control bleeding, dress & splint and transport with 02 while monitoring vitals. Again, while a very simple call... I diagnosed this patient with an open fracture. What is so difficult to comprehend about this topic?

JPINFV
02-11-2010, 06:48 PM
How about a more simple example... I arrive at a call of a teenager who wiped out on his skateboard. Upon assessment I see an open Tib fracture. Protocol is for me to control bleeding, dress & splint and transport with 02 while monitoring vitals. Again, while a very simple call... I diagnosed this patient with an open fracture. What is so difficult to comprehend about this topic?

Nope... sorry... that's just a painful swollen deformity. :P

dave3189
02-11-2010, 06:52 PM
My bad, I should have requested a Medic Unit to "diagnose" my "observation".

VentMedic
02-11-2010, 07:01 PM
So a sign and a symptom is essentially a diagnosis?

How many causes of CHF? Is it a sign, symptom or a disease or all? Can you make the diagnosis of acute renal failure as the cause or diagnosis?

What about wheezing? COPD or Asthma? What about all the other causes or disease processes? Do you treat the signs and symptoms or do you immediately go straight with asthma? What if it is an aspirated object? Does that change the diagnosis of the wheezing?

How much is "assumption"? Look in the scenarios heading for examples of the "guessing game" where some assume but really don't have much data to go on.

What about the commonly made diagnosis of "hyperventilation"? Isn't it really a symptom called tachypnea since there is not clinical data to prove hyperventilation?

What if you do a glucose check on a trauma patient and find a higher BGL? Are you going to assume the patient is a diabetic?


Protocol is for me to control bleeding, dress & splint and transport with 02 while monitoring vitals.


For the fx, if you have diagnosed it, why O2? Aren't you just following your protocols instead of actually clinical findings of hypoxia? Are you also going to stop your assessment since it is so "obvious"? Any chance of emboli?

And, for the respiratory distress, are you going to stop your assessment after giving the SQ? Since the child was eating, is aspiration and obstruction also not a possibility as well? Rarely are things always as easy as they seem and to ASSUME one thing you may miss another.

Yes, you must work under a preliminary diagnosis to initiate your protocols but one should also not stop assessing or believe that one diagnosis is the end all to every problem.

Let's do another scenario since pericarditis was just mentioned in anther thread. How about the "typical" OD patient with a history of IVDA. The narcan barely touches him. Do you suspect endocardititis which can lead to a CVA and/or MI? Or do you stick with the obvious of OD and keep giving narcan to the limit allowed by your protocol? Can an unconscious patient tell you about chest pain or slurred speech? So no, not everything will be a simple textbook diagnosis and treatment symptoms or signs as you find them will be all you can do. Just assuming you made "a diagnosis" and running with that may not provide all the treatment that can be done.

If you have ever shadowed the ED physician, you will find they may list as many as 6 or more differential diagnoses even with something that seems really obvious and will continue to treat the signs and symptoms as they appear until some definitive data is available.

This is to get some to thing there is more than just the obvious and rarely will a patient have just one diagnosis but can have many signs and symptoms that can pertain to many disease processes each with a different definitive treatment but similar treatment of the signs and symptoms.

dave3189
02-11-2010, 07:48 PM
Where does it indicate that a "diagnosis" has to reach some specific, (and yet unmeasurable) level of advanced diagnostic/clinical medicine to be considered such?

According to your contention, an attending at the ED who treats an elderly woman from a fall who scans her and finds a hip fracture isn't diagnosing her? How does he know that she doesn't have osteoporosis? According to your theory, the Doc is just treating the symptoms of the disease? What you fail to realize is there is always another layer of diagnostic speciality that a patient can be referred to.

I had a laminectomy when I was a kid for a herniated disc. It was caused by a staff infection that reached the lumbar area of my back. I guess the orthopedist who examined me, interpreted the films and performed the surgery didn't diagnose me? I suppose he was really only treating the back symptoms which were secondary to the infection. I was examined and treated by a pathologist who treated the infection, so he must have been the one to have ultimately diagnosed me.

That is how silly this argument is! There is no question that there are simple basic levels of diagnosis and there is an advanced level of diagnosis... however when you use signs, symptoms, patient history and a physical assessment to determine an appropriate level of care it is ludicrous to claim it is not a diagnosis!

