Do we diagnose, rule in/out, or just load and go.

[spenac]

Scott33 said the following on another topic.

"Yes we do, we do it all the time. Some of us just don't realize it.

Take your "diff breather" call. A basic assessment should point to whether it is an asthmatic, COPDer, CHFer, Pneumonia etc, even with PMHx of "all of the above". We should already have ruled out some of the other possibilities prior to treatment beyond that of positioning and O2. The reason the poorer providers out there give nitrates and lasix (and God forbid, CPAP) to patients with pneumonia, is down to poor assessment skills, which neglects a consideration towards other co-morbidities, which could present with similar (go figure ) initial findings.

This is the principle behind what AMLS are trying to endorse - possibilities to probabilities / ruling out and ruling in. It makes perfect sense if one knows what to look for, and encourages clinical development and a further understanding of common disease processes...

…or we can just load and go. "

I am a firm believer that we should examine patients, make a field diagnosis, treat, make a determination to transport or not. I do not feel that the patient has the right to demand transport, but has the right to refuse transport if they want to. I feel we need to be able to deny transport to those that do not need it. This is not lazy, this is actually using medical education.

OK discuss if you want but try and not stoop to attacks or the crap that makes you be an idiot unless everyone agrees with you.

[DartmouthDave]

[/font:258d3c7e55]Hello,

Taking a reasonable amount of time to assess and start treating most patients is a good idea. Considering, despite being sick, their acuity is relatively low and odds are you will spend time waiting at the triage desk.

It is nice to see a correctly dx patient with a decent history and physical done who appears better than they did when EMS arrived. As opposed to a c/c, with no hx, no IV and a NRB jammed on the patient's face.

However, I have seen CPAP used for patients with pneumonia before. In fact, I have seen it work well and prevent the need for intubation for some frail patients that would be next to impossible to wean.

Cheers,

D

[emt217]

While I'm not an ALS provider (yet!), I agree 1,000%. Too often I find myself at the "demands" of the pt. ie:

I wanna go HERE instead of there!

I need help, I have lockjaw (stated while eating an Otis Spunkmeyer Giant Chocolate muffin)

Or my personal favorite- I haven't feel good for about two weeks. I have a sore throat and runny nose.

(when I asked him if it was worse now than the last 14 days, his reply was, and I quote)

"I've missed 4 days from work. If I call in I'll get fired. I figure if my girlfriend calls in and tells them I'm so sick I had to go to the hospital by ambulance, I won't lose my job!

I firmly believe that the AMA, NREMT, etc., should legally recognize "dumbass" as a C/C.

On a more serious note, had one of those "poor providers" back me up on a pt with CHF so severe he was on the verge of flash edema. Now my protocols state no Albuterol if: Pt over 45, PMHx HD,HTN,MI. HR >130. This guy has weeping edema lower extremities. If you put your scope on and dropped the bell into a flushing toilet, there are his lung sounds. My "backup" gave me down the road in front of the pt and family for not giving neb Rx!

More often than not, I do my damndest to diagnose, not just "tech". I firmly believe you can't treat without an initial diagnosis. If we tech and don't diagnose, why are we even here?

[scott33]

However, I have seen CPAP used for patients with pneumonia before. In fact, I have seen it work well and prevent the need for intubation for some frail patients that would be next to impossible to wean.

Did you happen to know if the causative agent was viral, or bacterial (or other) with these patients? I believe there is a difference with the indication of CPAP / BiPAP in hospital.

My point being however, that apparently, many EMS providers have treated the pneumonia patient as a CHF'er (yes you can have both at the same time, which goes back to ruling in, and ruling out). This is supposedly one of the reasons for CPAP being slow to get off the ground nationally, and one of the reasons we will be moving away from Lasix - too many febrile, tachycardic, and dehydrated old ladies being diuresed in the field :shock:

[DartmouthDave]

Hello,

Most that I can think off were bacterial pneumonias.

As for the lasix, in most setting, it isn't required. Now for those poor folks with longer transport times I think it has a role. As for not being able to dx pneumonia, CHF or both at the same time as an argument against CPAP...I do not get it....I think that may be some sandbagging due to the costs.

