Diagnosis in EMS

It was pounded into our heads in Paramedic school that we do not diagnose.  Only Doctors can diagnose and we are not Doctors, so it seemed straight forward.

Then I went on a call.

I diagnosed.  Then I treated based on that diagnosis.

I violated one of the unwritten rules and it worked.  Go figure.

Websters reminds us that diagnose has a rather clear cut definition:

“The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.

The opinion derived from such an evaluation.”
I can hear them now…”But you don’t evaluate lab data Mr happy Medic Man!”  I will assume the position that drawing blood for evaluation using specific diagnostic tools would count as lab data, so that’s out of the way.
In a recent conversation I was reminded that Paramedics can’t determine appropriate non ER facilities because they can not diagnose.  Yet that is all we do day in and day out.
Our education, training and experience all combine to put the puzzle pieces together and find what is wrong.  We use our tools and techniques to make those wrongs better and all because we have to start somewhere, we need to decide, we need to diagnose.
So the next time you are told not to diagnose, ask them what to call your evaluation of patient’s presentation, medical history and blood sugar reading.  While they’re thinking, sneak away.
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33 thoughts on “Diagnosis in EMS”

  1. Medics Diagnose.

    You can call it a “Field Diagnosis”, a “working diagnosis”, or a “Presumption of the patients condition and status” if it makes you feel better. However, Medics DO diagnose.

    No, it’s not the final diagnosis in a lot of cases, and no we’re nowhere near as highly educated as are physicians. However we do evaluate a patient based upon a large number of subjective and objective observations and diagnostic tests and formulate a working treatment plan based upon our observations. This treatment plan is made more effective by our knowledge and experience of medicine as well as our knowledge and experience of the local and regional healthcare system.

    Sounds like we diagnose to me.

  2. Medics Diagnose.

    You can call it a “Field Diagnosis”, a “working diagnosis”, or a “Presumption of the patients condition and status” if it makes you feel better. However, Medics DO diagnose.

    No, it’s not the final diagnosis in a lot of cases, and no we’re nowhere near as highly educated as are physicians. However we do evaluate a patient based upon a large number of subjective and objective observations and diagnostic tests and formulate a working treatment plan based upon our observations. This treatment plan is made more effective by our knowledge and experience of medicine as well as our knowledge and experience of the local and regional healthcare system.

    Sounds like we diagnose to me.

  3. fine, if they don’t want to admit we sometimes diagnose, let’s just say we “come up with a list of possible medical conditions that may be the cause(s) of a patient’s complaint(s) and treat based on a risk-vs-benefit model.”

  4. fine, if they don’t want to admit we sometimes diagnose, let’s just say we “come up with a list of possible medical conditions that may be the cause(s) of a patient’s complaint(s) and treat based on a risk-vs-benefit model.”

  5. Sounds like a differential diagnosis to me. You start with a set of ok this is what it could be and widdle our way down to ok this is what it is. We often do this subconsciously without even realizing it. It is our job to properly define and treat a patient’s condition. And the whole physicians have more education then us….while that may be true…I’ve worked with plenty of residents who don’t know near as much as the paramedics i work with.

  6. Sounds like a differential diagnosis to me. You start with a set of ok this is what it could be and widdle our way down to ok this is what it is. We often do this subconsciously without even realizing it. It is our job to properly define and treat a patient’s condition. And the whole physicians have more education then us….while that may be true…I’ve worked with plenty of residents who don’t know near as much as the paramedics i work with.

  7. The only ones who get to make a “final diagnosis” are forensic pathologists. Everyone else formulates a “working diagnosis” subject to change based on new information.

  8. Paramedics diagnose just as often as MD’s do. If it has feathers, walks and sounds like a duck, it’s a duck. There are a lot of calls where we can not make the diagnosis. Severe abdominal pain. We can point to what we think it may be but not diagnose it definitively. A patient in VT on the other hand is an easy diagnosis. And we treat it. MD’s do the same thing on a broader scale. If the ER doc thinks someone may have cancer what do they do? Send them to an oncologist to be definitively diagnosed.

    We diagnose some things and punt the rest to the appropriate medical expert.