VentMedic
02-11-2010, 07:52 PM
Where does it indicate that a "diagnosis" has to reach some specific, (and yet unmeasurable) level of advanced diagnostic/clinical medicine to be considered such?

According to your contention, an attending at the ED who treats an elderly woman from a fall who scans her and finds a hip fracture isn't diagnosing her? How does he know that she doesn't have osteoporosis? According to your theory, the Doc is just treating the symptoms of the disease? What you fail to realize is there is always another layer of diagnostic speciality that a patient can be referred to.

I had a laminectomy when I was a kid for a herniated disc. It was caused by a staff infection that reached the lumbar area of my back. I guess the orthopedist who examined me, interpreted the films and performed the surgery didn't diagnose me? I suppose he was really only treating the back symptoms which were secondary to the infection. I was examined and treated by a pathologist who treated the infection, so he must have been the one to have ultimately diagnosed me.

That is how silly this argument is! There is no question that there are simple basic levels of diagnosis and there is an advanced level of diagnosis... however when you use signs, symptoms, patient history and a physical assessment to determine an appropriate level of care it is ludicrous to claim it is not a diagnosis!

Do you think any of these doctors were looking for only one diagnoses bases soley on the obvious? If you had read my previous post you would have noticed my comment about an ED have several different diagnoses to work from and does not pigeon-hole him/herself into one.

Do you know how differently a CCT, Flight or Specialty team might treat the same patient brought to the ED by EMS based on a couple of lab values? What about the obvious OD? Do you think a CT Scan finding of a CVA might change the "OD" diagnosis or at least add to it?

dave3189
02-11-2010, 08:26 PM
You seem to think that a diagnosis has to be the ultimate, final, significant factor which is ultimately responsible for the disease, injury or illness. That is not the case.

I can take one scenario of an MVC and give several examples of correct diagnosis.

-EMT arrives and diagnoses bilateral femur Fractures

-Medic arrives and diagnosis hypoperfusion-Hypovolemia (starts fluids)

-ED Doc does CTs and finds multiple fractures

-Later Blood tests reveal Bone cancer (contributing factor to the multiple fractures)

These are all correct levels of diagnosis, although clearly at different levels

CAOX3
02-11-2010, 09:17 PM
I recognise a problem then if possible I treat the symptoms associated with the underlying problem.

If thats diagnosing then so be it, I dont get overly concerned with the definition.

Veneficus
02-11-2010, 09:18 PM
So a sign and a symptom is essentially a diagnosis?

[QUOTE=VentMedic;208118]How many causes of CHF? Is it a sign, symptom or a disease or all?.

It is a common pathology from a number of potential causes. Here is a quick quote from Robins and Cotran Pathological Basis of Disease. (7th edtion) page 560.

"CHF is the leading discharge diagnosis in hospitalized patients over the age of 65 and has an associated annual cost of $18 billion"

So it is a diagnosis. So says what amounts to the bible of pathology.

I think you are getting too hung up on all the preceding causes of diseases. There are multiple diagnosable diseases from preceding pathologies and some that don't, like primary hypertension.

Figuring out if hypertension is primary or secondary and if so from what is why IM folks get paid what they do. Some pathologies can only be confirmed post mortem. Does that mean nobody ever made a dx?

There really is no need to make this more complicated than it is. Today I diagnosed a patient with pneumonia. Bronchial pneumonia? Lobar Pneumonia? I “guess “it was bronchial. I don't know. I don't care. When I see the culture results in a couple of days, I may suggest changing the antibiotic. (if it hasn't already been done prior to me seeing the patient, even then it might not be required.) Is it secondary to an upper respiratory infection? Most likely by both the numbers and in this particular patient. But that is simply a “guess”. An "assumption" if you will. On the official chart the Dx is still pneumonia. It will not change from that. Maybe a secondary Dx. of thrush in a day or two after antibiotics. It will not be cultured to find out if it is truly candida albicans or not. It will be assumed. No need to pay the money for the test or bother the microbiologist.

Does the patient have other pathologies that predispose to pneumonia? Sure he does. So what? His current therapy for that is being maintained. When he comes back for something else, his chief complaint will be diagnosed and it will not be a major production to find every possible pathology and benign condition once the complaint is addressed. We didn't biopsy the mass on his mandible he said had been there for 40 years and was previously diagnosed as benign. It was listed as history in his chart, physically examined and determined to meet all the requirements not to biopsy it from palpation and visualization.

