What’s your problem? Really. . .
When we work with our patients, before we can really fix their problem we need to figure out what the real complaint is and where it’s true cause. This can be difficult when we realize that some problems can be caused by seeming unrelated issues; difficulty breathing may not be the airways or lungs, but possibly cardiac. As the body senses hypoxia the brain’s initial reaction is to make the body breathe more. But if hypoxia is caused by lack of blood flow, more air will not fix the problem.
So how do we figure out where our problem really lies? This comes from Diagnosis. I’ve heard many people say that we don’t diagnose, but we must and do frequently. When our car sputters and stops, we diagnose that it needs more gas. Without diagnosis, we really have no idea how to fix a problem.
Now, while I am advocating diagnosing, I am not advocating definitive diagnosis. If you prefer, I am advocating troubleshooting (medically known as Differential Diagnosis). Differential Diagnosis is creating a group of things that may cause the problem and trying to fix all, prioritizing the most life threatening. This provides a basis for our treatment. We’ll leave the definitive diagnosis and long term treatment plan to other experts. Our job is to ensure that we cover all of the bases.
Have you ever watched the way a doctor diagnoses? I’ve had many in my classes and they all agree that this seems to be an accurate description. A doctor will immediately fix obvious life threats, but if those are not readily apparent, they will talk with the patient for a period of time that seems to involve much more patience that we have as pre-hospital providers. She/he will ask directed questions regarding their history and include some other observations that help them figure out the real problem.
They ask the patients about their history using the SAMPLE mnemonic
- Signs & Symptoms
- Pertinent Medical History
- Last Oral intake
- Events that led up to the problem
They also use another mnemonic that we’ve all learned OPQRST
- Onset, Provocation or Palliation, Quality, Radiation, Severity, Time
As we’ve all learned these mnemonics, I will not go in-depth with each. But, we’ve been taught their use incorrectly. OPQRST is not a stand-alone item, but rather quantifies and helps the patient describe their signs and symptoms. Asking these questions helps us better understand what’s going on. Please consider this diagram to help your remember for future use
In addition the physician will consider the leading causes of all injuries or illnesses. Known as the H’s & T’s these include:
- Hypoxia (shock)
- Hydrogen Ion (Acidosis)
- High or low electrolytes
- Thrombosis (Pulmonary Embolism, AMI)
- Tension Pneumothorax
Most of these are pretty easy to tell in looking at and talking to our patient. It’s easy to see when they have normal color to their face or not dehydrated; they are likely not hypovolemic. Not guppy breathing; likely not hypoxic etc.
They also ask the patient if they’ve ever had symptoms similar in the past. If so, was it diagnosed? The same symptoms generally lead to the same diagnosis.
As you can see, there’s a lot of information to be gathered and rushing it will only cause us to rush to judgement, often inaccurate. A physician will spend time gathering this information and they take all of the data and run it through a huge computer program . . . called EXPERIENCE to create their diagnosis.
After the interview, he/she will generally physically examine the patient by palpating, auscultating and assessing. These are done to continue to assess the remaining H’s & T’s. After the examination, labs may be ordered to complete the process.
In all of my time working with physicians, most have said that they generally have their diagnosis before touching the patient. But patients don’t feel as though they are being treated unless touched and the lab work is to confirm or negate their diagnosis.
Diagnosis comes with practice; the ability to ask questions, listen for answers and develop the experience to be accurate. While we can teach mnemonics, nothing can take the place of time spent practicing with real patients.
With this working diagnosis or differential we can begin to formulate and prioritize treatment for our patient. As a last bit of warning, don’t get hung up on distracting injuries. A small laceration from the head may appear bad, but is secondary to cardiac arrest . . . or maybe not.