EMS and Diagnosis

At the beginning of October, one of the big topics online was a case from 2008 where an EMS crew misdiagnosed a chest pain patient with acid reflux, recommended Maalox and left the patient at home. The next day, the patient called 911 again with chest pain and shortness of breath. This crew transported the patient to the hospital where the patient ultimately died of a pulmonary embolism. The new turn in this story was a judge rejecting immunity from liability for the first crew since the original situation was “non-emergent.” A discussion of the call, as well as the court document for the ruling, can be found over at Fire Law.

In response to the case, the most common refrain online was “EMTs don’t diagnose,” to which I say phooey. EMS providers DO diagnose, in fact it’s a requirement to do the job properly. They just aren’t taught to use clinical judgment properly when making a diagnosis. So, the big question is, “What is a diagnosis?” and “How exactly does the process work?”

The first misconception that needs to be laid to rest is the concept of a diagnosis as being final. There are many types of diagnoses (working, differential, admitting, discharge, etc) and the diagnosis changes as more information is learned about the patient and as other providers become involved. A patient in the emergency room may have one diagnosis by the emergency physician, a more specific diagnosis by the hospitalist, and an even more specific diagnosis from an infectious disease specialist due to more information being gained over the course of the patient’s stay and differing levels of education. Similarly, a patient with chest pain may be diagnosed with “chest pain, possible MI” by an EMT (symptoms can be a diagnosis when the provider at any level is unable to narrow it down at that time), STEMI, including a general location, by a paramedic, and the cath lab team will be able to diagnosis the specific branch of the vessel with the amount of occlusion. Given the knowledge of the provider and the tools available, all three are valid diagnosis for the same patient.

A second misconception that seems to be present is that there is only one diagnosis that explains everything. A patient can have multiple problems that haven’t been found before. One thing to think about if a presentation doesn’t make sense is, “Is this one problem or several?” Over at Street Watch: Notes of a Paramedic, Peter C related a case where he caught (diagnosed) a patient who was having a concurrent CVA and STEMI.

Bates’ Guide to the Physical Examination and History Taking lays down a 5 step process for “clinical reasoning: developing hypotheses about patient problems.” Feel free to substitute “diagnosis for hypothesis.”

1.       “Start with the most critical finding.” The example given is a patient with the “worst headache of the patient’s life,” nausea, and vomiting, think increased intracranial pressure, not GI problems.

2.       “Match your finding with all possible causes.” This is essentially the formation of differential diagnoses (DDx). All a DDx says is, “Given what I know right now, these are the possible causes.” This should start as soon as you hear the patient’s chief complaint. Take a second and think of all of the causes of chest pain? Trauma, pericarditis, MI (STEMI –and- NSTEMI), pulmonary embolism, pneumonia, pleuritis, and probably many more. These are your differential diagnoses.

3.       “Eliminate the diagnostic possibilities that fail to explain the findings.” As you interview, perform a physical exam, and perform point of care testing (most common in EMS is a 12 lead EKG, pulse oximetry, and blood glucose testing), some things you didn’t think of based on the chief complaint may come up. Those get added to your list of DDxs. Say the patient doesn’t complain of trauma and there are no signs of trauma. Ok, mark trauma off of the list. You acquire a 12 lead EKG and no ST elevation is noted. Mark off STEMI (but not NSTEMI).

4.       “Weigh the competing possibilities and select the most likely diagnosis.” Ok, what makes sense out of the list given what the signs, symptoms, and lab results are while taking into account the course of the disease? When did the pain start? Did it start 5 days ago or 2 hours ago? Has this happened before? Given what you know about the patient and your knowledge base (taking into account the limits of your knowledge. This is sound advice for everyone from the EMR through physician), what makes sense? Is this a patient that I need to refer (for EMS, push hard for transport)?

5.       “Give special attention to potentially life-threatening and treatable conditions.” This is, of course, where the original crew failed. Is gastric reflux a valid possibility? Sure, but so is NSTEMI (which, given the limited information provided about what the crew knew, I’d argue this is more likely  than a PE. Of course limitations in diagnostic tools is an important consideration) and pulmonary embolism, both of which cannot be ruled out in the field.

In other words, if you take a history, perform a physical examination, and use diagnostic tools to gather information, incorporate that information into a conclusion about what the patient is experiencing, and use that to guide treatment, then you are making a [working] diagnosis. If you are considering that multiple diseases can give the same symptoms, you are making a [differential] diagnosis. How close does this sound to describing how you actually practice?

If you are truly not making a diagnosis then what exactly are you treating? I’d argue that the vast majority of the physical exam is useless and that provider should be content to following cook book, symptom relief protocols with zero deviation. After all, if you deviate even a little, the only true basis is that you made a diagnosis. I sincerely hope that most EMS providers diagnose, even if they call it something else.

1. Bickley, Lynn S., Szilagyi, Peter G. “Bates’ Guide to Physical Examination and History Taking.” (10th edition). Philadelphia: Wolters  Kluwer/Lippincott, Williams, & Wilkins. 2009. Pg. 28-29.