Can you make the diagnosis of acute renal failure as the cause or diagnosis?

Depends on the patient.

What about wheezing? COPD or Asthma? What about all the other causes or disease processes? Do you treat the signs and symptoms or do you immediately go straight with asthma? What if it is an aspirated object? Does that change the diagnosis of the wheezing?

Unlike CHF and pneumonia, wheezing is not a diagnosable pathology. As you pointed out, that is a symptom of an underlying pathology.

How much is "assumption"?

A lot more than you seem willing to admit I'd wager.

Look in the scenarios heading for examples of the "guessing game" where some assume but really don't have much data to go on.

Nobody on any EMS site I have ever seen ever puts up enough information to make a reasonable educated guess. Look at the publication like NEJM for case presentations. PPTs of radiographs, lab values, complete history and physical findings. It just doesn't compare. The last scenario I commented on here didn't even have a full set of vitals. The history was incomplete and looked unreliable anyway. You could guess at it all day and still be no nearer the answer.

What about the commonly made diagnosis of "hyperventilation"? Isn't it really a symptom called tachypnea since there is not clinical data to prove hyperventilation?

Never saw that as a Dx. seen it as a finding though.

What if you do a glucose check on a trauma patient and find a higher BGL? Are you going to assume the patient is a diabetic?

Depends on just how high that number is. But if it is high enough the Dx will be assumed and treated in an unconscious person until something more definitive is discovered. If they are awake and alert, they will be asked. I am sure you are aware there is a body of research for aggressive glucose control in ICU.

For the fx, if you have diagnosed it, why O2? Aren't you just following your protocols instead of actually clinical findings of hypoxia? Are you also going to stop your assessment since it is so "obvious"? Any chance of emboli?

So the EMT is following treatment protocols prescribed to the patient by a physician until a higher level of provider can alter that decision. What has that got to do with Dx? You and I are held to the same requirements. We just have more leeway on what those requirements are. Are you now complaining that an EMT-B isn't allowed to make treatment decisions based on the education level? Yes there is a chance of an emboli, so what? What is the EMT in the field going to do for it? In an open Fx. there is also wound contamination, nothing to do about that in the field except rinse the superficial wound. Unless you are advocating an orthopedic surgery procedure. Even the Emergency doc is going to have to turf that one.

And, for the respiratory distress, are you going to stop your assessment after giving the SQ? Since the child was eating, is aspiration and obstruction also not a possibility as well? Rarely are things always as easy as they seem and to ASSUME one thing you may miss another.

I'm not, and the pt. is going to get some Maalox too in addition to the other tricks up my sleeve like a CXR. But the epi will come long before such bells and whistles in a patient in a medical emergent state. (Where advanced diagnostics become secondary to focused interventions.)

Yes, you must work under a preliminary diagnosis to initiate your protocols but one should also not stop assessing or believe that one diagnosis is the end all to every problem.

I don't see where he was making that assumption; merely pointing out easily diagnosed pathologies. Medicine does not always have to be some infinitely complex problem. Actually it is rather nice when it is a simple case.

Let's do another scenario since pericarditis was just mentioned in anther thread. How about the "typical" OD patient with a history of IVDA. The narcan barely touches him. Do you suspect endocardititis which can lead to a CVA and/or MI? Or do you stick with the obvious of OD and keep giving narcan to the limit allowed by your protocol? Can an unconscious patient tell you about chest pain or slurred speech? So no, not everything will be a simple textbook diagnosis and treatment symptoms or signs as you find them will be all you can do. Just assuming you made "a diagnosis" and running with that may not provide all the treatment that can be done.

I want to play too, maybe in the poorly described scenario she was using contraception, smokes and she had a PE? I am sure you have had patients who denied taking meds and then admitted to oral contraceptives when further pressed. How about endocarditis that leads to a ruptured or otherwise incompetent valve? That was an unfair challenge. Is he again supposed to take it upon himself to change the treatment modality based on pathology possibly beyond his knowledge or capability on a single patient? If that were the case, the AHA is going to have to start printing some really thick books with every possible caveat accounted for in the ACLS algorithms.

If you have ever shadowed the ED physician, you will find they may list as many as 6 or more differential diagnoses even with something that seems really obvious and will continue to treat the signs and symptoms as they appear until some definitive data is available..

