FIRST ARRIVING NETWORK
First Arriving Network
Powered by the First Arriving Network, Reaching 1M+ First Responders Worldwide

Demystifying Diagnosis

Want to start a fight in an EMS social media forum?

Just ask if EMTs diagnose. Invariably, you'll get hordes of people shitting their pants over a simple word, and twisting the English language into something unrecognizable in an effort to avoid calling something what it really is.

General impression.

Field diagnosis.

Presumptive diagnosis.

Field impression.

We have an entire lexicon of weasel words to differentiate what we base treatment plans upon, and when they describe the process, what they describe is essentially… a diagnosis.

It's not a magic word, people, nor is it exclusively owned by physicians. Nor is it something solely based upon laboratory analysis and diagnostic imaging.

di·ag·nose
ˌdīəgˈnōs
verb
1.
identify the nature of (an illness or other problem) by examination of the symptoms.
Not that it does not mention lab tests. Or x-rays. Or CT scans. Or ultrasounds. Or even doctors, except in examples demonstrating word usage.
 
We. Do. Diagnose. 
 
We do it every damned day, every damned patient, in every interaction with a healthcare provider along the treatment continuum. It is what treatment decisions are based upon.
 
The diagnosis often starts as something rough, eg. unstable narrow complex tachycardia. As expertise, education, experience and available technology increase, the diagnosis is often refined, until eventually, we arrive at a definitive diagnosis, eg unstable orthodromic WPW tachycardia utilizing a posteroseptal bypass tract, and hopefully the person making the definitive diagnosis can provide definitive treatment, like, say, high frequency radio ablation of that aforementioned posteroseptal bypass tract.
 
And sometimes, the original diagnosis is disproven entirely, and the actual diagnosis turns out to be something much different than originally believed.

 

And you know what? That sort of thing still happens even when the person making the original diagnosis is a physician, with all the education and technology they have at their command.

It does not make what we do anything less than diagnosing the patient, even when we are proven wrong. Misdiagnoses happen in medicine. Hopefully, the treatment provided for the incorrect diagnosis isn't harmful to the patient, and much of the treatment we provide in EMS is so broad as to be useful for multiple diagnoses, and not overly harmful if we happen to be wrong.

Many EMTs will stubbornly cling to those weasel words like field impression in the mistaken belief that diagnosis is a specific legal term, and that avoiding use of that word provides them some measure of protection from legal action.

 

Yet, no one can cite a specific case where the term diagnosis was at issue. Some will cite cases based upon a misdiagnosis that resulted in patient harm, but the fact that they diagnosed was not. You could call what those EMTs did an incorrect field impression, and their legal liability would be the same. I happen to know a number of real EMS lawyers, folks who went to paramedic school and law school, folks who make a living providing legal opinions on healthcare issues, providing expert witness testimony and so on, and invariably they roll their eyes at some guardhouse lawyer's halfassed opinion that use of the word diagnosis will call you to the attention of the Lawsuit Boogeyman.

It is just a damned word. It has no specific legal meaning, and it accurately describes what we do.
 
If using the word still makes you uncomfortable, fine. Call it a "rough paramedical field impression educated guess" if you like, but let's not kid ourselves that whatever tortured terminology we conjure, it is still a synonym of… diagnosis.

 If an EMT treats a patient with a history of asthma whose chief complaint is difficulty breathing and wheezing, and after obtaining a history and performing a physical exam, determines that the symptoms began immediately following a bee sting, notes the presence of urticaria on the patient's arms and chest, and opts for treatment with an epinephrine auto-injector over assisting the patient with his albuterol inhaler…

… that EMT has diagnosed anaphylaxis, and is treating according to that diagnosis.

The patient's chief complaint was wheezing and difficulty breathing. If he treated purely based upon those symptoms, he'd use the inhaler.

He'd also be an idiot.

Instead, if he chose the epinephrine auto-injector and followed his anaphylaxis protocol because he identified the nature of (an illness or other problem) by examination of the symptoms, he diagnosed anaphylaxis. He had to, to know which treatment protocol was appropriate.