  9. Paramedics diagnose just as often as MD’s do. If it has feathers, walks and sounds like a duck, it’s a duck. There are a lot of calls where we can not make the diagnosis. Severe abdominal pain. We can point to what we think it may be but not diagnose it definitively. A patient in VT on the other hand is an easy diagnosis. And we treat it. MD’s do the same thing on a broader scale. If the ER doc thinks someone may have cancer what do they do? Send them to an oncologist to be definitively diagnosed.

    We diagnose some things and punt the rest to the appropriate medical expert.

  10. Well put, Justin. I never heard you as passionate as you were ranting (in a Happy Medic kind of way) the other night. Ted’s computer wasn’t recording then, but your conversation with Patrick got saved. I was playing the devil’s advocate with you on this subject, but you’re absolutely right!

  11. Well put, Justin. I never heard you as passionate as you were ranting (in a Happy Medic kind of way) the other night. Ted’s computer wasn’t recording then, but your conversation with Patrick got saved. I was playing the devil’s advocate with you on this subject, but you’re absolutely right!

  12. my Paramedic instructor said you have to diagnose them if you plan on pushing medications. otherwise why would you push meds and if things go wrong you had better have a good reason why you pushed vasopressin instead of Dopamine you cant do that without having a diagnoses.

  13. my Paramedic instructor said you have to diagnose them if you plan on pushing medications. otherwise why would you push meds and if things go wrong you had better have a good reason why you pushed vasopressin instead of Dopamine you cant do that without having a diagnoses.

  14. So if someone is in a car accident and their tibia is sticking out through the skin, what do you say when they ask you if their leg is broken?

    Technically you can’t say yes because you can’t diagnose and you don’t have X-Ray vision.

  15. So if someone is in a car accident and their tibia is sticking out through the skin, what do you say when they ask you if their leg is broken?

    Technically you can’t say yes because you can’t diagnose and you don’t have X-Ray vision.

  16. Do EMS Professionals diagnose? As an ED physician and former paramedic I remind students and attendees in my courses that often physicians are not even able to make a definitive diagnosis on all patients all the time. But what is a diagnosis? We presume a patient has appendicitis based on our clinical findings. But even with a positive CT I will not make that diagnosis until the appendix has been removed and confirmed. We can make the presumptive diagnosis of MI based on S-T and Troponin elevation, but until we see the obstruction during a cath or autopsy, can we definitively say it is an MI? In the ED we treat sepsis frequently. But sepsis is not a diagnosis-it is a clniical condition. So, it seems we treat patients all the time without a true “diagnosis.”

    Do we need labs to make a diagnosis? Of course not. Dianosis is made on history about 75% of the time (this has been weakly confirmed). Physical exam adds about 8% to the diagnostic confirmation. Labs are required in a small number of cases. Otitis, pharynigitis, dermatitis, and many other diagnoeis can be made and treated without labs. So is it required that diagnoses be made only by those qualified to interpret labs? Of course not.

    So what does it take to make a diagnoses? It takes appropriate clinical information. This information must be obtained by an adequate history, physical, and labs when appropriate. Can EMT’s and Paramedics obtain and interpret this information adequately? Of course they can.
    Medical students are often put into the position of making these decisions without a medical license (though it may take a bit of time to make that decision). What is the difference? Physicians are taught a thorough history and physical appropriate to make decisions. Do we make mistakes? Sure. Are EMS professionals taught this same information? Unfortunately, not often. Are some capable? Yes, many do a great job. Are diagnostic mistakes made by EMS professionals? Yes, often. Are EMS professionals required to treat patients based on clinical impresson (“working” diagnosis)-all the time.

    What is important? 1) Diagnosis is not as important as “differential diagnosis.” It is not always as important to know what the problem is as what it is not, or what are all the other critical diagnoses to consider or rule out. 2) Know your differential diagnoses. This comes with time and experience. Continue your learning. Ask questions. Talk to your physicians. Follow-up on patients. 3) Learn, improve your patient assessment skills. 4) Communicate frequenly with your medical director or base station so you can learn and continue to improve yourself.

    You want to make “diagnoses”? Go ahead. Be bold. Take the chance. But accept the responsibility that goes along with it-you must continue to challenge yourself and make yourself better. Its ok with me.

    Tell me aobut some of your diagnoses, and diagnostic challenges.