And sometimes that's all they do and punt to a specialist. But there is usually only one admitting dx. "Closed head injury" being my favorite too see on a chart coming from the ED. "I have no idea" isn't really billable.

This is to get some to thing there is more than just the obvious and rarely will a patient have just one diagnosis but can have many signs and symptoms that can pertain to many disease processes each with a different definitive treatment but similar treatment of the signs and symptoms.

Isn't everyone aware of that? ACS is a common one. STEMI anyone?

http://www.ncbi.nlm.nih.gov/pubmed/19166679
For some reason I just don’t feel the need to constantly point out what basic healthcare providers can’t possibly know after their few hours of training. A post graduate healthcare provider belittling an EMT or even a medic seems like an 40 year old finding satisfaction beating up a 3 year old for showing off their ice cream cone when the adult didn’t have one.

46Young
02-11-2010, 10:00 PM
[QUOTE=VentMedic;208118]So a sign and a symptom is essentially a diagnosis?



It is a common pathology from a number of potential causes. Here is a quick quote from Robins and Cotran Pathological Basis of Disease. (7th edtion) page 560.

"CHF is the leading discharge diagnosis in hospitalized patients over the age of 65 and has an associated annual cost of $18 billion"

So it is a diagnosis. So says what amounts to the bible of pathology.

I think you are getting too hung up on all the preceding causes of diseases. There are multiple diagnosable diseases from preceding pathologies and some that don't, like primary hypertension.

Figuring out if hypertension is primary or secondary and if so from what is why IM folks get paid what they do. Some pathologies can only be confirmed post mortem. Does that mean nobody ever made a dx?

There really is no need to make this more complicated than it is. Today I diagnosed a patient with pneumonia. Bronchial pneumonia? Lobar Pneumonia? I “guess “it was bronchial. I don't know. I don't care. When I see the culture results in a couple of days, I may suggest changing the antibiotic. (if it hasn't already been done prior to me seeing the patient, even then it might not be required.) Is it secondary to an upper respiratory infection? Most likely by both the numbers and in this particular patient. But that is simply a “guess”. An "assumption" if you will. On the official chart the Dx is still pneumonia. It will not change from that. Maybe a secondary Dx. of thrush in a day or two after antibiotics. It will not be cultured to find out if it is truly candida albicans or not. It will be assumed. No need to pay the money for the test or bother the microbiologist.

Does the patient have other pathologies that predispose to pneumonia? Sure he does. So what? His current therapy for that is being maintained. When he comes back for something else, his chief complaint will be diagnosed and it will not be a major production to find every possible pathology and benign condition once the complaint is addressed. We didn't biopsy the mass on his mandible he said had been there for 40 years and was previously diagnosed as benign. It was listed as history in his chart, physically examined and determined to meet all the requirements not to biopsy it from palpation and visualization.



Depends on the patient.



Unlike CHF and pneumonia, wheezing is not a diagnosable pathology. As you pointed out, that is a symptom of an underlying pathology.



A lot more than you seem willing to admit I'd wager.



Nobody on any EMS site I have ever seen ever puts up enough information to make a reasonable educated guess. Look at the publication like NEJM for case presentations. PPTs of radiographs, lab values, complete history and physical findings. It just doesn't compare. The last scenario I commented on here didn't even have a full set of vitals. The history was incomplete and looked unreliable anyway. You could guess at it all day and still be no nearer the answer.



Never saw that as a Dx. seen it as a finding though.



Depends on just how high that number is. But if it is high enough the Dx will be assumed and treated in an unconscious person until something more definitive is discovered. If they are awake and alert, they will be asked. I am sure you are aware there is a body of research for aggressive glucose control in ICU.



So the EMT is following treatment protocols prescribed to the patient by a physician until a higher level of provider can alter that decision. What has that got to do with Dx? You and I are held to the same requirements. We just have more leeway on what those requirements are. Are you now complaining that an EMT-B isn't allowed to make treatment decisions based on the education level? Yes there is a chance of an emboli, so what? What is the EMT in the field going to do for it? In an open Fx. there is also wound contamination, nothing to do about that in the field except rinse the superficial wound. Unless you are advocating an orthopedic surgery procedure. Even the Emergency doc is going to have to turf that one.



I'm not, and the pt. is going to get some Maalox too in addition to the other tricks up my sleeve like a CXR. But the epi will come long before such bells and whistles in a patient in a medical emergent state. (Where advanced diagnostics become secondary to focused interventions.)



