When less is more: why sometimes we need to treat before we diagnose

Let’s face it.

A lot of the patients we see as paramedics or DEM healthcare workers really don’t need our care.

Even worse, it’s being shown more and more (especially in pre-hospital) that often the care we provide doesn’t actually make a difference to the patient’s long term outcome.

In truth, it’s not unusual for us to discover that a treatment that was routinely thought of as best practice was actually detrimental to the patient…. and many of the treatments we give patients have a relatively significant lack of evidence behind their efficacy (just consider adrenaline, amiodarone and oxygen for starters).

Even worse, the time we spend trying to diagnose a condition and work out which (potentially ineffective) medications we’re going to give, can prevent us from performing interventions that actually will work, on patient’s they will actually make a difference for.

So what do you do? Cut paramedics and nurses back to a more basic level of care? Refuse care to patients who ‘aren’t real emergencies’?

Whilst I eagerly await the day when public health has relegated paramedicine and emergency care to the point of near obselete, when a smart phone or tablet will perform bloods, 12 lead, CT, X-RAY and interpret the lot for us in under 30seconds……. that sort of care is still decades away.

In the mean time, it’s about learning to tier our treatment regimes. 

With students and professionals seeking further education graduating University/College with more and more knowledge, there is a tremendous temptation to diagnose. Even more so in the world where good faith exists less and less, we want to do thorough assessment so we don’t get things wrong…. and don’t get sued.

But here’s the key point. We don’t always need to diagnose. Diagnosis can be notoriously difficult. Something less difficult, that we can get very good at very quickly is treating symptoms.

This means finding ways to give low risk medications and interventions that we know are effective  first, and then keep looking for information to justify giving a more dangerous or less efficient drug once we know what’s going on.

Heck, you may even be able to work out that diagnosis as you go.

For example, you have a patient with a complex history, multiple co-morbidities and is a poor historian….. who has chest pain.

You know they have chest pain. You put on an ECG and maybe you see elevation… maybe you see rate…… maybe you see nothing unusual. But as soon as you see that you confirm there are no contra-indications and you give an aspirin.

By giving the drug now, you’ve saved potentially 15 minutes or more of asking questions which whilst useful at hand over…….. won’t actually be effecting whether or not that patient receives an aspirin.

But what if it’s not cardiac you ask? Well let’s say it’s reflux… or an infection? Aspirin is an anti-pyretic… so it’ll still help.

The same application can occur with pain relief: If the patient is in pain, asking what protective clothing, vehicle or speed  isn’t going to change that they’re in pain. Rule out your C/I’s, get some vital signs and then give them morphine. Ask the questions when they’re not rolling in agony. You may even get some better answers.

For many seasoned veterans this may seem common sense, but for me as a new grad, it blew my mind.

It can be difficult to implement without missing things. But spend the time intentionally working on it and once you wrap your head around it you’ll find your cases are much faster and much smoother.

 

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