Yes, We Do Diagnose
By Kelly Grayson
I found myself engaged in an interesting philosophical debate a couple of weeks ago. My opponent, the Operations Manager of a nearby EMS service, insisted that his medics apply an EKG to every single patient they transported. They even went so far as to code and bill every call that involved a patient complaint of chest or abdominal pain, dizziness, weakness, nausea and vomiting as a myocardial infarction. Didn't matter if it was a 19-year-old with alcohol intoxication or a constipated six-year-old who hadn't pooped in four days, it got billed and treated as a "possible MI."
So, during a break from ACLS class, several of his medics urged me to challenge his defense of the practice. I made my points, and he made his points. I countered them, and he drug out the concept of anginal equivalents, and I responded that one shouldn’t think of zebras when he hears hoof beats, which is exactly what an MI would be in a constipated six-year-old with lower abdominal pain — a very unusual equine with a very fancy custom paint job.
And then he said it, the rebuttal equivalent of sticking your fingers in your ears and shouting "Lalalalalala, I can't hear yooouuuuu…"
"But we can't know for sure," he protested. "EMTs don't diagnose!"
"Sure we diagnose," I smiled. "We do it every day!"
"No we don't," he doggedly insisted. "We treat symptoms, but we don't diagnose."
"Okay, suppose you have a patient with traumatic ankle pain. It's tender, maybe a little swollen, starting to bruise. A textbook 'painful, swollen, deformed extremity,' right?"
He nodded in agreement.
"Now, without x-rays, we can't know for sure whether it's a strain, a sprain or a fracture, right? But it doesn't really matter; we're going to treat them all with a splint and appropriate analgesia, correct?"
Again he nodded.
"What if there’s bone poking through the skin on the medial side? Would you call that an open distal tibia fracture?"
"Well, of course! If it’s obvious, you can — "
"Don't look now," I interrupted with a smile, "but you're dangerously close to making a diagnosis."
This little bit of dogma has been passed down through EMT and paramedic classes since I was in school, and it was no more true then than it is now. It took on a life of its own with the 1993 EMT-Basic curriculum and its focus is on symptomatic treatment only, and de-emphasis on anatomy, physiology and disease pathophysiology.
Whenever someone is uncomfortable with EMTs actually thinking, they trot out the "we don't diagnose" canard. It may be the doctor who writes restrictive treatment protocols, or instructors seeking to justify their superficial coverage of complex subject matter, or the intellectually lazy medic who thinks that our thought processes simply don’t matter: monkey see, monkey do.
A search of Dorland's Medical Dictionary yields the following definitions for the word diagnose:
Diagnosis: determination of the nature of a cause of a disease. A concise technical description of the cause, nature, or manifestations of a condition, situation, or problem.
- clinical diagnosis: diagnosis based on signs, symptoms, and laboratory findings during life
- differential diagnosis: the determination of which one of several diseases may be producing the symptoms
- medical diagnosis: diagnosis based on information from sources such as findings from a physical examination, interview with the patient or family or both, medical history of the patient and family, and clinical findings as reported by laboratory tests and radiologic studies
- physical diagnosis: diagnosis based on information obtained by inspection, palpation, percussion, and auscultation
It would seem that those definitions, at least in some part, encompass what we do as EMTs. If you actually believe that EMT-Basics don't need to understand why they provide BLS treatments, then I suppose you could indeed say that the EMT-B does not diagnose. That rationale does not, however, apply to paramedics.
And in reality it doesn't even apply to EMTs.
Case in point: you're an EMT-Basic responding to a complaint of difficulty breathing for ten minutes. When you approach the patient, his only complaint is difficulty breathing, and he has a history of asthma. He has taken his prescribed albuterol inhaler without relief. Upon examination, you notice that he has urticaria on his arms and chest, pronounced wheezing and inspiratory stridor.
With further questioning, he states that now he has difficulty swallowing, and his breathing is worse. The symptoms began after sampling his first-ever bowl of Louisiana seafood gumbo.
So do you help him take another puff of his inhaler, or do you opt instead for the Epinephrine auto-injector you carry in your rig?
If you chose the Epinephrine, then congratulations! You have just made a presumptive diagnosis of anaphylaxis.
We make decisions like this every day in clinical practice. Whether it is distinguishing asthma from anaphylaxis, pneumonia from CHF, or hypoglycemia from a stroke, the examples are legion. While it is important to keep an open mind when assessing patients and obtaining a history, at some point in the process our actions are guided by a presumptive diagnosis.
Granted, the nature of our profession and the austerity of the environment in which we work limits our diagnostic capabilities to the rough and rudimentary, and the diagnosis may indeed change significantly once the patient arrives at the hospital.
The EMT-B assesses the patient for his reported symptoms of chest pain and palpitations. He applies oxygen, obtains a SAMPLE history and vital signs, and makes a working diagnosis of tachycardia at 250 beats per minute.
The paramedic arrives, gathers more history and performs a 12 lead EKG, and refines the diagnosis to a narrow-complex, supraventricular tachycardia. He considers the patient’s reported history of Wolff Parkinson White syndrome, but notes the absence of characteristic delta waves on the EKG. Based on these findings, he refines the diagnosis to a possible orthodromic atrioventricular reentry tachycardia, and opts for sedation and synchronized cardioversion over antiarrhythmic therapy.
The ER doctor agrees with the paramedic's diagnosis and treatment, performs a post-cardioversion 12 lead EKG, and notes subtle findings that indicate the presence of a posteroseptal AV tract. Accordingly, he further refines the diagnosis to orthodromic WPW tachycardia, utilizing a posteroseptal bypass tract, and consults an electrophysiologist to schedule the patient for an EP study.
The electrophysiologist confirms the presence of a posteroseptal bypass tract, along with a couple of others, and performs a high frequency radio ablation of those abnormal conduction pathways, curing the episodes that have been plaguing the patient.
Every step of the way, at every interaction with a healthcare provider, a diagnosis was made. With each successive increase in provider expertise and diagnostic capability, the diagnosis was refined, until finally the patient received a specific resolution to his illness.
If you don't think it works that way in real life, I beg to differ. It happened exactly that way not a month ago with one of my patients, and similar stories are carried out in ambulances every day.
The next time a doctor tells you that EMTs don't diagnose, just remember that what he's really saying is that he doesn't trust EMTs to think for themselves. If a fellow EMT tells you that, what he's really saying is that he doesn't think.
And you really don't want to be that kind of EMT.