About Joe Paczkowski

I am an EMT and a second year medical student at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific (COMP).
This entry was posted in Clinical EMS, EMS Operations, EMS: A Profession and tagged , , , , , , , , , , , , , . Bookmark the permalink.

4 Responses to EMS and Diagnosis

  1. Justin J. Rebbert says:

    How would an EMT-B, with only the knowledge a person is required to have in order to become an EMT-B, be able to complete a DDx? We are only taught about a handful of conditions, and really not much about them. Using your example of “chest pain”, the possible causes of chest pain I might come up with are trauma, CHF, and MI. I don’t know enough to include pericarditis, STEMI vs. NSTEMI, pulmonary embolism, pneumonia, and pleuritis, nor would most EMT-Bs without training and education that goes beyond what is required to become an EMT-B.

    You can use this to make a point about the value of continued education beyond the bare minimum, and I’d certainly agree that that’s nice if it’s possible.

    You could also say, “Just make do with whatever you do know,” but it seems the value of a DDx is drastically diminished if all possibilities aren’t considered. It could even be dangerous, if an EMT-B with limited knowledge and experience makes an incorrect diagnosis and presents the patient to the ER as having that condition.

    So let’s take it as given that “get more education and experience” will be part of the answer, but until that is possible, what is the bare-minimum EMT-B to do?

    • Good comments

      The first think to realize is that even physicians coming out of medical school can’t diagnose (or know of) every single condition or disease known. Sure, physicians know much more (and, granted, you can’t consider something you’ve never heard of), but through continuing education, experience, or even just basic curiosity, the list of what could be considered would grow quickly. I’ve read stories where a paramedic picked up a diagnosis based on a scenario in a forum (dystonic reaction), ran it by online medical control, and got an order for diphenhydramine (benadryl). At some point, he had to remember dystonic reaction, weigh it against the more common causes, and then make the decision to contact medical control.

      I think the overall key is that there’s no reason to be overly fancy with it. No one should expect an elaborate list out of EMTs. The list you gave for chest pain would work great for someone coming straight out of EMT school. To me, at least, I think the two biggest things are trying to get providers to think about multiple causes (thus avoiding tunnel vision) and having a framework to work with. It’s essentially applying “AEIOUTIPS” type thinking to everything instead of just altered mental status. AEIOUTIPS doesn’t cover everything that can cause altered mental status, but it’s a really good starting place if nothing has jumped out.

      For the pulmonary embolism case that was treated as reflux, did the paramedics consider the possibility that there was numerous other emergency conditions that could have caused the patient’s symptoms, of which they cannot rule out? I honestly don’t know, but I can say that there is value in recognizing specific diseases are likely causes that you can’t rule out. I think saying, “Your chest pain could be acid reflux, but it could also be an MI, embolism, or other disease that we can’t rule out” carries more weight than a generic, “Well, something could be occurring that could kill you, so you should just get it checked out to be safe.” At a minimum, you could explain how an MI would kill him. You can’t explain a generic “something else.”

      Finally, when taking as a “these are the things that could be wrong,” I don’t think there’s much of a risk present. Unless the provider is honestly stumped, I think the thought is going to be present regardless of whether it’s recognized or not. Sure, instructors can tell EMTs that “it’s not a broken bone, it’s a swollen painful deformity,” and I think just about everyone ends up nodding their head and saying yes just to get through the course while thinking, “In the real world, we call it a fracture.” Ultimately, if you’re focusing on the potentially life threatening causes, what’s the worst that could happen?

      First off, a list of differentials isn’t limited to one thing, even if eventually you have to take a leap and pick a working diagnosis. So let’s say embolism is left off or CHF is picked as the working diagnosis. As an EMT, you’re still going to give supplemental oxygen, still going to consider the need for paramedics based on the patient’s condition and ETAs, and still going to drive to the hospital. It doesn’t necessarily have to be communicated at handover. If you do feel like mentioning it, hedge it with something like, “I was considering….” after relying the pertinent exam findings. The worst would be you’re wrong and the physician or nurse points out something overlooked that would have made a difference (OK, the worst would be the person receiving report would be an as.. err… unprofessional, but to that I say, “Meh”).

      Finally, there’s nothing wrong with calling a spade a spade. “Abdominal pain” is a perfectly fine working diagnosis if nothing reasonable can be thought of. “Chest pain” is a perfectly fine working diagnosis if nothing jumps out about a patient complaining of chest pain. If it’s a square peg, and all you have is round holes, there’s no need to smash the square peg into a round hole. Recognize you have a square peg and move on.

      So, what’s a bare minimum EMT to do? Same as with everything else that EMTs are undertrained, undereducated, and underequipped, hopefully the best he or she can do, recognize the limitations they have, defend their decisions (“based on my education, training and experience…”), and hope that the other provider taking over understands that.

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