I want to hear thoughts from the group for this one - it seems quite a widespread thought process.
I mean... how do you get through a shift if you don't?
I had a pretty interesting discussion while holding up the walls of a local ED - “we don’t diagnose.” was the argument by a couple of paramedics, albeit the trend between them was that they have many years of experience with this thought process. The paramedics who were fresher out of university were on par with the diagnosis opinion.
I do I get what people are trying to say. We are not sitting in a hospital with pathology, imaging, specialist review and hours to work through a definitive diagnosis. We also shouldn’t pretend we can confirm things we can’t confirm.
But the idea that paramedics don’t diagnose is not really true in my opinion.
In practice, we diagnose all the time. We make provisional diagnostic judgements constantly - for example:
- Chest pain: STEMI, ACS, PE, dissection, reflux, anxiety, musculoskeletal pain.
- Shortness of breath: asthma, COPD, APO, pneumonia, sepsis, PE, panic.
- Altered conscious states: hypoglycaemia, seizure, stroke, overdose, sepsis, head injury.
- Abdominal pain: AAA, ectopic, renal colic, gastro, appendicitis, bowel obstruction.
- Behavioural disturbance: psychosis, intoxication, delirium, hypoxia, hypoglycaemia, head injury.
Every treatment pathway depends on us forming a working diagnosis or at least a ranked differential.
We don’t give salbutamol because someone is generally unwell - we have a suspicion that their condition is related to asthma or copd. We don't give every chest pain aspirin and gtn or every unconscious person naloxone and glucose.
We don’t thrombolyse, sedate, pace, cardiovert, decompress a chest, give TXA, treat sepsis, activate stroke pathways or pre alert cath lab because we avoided diagnosis. I am not going to reduce an anterior shoulder if I think there is a fracture.
We do it because we have assessed the patient, interpreted the findings, weighed the likely causes and made a clinical judgement. That is diagnosis.
Paramedic diagnosis should be:
- provisional
- evidence informed
- open to revision and reflection
- based on pattern recognition and structured assessment
- supported by differential thinking
- honest about uncertainty
I think we do the below:
“We form provisional diagnoses and differential diagnoses to guide treatment, referral and risk management.”
Paramedics are clinicians. Clinical decision making requires diagnostic reasoning. The culture should reflect that.