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EMS Doesn’t ‘Diagnose’ … or Do We?

Oglesbee-Diagnose

EMS providers have long been taught that we don’t diagnose: we assess and treat. The definition of diagnosis, according to Black's Law Dictionary is: the discovery of the source of a patient's illness or the determination of the nature of his disease from a study of its symptoms. The definition goes further: a "clinical diagnosis" is one made from a study of the symptoms only and a "physical diagnosis" is one made by means of physical measure, such as palpation and inspection. This certainly sounds a lot like what EMS does. So, why are we consistently warned against using the term "diagnose" to describe what we do as if it were some hallowed ground upon which we shouldn’t enter?

Perhaps it’s because we lack key diagnostic tools such as laboratory and radiology. Certain conditions, such as abdominal pain, are very difficult to pin down definitively in the prehospital setting without the help of these important studies. However, in other situations—such as an open femur fracture—it doesn't take an X-ray to know what we have. When we find out our unconscious patient is an insulin dependent diabetic, measure the blood glucose, find that it is 58, and administer 50% dextrose intravenously, we’ve made a field diagnosis and provided appropriate treatment. While the fine points and definitive diagnoses are certainly better left to the ED physicians, in many situations we do make a diagnosis.

So, what's wrong with calling what we do a "field diagnosis"? Nurses make a "nursing diagnosis." Perhaps the real issue is what I call medical snobbery. For years, EMS personnel have been looked down upon by others on the medical team. They say our education is lacking, although my paramedic training included a full anatomy and physiology course and cadaver lab, and ACLS which many nurses and physicians don't take. Our paramedic courses now run almost as long as a two-year nursing program, although skip the part about bed changing and baths. They say that we are only "certified" and not "licensed" medical personnel, when in fact we take a national or state examination to earn the privilege of practicing in EMS, just like other members of the healthcare team. Some states, like mine (New Mexico), have grudgingly admitted us to the ranks of "licensed" health care providers. Even though some states call it "certified," the correct legal term is "licensed."

I propose that we begin asserting our abilities to make a field diagnosis, and that we start calling what we do just that. We’re the ones who are first on the scene, able to observe the patient in the environment in which the illness or injury occurred. This gives us a tremendous advantage if we use our senses to see what the environment can tell us. The presence of drug paraphernalia, alcohol containers, or trash that hasn't been taken out for a month can be significant clues to what is going on with our patient. Then we add the patient's prescribed medications to a carefully taken patient history. We take a full set of vital signs (the fact that EMS excludes temperature remains a mystery to me) and perform a physical examination (we call it a "head to toe"), including palpation, inspection and auscultation. We have then accomplished what physicians call a "history and physical" or H&P.

Yes, our examinations are limited. We often don't disrobe our patients and our exams are hurried and often performed in noisy, poorly lit environments. And we should recognize our limitations. But as EMS moves in the direction of becoming acknowledged as a medical profession, we’ve acquired better diagnostic tools designed for prehospital use. A field diagnosis has its limitations, but it’s a diagnosis nonetheless. 

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