Thinking horses not zebras

[crotchitymedic1986]

I dont think it really matters which diagnoisis is correct, either way, the ambulance crew is likely to take the lazy way out and tell the mom to give tylenol/motrin and see the doc in the morning, then ask her to sign a statement that says she is refusing EMS transport.

P.S. : To all you rookies and wannabes that think you know more than me because you read a book once (I was cancelled on more calls than most of you have run in your career) this scenario was flawed from the beginning, because you were only given the choice of two possiblities of diagnosis; strep throat or meningitis. Did any of you genuises remember that not all kids get immunized for a variety of reasons, and that this child could just as easily have mumps or measles, or any number of viruses or other infections that start with fever and general body pain ? But as usual in today's world of cookbook medicine, when you have symptoms A & B, the diagnosis must be C.

That snappy enough for you

Edited May 3, 2009 by crotchitymedic1986

[chbare]

To clarify, a "zebra" is not just unlikely, it's unlikely and rare. And this statement is common among internists but not emergency physicians.

Emergency medicine is patently different from other specialties in how we approach a complaint and form a differential diagnosis. Most specialties look at what is "most likely" the cause of the patient's symptoms. As the "health care safety net", emergency care providers are the last chance many patients have to catch a potentially life-threatening disease. Our ability to perform an intense, broad evaluation in a very short period of time lends us the ability to quickly diagnose something that may take a primary care physician (if the patient even has one) much longer, and perhaps too long, to find. We can't afford to say that the burning retrosternal chest pain is probably GERD and leave it at that. We have to make sure it isn't something far worse, like MI, or TAD, or PE, or pneumonia, or pericarditis. Speaking from experience, there are few feelings worse than finding out later that your diagnosis was incorrect and you missed something dangerous. The hair stands up on my neck anytime one of my partners says, "Hey, you remember this patient you saw the other day..."

When confronted with a diagnostic dilemma (and they are all dilemmas until you think through it), think about not only what is most likely, but what is perhaps less likely but potentially lethal. It is our job to consider the potentially life-threatening cause of every complaint. Nausea? You'd better think about MI. Back pain? AAA should be somewhere in your mind. That's not to say that every patient with nausea gets an admission for serial enzymes and a stress test, but you've got to think about it. That's also not to say that every kid with a fever should get an LP, but it should be considered even if just briefly.

While you might be correct that ultimately the patient will turn out to have a non-worrisome diagnosis, your instructor's point is a good one.

'zilla

I do not disagree; however, my concern is that we have people who are trained to take this concept to a zealous extreme and tend to assume the worst with every patient. This is where I disagree, and unfortunately, I have been around many of these proviers who simply have to perform an intervention based on half arsed evidence.

I suspect this is some of what is fueling the RSI problems we see. People are performing RSI on every head injury or every altered mental status patient without actually considering the big picture.

I agree, be prepared for the worst case scenario; however, do allow your self to fall into the every patient is going to crash on the way to the hospital concept I often see taught to EMS providers.

Take care,

chbare.

[AnthonyM83]

P.S. : To all you rookies and wannabes that think you know more than me because you read a book once (I was cancelled on more calls than most of you have run in your career)

Gawdamnit, right when I was backing you up, you gotta go say something like that.

[croaker260]

I suspect this is some of what is fueling the RSI problems we see. People are performing RSI on every head injury or every altered mental status patient without actually considering the big picture.

I disagree here, the reason we are having problems with RSI is to many new medics dont have their basics (Basic ETT) down correctly, and to be honest its not usually taught correctly...and when they are "taught " RSI/MAI, they arnt taught that correctly either......so they should never be doing RSI to begin with.

We have no one to blame but ourselves there.

Edited May 4, 2009 by croaker260

[chbare]

I disagree here, the reason we are having problems with RSI is to many new medics dont have their basics (Basic ETT) down correctly, and to be honest its not usually taught correctly...and when they are "taught " RSI/MAI, they arnt taught that correctly either......so they should never be doing RSI to begin with.

We have no one to blame but ourselves there.

I respectfully disagree with you as well. I stated "one of the reasons" is the over emphasis on RSI. I agree that poor education and experience is part of the equation; however, this is not a new medic problem as many people across the board are having problems in systems that use RSI.

I do not want to go into a RSI debate, and simply used RSI as an example. I still stand by my point that I have seen providers push for RSI on every head injury because they only see the worse case scenario. I agree, the root cause is perhaps poor education.

Take care,

chbare.