If you're one of those people who insists we don't diagnose, and we provide symptomatic treatment only, there is a word for you: skills monkey. Don't go around bitching because the bunch of bananas they pay you every week doesn't add up to a living wage. You're part of the problem.

In 20 years in EMS, I have yet to encounter a doctor who took exception to my use of the word diagnosis. Not even once. In fact, the people who most often shit their pants over the word are EMTs. But in in the off chance a doctor does tell you, "EMTs don't diagnose," allow me to translate that for you: "I don't trust you to think for yourself."

And if you accept it at face value, and repeat it to other EMTs, what you're really saying is, "I don't think for myself, and I'm not worthy of the doctor's trust."

And you really don't want to be that kind of EMT.

Edited to add: Mere hours after posting this, I came across this post on Kevin, MD:

Finding a diagnosis is not always an easy task.

Sometimes, it is a work in progress.

One of the most salient lessons I learned from these sessions was the importance of clinical discretion and sequential testing. Medical resources are not infinite, nor are they free or even cheap. Every test run or scan ordered is often accompanied by a hefty price tag. As such, we are encouraged to use clinical evidence to guide decision making. When it comes to pinpointing a diagnosis, we are supposed to order tests to specifically confirm a clinical suspicion, based on the patient’s history and exam findings, in addition to our knowledge of statistical probabilities. We also order tests to collect data that would help us rule out an etiology that would alter the patient’s treatment.

(emphasis mine)

So diagnosisis is a work in progress, and often it starts with the paramedic, and is refined, confirmed or disproven with further study in the hospital. And please tell me again that the things that define a diagnosis are lab tests and imaging studies and not history and exam findings. You know, the same history and exam findings that paramedics are capable of obtaining.

For further reading:

Yes, We Do Diagnose

Comments - Add Yours

  • Ambulance_Driver

    True dat.

    I don’t mind so much the people who argue definitions, even though it’s a specious argument.

    What chaps my ass like steel wool underwear are people who insist that we just follow protocols, or treat symptoms only, and our thought process doesn’t matter. Those people are dangerous.

    • John Shady

      Those people are cookbook medics. And to think I once had my Manager and Medical Director tell me to stop thinking and be a cookbook medic…

  • Divemedic

    I agree with you. EMTs look at the symptoms, a limited amount of diagnostic information, decide what the problem is, and develop a course of treatment. The only thing we don’t do is assign an ICD-9 code, bill for what we do (we are pretty much the only part of the medical field that doesn’t itemize), and get paid an amount equal to our education and experience.

  • ThatOneEMT

    What do you expect when programs are designed to turn out EMTs after 120 hours following a set curriculum of topics required to be covered. Adding more education to EMS wouldn’t be to add more skills, but to advance our comprehension of illnesses and injuries and encourage us to think about the best way to approach prehospital treatment. That’s what would separate an EMT from the common first aider.

    EMTs who do not know how to think, don’t diagnose.

  • 40lizard

    Amen Kelly!

  • Too Old To Work

    Of course we diagnose. If we didn’t we couldn’t treat patients. Or at least that’s what one of my medical directors once told me. He thought the whole thing was silly and didn’t care what we called it as long as we did it.

    I stopped worrying about it years ago and I don’t much care what people on social media have to say about just about anything.

    Two weeks ago Mrs. TOTWTYTR developed a hacking cough, which in a few days became productive. She went to see her PCP who said it was “probably viral” and prescribed cough medicine.

    Yesterday she told me that the previously yellow sputum was now green.

    “Pneumonia, let’s go see a doctor.”

    Two hours and a chest Xray later, guess what the diagnosis was?

    The CXR is confirmatory for pneumonia, not diagnostic, just at the 12 Lead is confirmatory not diagnostic for STEMI.

  • Pingback: DeMYTHifying Diagnosis – Part I | Rogue Medic()

  • Pingback: DeMYTHifying Diagnosis – Part II | Rogue Medic()

  • mpatk

    Thank you for pointing this out. The word “diagnosis” has many levels……just like the word “treatment”. Just as we can treat without giving the “definitive” treatment, we can diagnose without giving the “definitive” diagnosis.

  • Pingback: A Lawyer Speaks Out On Diagnosis | A Day In The Life Of An Ambulance Driver()