    Jerry Allison, MD

  17. Do EMS Professionals diagnose? As an ED physician and former paramedic I remind students and attendees in my courses that often physicians are not even able to make a definitive diagnosis on all patients all the time. But what is a diagnosis? We presume a patient has appendicitis based on our clinical findings. But even with a positive CT I will not make that diagnosis until the appendix has been removed and confirmed. We can make the presumptive diagnosis of MI based on S-T and Troponin elevation, but until we see the obstruction during a cath or autopsy, can we definitively say it is an MI? In the ED we treat sepsis frequently. But sepsis is not a diagnosis-it is a clniical condition. So, it seems we treat patients all the time without a true “diagnosis.”

    Do we need labs to make a diagnosis? Of course not. Dianosis is made on history about 75% of the time (this has been weakly confirmed). Physical exam adds about 8% to the diagnostic confirmation. Labs are required in a small number of cases. Otitis, pharynigitis, dermatitis, and many other diagnoeis can be made and treated without labs. So is it required that diagnoses be made only by those qualified to interpret labs? Of course not.

    So what does it take to make a diagnoses? It takes appropriate clinical information. This information must be obtained by an adequate history, physical, and labs when appropriate. Can EMT’s and Paramedics obtain and interpret this information adequately? Of course they can.
    Medical students are often put into the position of making these decisions without a medical license (though it may take a bit of time to make that decision). What is the difference? Physicians are taught a thorough history and physical appropriate to make decisions. Do we make mistakes? Sure. Are EMS professionals taught this same information? Unfortunately, not often. Are some capable? Yes, many do a great job. Are diagnostic mistakes made by EMS professionals? Yes, often. Are EMS professionals required to treat patients based on clinical impresson (“working” diagnosis)-all the time.

    What is important? 1) Diagnosis is not as important as “differential diagnosis.” It is not always as important to know what the problem is as what it is not, or what are all the other critical diagnoses to consider or rule out. 2) Know your differential diagnoses. This comes with time and experience. Continue your learning. Ask questions. Talk to your physicians. Follow-up on patients. 3) Learn, improve your patient assessment skills. 4) Communicate frequenly with your medical director or base station so you can learn and continue to improve yourself.

    You want to make “diagnoses”? Go ahead. Be bold. Take the chance. But accept the responsibility that goes along with it-you must continue to challenge yourself and make yourself better. Its ok with me.

    Tell me aobut some of your diagnoses, and diagnostic challenges.

    Jerry Allison, MD

  18. I feel that if it were not for our “diagnosis” certain medical practitioners would have no clue as to where to start or in which direction to go in, while trying to treat the patients! so much for us not making a diagnosis

  19. I feel that if it were not for our “diagnosis” certain medical practitioners would have no clue as to where to start or in which direction to go in, while trying to treat the patients! so much for us not making a diagnosis

  20. The idea that paramedics (or even BLS providers) don’t diagnose is based on some medic-legal mumbo jumbo, not reality. My recently retired medical director had the pragmatic view that of course we diagnose, we just call it something else. It’s the same thing that nurses have been doing for 100 years. In their case, they call it “nursing impression”. In the case of EMS we call it “diagnostic impression”. Either way, it’s a diagnosis and we devise our treatment plan based on that impression.

    In so many areas, jurisprudence has not only not caught up with the real world of science and medicine, but has hindered advancement thereof.

  21. The idea that paramedics (or even BLS providers) don’t diagnose is based on some medic-legal mumbo jumbo, not reality. My recently retired medical director had the pragmatic view that of course we diagnose, we just call it something else. It’s the same thing that nurses have been doing for 100 years. In their case, they call it “nursing impression”. In the case of EMS we call it “diagnostic impression”. Either way, it’s a diagnosis and we devise our treatment plan based on that impression.

    In so many areas, jurisprudence has not only not caught up with the real world of science and medicine, but has hindered advancement thereof.

  22. Definition from yourdictionary.com

    di·ag·no·sis (dīˌəg-nōˈsÄ­s)

    noun pl. diagnoses di·ag·no·ses (-sÄ“z)
    1.Medicine
    a. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.
    b. The opinion derived from such an evaluation.
    2.a. A critical analysis of the nature of something.
    b. The conclusion reached by such analysis.

    As An EMS professional we are not diagnosing cancer, osteoporosis, HIV, or Brain injuries.
    when you are working on a patient with an arm amputation, a compound fracture where the bone is sticking out I am almost positive you would be safe to diagnose these. i think the only reason everyone tells us not to diagnose is because there are alot of doctors out there that go to school for a long time to be able to diagnose, and some of them (not all) are gonna get REALLY mad if you tell a patient what is wrong before the Doctor runs all of his tests and confirms your diagnosis. Dont get me wrong the doctors i work with are pretty cool but i have met a few that just cant be dealt with even if your diagnostic impression saved the patients life.