From my point of view, anytime EMS can prevent a tube thereby allowing time to flog the patient...I say great. For us and the patient.

I will float this one by the RT at work tonight.

D

[BushyFromOz]

these topics ask for simple answers od dynamic situations. The best i can say is that my clinical approach (the way to run thorugh things in my head) on scene determines weather i work on scene, work while moving to the truck or load and go. Theres so many variables as to what decision i would make that i cant see how anyone can have a hard and fast rule.

[VentMedic]

Did you happen to know if the causative agent was viral, or bacterial (or other) with these patients? I believe there is a difference with the indication of CPAP / BiPAP in hospital.

My point being however, that apparently, many EMS providers have treated the pneumonia patient as a CHF'er (yes you can have both at the same time, which goes back to ruling in, and ruling out). This is supposedly one of the reasons for CPAP being slow to get off the ground nationally, and one of the reasons we will be moving away from Lasix - too many febrile, tachycardic, and dehydrated old ladies being diuresed in the field :shock:

How many have treated aspiration like CHF....with CPAP? That will buy a tube at the hospital and may later be fatal. A couple times a week I can count on suctioning scrambled eggs from the airways of an elderly NH patient who had an acute onset of "CHF" while eating breakfast.

There is a big difference between CPAP and BiPAP (Respiratonics trade name). There is a big difference between prehospital machines. When looking at the studies, one shouldn't just read the oversimplified version in JEMS but should see what CPAP device was used for the study in the original article. The trick to CPAP is to know what your device can and can not do. Putting a plastic "toy" with low flow and high resistance on the face of someone who is about to fatique or in the face of an MI may bring failure quickly. You also need to know what you want to affect or will affect. Preload? Afterload? Oxygenation? Ventilation?

CPAP has been around for about 60 years and maybe longer depending on other applications and machines it has been used with. It has also been used in homecare for at least 15 years for a variety of different medical reasons including decreasing risks of CHF.

At this time you are not going to find many Bilevel (or BiPAP) machines in prehospital.

Some people also use the term "COPD" as ONE disease. It is a category of many several diseases and can be mixed with many other lung disorders. Often, it is something other than the COPD itself that is causing the exacerbation such as PNA, right heart failure or pulmonary hypertension. Not all diagnoses will be blatant. Sepsis does not always have a big presentation but can turn deadly quickly.

Some just follow protocols for a limited amount of "working dxs". Those that have knowledge of various pathologies can choose a treatment plan without having to pigeon hole a patient into ONE working diagnosis. Most patients are complex medically and may meet the requirements for the entire recipe book.

If you ever listen to physician/professional rounds at a hospital, they may list 10 working diagnoses or identifiable problems that are being treated at the same time...and that is just for that day. Something else might break and add another problem that must be solved within the next few minutes.

[crotchitymedic1986]

Getting back to the original question, I say all of the above. I hope you have a diagnosis in mind before you start shoving tubes, needles, and medicines into patients, but with that being said, we can not make a true diagnosis on many patients due to our inability to do labs and xrays. I hope that you do take the time to perform the proper treatment, and that you transport to the most appropriate facility.

With that being said, sometimes we are a glorified taxi service. Every job has some aspect that makes the job less than perfect, otherwise they wouldnt have to pay us to show up every day. Like I have said many times, most people dont become police officers to direct traffic in the rain, but that is part of the job. Part of our job, like it or not, is responding to, and sometimes transporting low acuity calls.

And as i have also said many times, be careful what you wish for, because if the only people who called 911 were people experiencing true emergencies, your call volume would drop about 90% overnight, and you would be out of work.

[Richard B the EMT]

Let us not forget that the CPAP machine is also used for the ongoing treatment of Acute Sleep Apnea. I, for one, can not, because that is why I use one!

http://www.sleepapnea.org/ for the American Sleep Apnea Association

[Boolancedriver911]

I was always taught that EMS workers or nurses were not allowed to diagnose.