I don't see where he was making that assumption; merely pointing out easily diagnosed pathologies. Medicine does not always have to be some infinitely complex problem. Actually it is rather nice when it is a simple case.



I want to play too, maybe in the poorly described scenario she was using contraception, smokes and she had a PE? I am sure you have had patients who denied taking meds and then admitted to oral contraceptives when further pressed. How about endocarditis that leads to a ruptured or otherwise incompetent valve? That was an unfair challenge. Is he again supposed to take it upon himself to change the treatment modality based on pathology possibly beyond his knowledge or capability on a single patient? If that were the case, the AHA is going to have to start printing some really thick books with every possible caveat accounted for in the ACLS algorithms.



And sometimes that's all they do and punt to a specialist. But there is usually only one admitting dx. "Closed head injury" being my favorite too see on a chart coming from the ED. "I have no idea" isn't really billable.



Isn't everyone aware of that? ACS is a common one. STEMI anyone?

http://www.ncbi.nlm.nih.gov/pubmed/19166679
For some reason I just don’t feel the need to constantly point out what basic healthcare providers can’t possibly know after their few hours of training. A post graduate healthcare provider belittling an EMT or even a medic seems like an 40 year old finding satisfaction beating up a 3 year old for showing off their ice cream cone when the adult didn’t have one.

I almost aspirated my dinner after reading the last part :lol:

Veneficus
02-11-2010, 10:08 PM
[QUOTE=Veneficus;208157]

I almost aspirated my dinner after reading the last part :lol:

careful now, who the hell could possibly dx that B)

46Young
02-12-2010, 01:25 AM
[QUOTE=46Young;208163]

careful now, who the hell could possibly dx that B)

Just use the cookbook. Can't go wrong with that :P

VentMedic
02-12-2010, 07:03 AM
I almost aspirated my dinner after reading the last part :lol:


That wasn't part of my quote. That was Veneficus. But then he believes there is not need to look for a cause to the CHF as it is an end all diagnosis. That however is also how some look at a "diagnosis" as well and go with what fits to initiate a protocol.

Look at the examples we have had in the scenarios and in the news. If it doesn't "fit" one of the working diagnoses listed in someone's protocols, too bad. Look at the example of the high school football player that died. Too often Paramedics try to fit the patient into a "work diagnosis" rather than allowing the symptoms to lead them to other possibilities. How many here feel they MUST make a diagnosis to run a specific protocol? Or, if it doesn't fit, it is "BLS'd" in with or without a Paramedic even if the patient is truly sick.



Just use the cookbook. Can't go wrong with that :P

Thank you. That is exactly my point. As long as you can get a couple of symptoms to fit to run a protocol, it all good...except for the patients that didn't get the proper treatment because they were "fitted" into one recipe.

Originally Posted by VentMedic http://www.emtlife.com/styles/images_pb/buttons/viewpost.gif (http://www.emtlife.com/showthread.php?p=208118#post208118)
How much is "assumption"?

A lot more than you seem willing to admit I'd wager.

I asked the question "how much is assumption" since I do know a large part is based on it. Much becomes a guessing game as evidenced on scenario threads as some state "looks like something I saw once" or "I heard that maybe this" rather then knowing how to actually make the diagnosis of that disease.

For some reason I just don’t feel the need to constantly point out what basic healthcare providers can’t possibly know after their few hours of training.

As far as the EMT vs Paramedic comment, the last time I looked there is a difference in the levels. But yet some do believe they are at the same level or better than any doctor. It is those I would caution to know their limitations and continue assessing since what you think you "see" may have much more to the story and may not be just "BLS".

Both of you are missing the message in my posts since I stated the use of preliminary or working diagnosis when referring to the Paramedic many times. My point is not to confuse a symptom as an end all diagnosis as there may be many other symptoms or "working diagnoses" that could be made or found.

ivanh3
02-12-2010, 11:35 AM
I think EMTs/medics diagnose accurately quite frequently. However, some times we just address our symptoms and do follow up later. This is all part of the growth that happens during a career. I think some people get a bit caught in the cookie cutter vs critical thinking aspect of the job. There can be both. Algorithms can be great in the beginning and when there is a need for speed. Likewise with critical thinking. One is not mutually exclusive of the other.