  23. Definition from yourdictionary.com

    di·ag·no·sis (dīˌəg-nōˈsÄ­s)

    noun pl. diagnoses di·ag·no·ses (-sÄ“z)
    1.Medicine
    a. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.
    b. The opinion derived from such an evaluation.
    2.a. A critical analysis of the nature of something.
    b. The conclusion reached by such analysis.

    As An EMS professional we are not diagnosing cancer, osteoporosis, HIV, or Brain injuries.
    when you are working on a patient with an arm amputation, a compound fracture where the bone is sticking out I am almost positive you would be safe to diagnose these. i think the only reason everyone tells us not to diagnose is because there are alot of doctors out there that go to school for a long time to be able to diagnose, and some of them (not all) are gonna get REALLY mad if you tell a patient what is wrong before the Doctor runs all of his tests and confirms your diagnosis. Dont get me wrong the doctors i work with are pretty cool but i have met a few that just cant be dealt with even if your diagnostic impression saved the patients life.

  24. In class last week, in the middle of very long chapter 2 of Vol 2 of Paramedic Care on physical assessment, we were told we do “Differential Field Diagnosis”. Which is defined as “The list of possible causes for your patient’s symptoms”. And in Emergency Pharmacology we were reminded that one of the reasons to give a drug is to diagnose the disease, which seems a little weird, but is done alot.

  25. In class last week, in the middle of very long chapter 2 of Vol 2 of Paramedic Care on physical assessment, we were told we do “Differential Field Diagnosis”. Which is defined as “The list of possible causes for your patient’s symptoms”. And in Emergency Pharmacology we were reminded that one of the reasons to give a drug is to diagnose the disease, which seems a little weird, but is done alot.

  26. I see that this is a few months old, but I recently tackled this concept over at my blog due to the November court ruling rejecting immunity for two paramedics who misdiagnosed a patient with gastric reflux when the patient had a pulmonary embolism.

    I agree with the argument that differential diagnosis is the most important part of the process. “What else is possible?” is important if the patient isn’t responding properly to your interventions or something seems off. Similarly, even the truism “Chest pain is cardiac until proven otherwise” requires differentials going both ways. If it’s cardiac in nature until proven else wise, what needs to be done to do so? Can it be done in the field? Similarly, if it is cardiac in nature, what is it? Cardiac chest pain does not always mean an infarct.

    Additionally, it becomes really important when it comes to patients who are refusing care. There’s a difference between an amorphous “Well, something’s happening, but we can’t tell what, you need to be evaluated by a physician,” and “Well, you have chest pain and shortness of breath. The cardiac monitor doesn’t show anything, but you could also be suffering from (insert list of differentials such as PE, pneumonia, NSTEMI, etc here) which we can’t appropriately evaluate for in the field.”

  27. I see that this is a few months old, but I recently tackled this concept over at my blog due to the November court ruling rejecting immunity for two paramedics who misdiagnosed a patient with gastric reflux when the patient had a pulmonary embolism.

    I agree with the argument that differential diagnosis is the most important part of the process. “What else is possible?” is important if the patient isn’t responding properly to your interventions or something seems off. Similarly, even the truism “Chest pain is cardiac until proven otherwise” requires differentials going both ways. If it’s cardiac in nature until proven else wise, what needs to be done to do so? Can it be done in the field? Similarly, if it is cardiac in nature, what is it? Cardiac chest pain does not always mean an infarct.

    Additionally, it becomes really important when it comes to patients who are refusing care. There’s a difference between an amorphous “Well, something’s happening, but we can’t tell what, you need to be evaluated by a physician,” and “Well, you have chest pain and shortness of breath. The cardiac monitor doesn’t show anything, but you could also be suffering from (insert list of differentials such as PE, pneumonia, NSTEMI, etc here) which we can’t appropriately evaluate for in the field.”

  28. Thank for share a nice post.
    After diagnosing the issues your company has, getting on a plan to resolve them is the next step. I think in your article you do a nice job of explaining the check list to diagnose the issues with your company and consider reality that something may be wrong.

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