Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

DeMYTHifying Diagnosis – Part II

 

Continuing from Part I of my comments on what Kelly Grayson writes in Demystifying Diagnosis.

But diagnosis refers to definitive care!

We diagnose some patients as well enough to be left safely at home, even if we tell some people with abrasions that we think abrasions are deadly.[1] 😳
 
Anaphylaxis

We treat anaphylaxis with epinephrine (and/or diphenhydramine, methylprednisolone, . . . ) and some patients refuse transport, while most are just observed in the ED before discharge.[2] Should we be leaving patients on scene with anaphylactic-like presentations, but without a diagnosis of anaphylaxis?

Bradykinin-mediated angioedema may look like anaphylaxis, but it does not respond well to epinephrine. Angioedema can be bradykinin-mediated (non-allergic) or histamine-mediated (allergic).[3],[4]
 
Hypoglycemia

We treat hypoglycemic emergencies and routinely leave patients on scene following a refusal of transport. This is only possible because the unresponsive/minimally responsive patient is now awake, alert, and has the capacity to make informed decisions to accept/refuse further treatment, assessment, and/or transport.[5],[6]
 
Opioid overdose

With some unresponsive opioid overdose patients, we can reverse their conditions. most of these patients may refuse further treatment, refuse further assessment, and/or refuse transport.[7],[8],[9]
 
Seizure

Seizure patients can awaken and be alert enough to refuse treatment and transport.[10]
 


Image credit.[11]
 

We do diagnose and leave patients on scene.

We do not seem to have major problems with patient-initiated refusals.

With increasing use of community paramedics, this will only become more common.

Those are examples of four conditions where we provide assessment, treatment, and a recommendation to follow up with the patient’s primary care provider (not necessarily a physician).
 
Death

We also leave dead patients on scene. No doctor will ever see some of these patients, because we are transferring care to the family/funeral home/police.

The patient’s physician will sign the death certificate, but with no requirement that the doctor has seen the patient after the cardiac arrest. Do we misdiagnose death? Yes, but so do doctors.

Dead is about as definitive as a diagnosis will get.
 

Once we start using words like diagnosis, accountability, and research, it is just a slippery slope to better patient care. 💡

Footnotes:

[1] The Power of the ‘Death’ Chant will protect Us
Wed, 29 Jan 2014
Rogue Medic
Article

[2] Clinical predictors for biphasic reactions in children presenting with anaphylaxis.
Mehr S, Liew WK, Tey D, Tang ML.
Clin Exp Allergy. 2009 Sep;39(9):1390-6. doi: 10.1111/j.1365-2222.2009.03276.x. Epub 2009 May 26.
PMID: 19486033 [PubMed – indexed for MEDLINE]
 

RESULTS:
There were 95 uniphasic (87%), 12 (11%) biphasic and two protracted reactions (2%). One child with a protracted reaction died. For the management of the primary anaphylactic reaction, children developing biphasic reactions were more likely to have received >1 dose of adrenaline (58% vs. 22%, P=0.01) and/or a fluid bolus (42% vs. 8%, P=0.01) than those experiencing uniphasic reactions. The absence of either factor was strongly predictive of the absence of a biphasic reaction (negative predictive value 99%), but the presence of either factor was poorly predictive of a biphasic reaction (positive predictive value of 32%). All biphasic reactors, in which the second phase was anaphylactic, received either >1 dose of adrenaline and/or a fluid bolus.

CONCLUSIONS:
Children who received >1 dose of adrenaline and/or a fluid bolus for treatment of their primary anaphylactic reaction were at increased risk of developing a biphasic reaction.

 

It appears to be safe to leave children at home as long as they have received only one epinephrine injection and have not received any IV (IntraVenous) fluids. Most of my 911 anaphylaxis calls have been refusals.

[3] Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema.
Bernstein JA, Moellman J.
Int J Emerg Med. 2012 Nov 6;5(1):39. doi: 10.1186/1865-1380-5-39.
PMID: 23131076 [PubMed]

Free Full Text from PubMed Central.

[4] Delayed takotsubo cardiomyopathy caused by excessive exogenous epinephrine administration after the treatment of angioedema.
Patankar GR, Donsky MS, Schussler JM.
Proc (Bayl Univ Med Cent). 2012 Jul;25(3):229-30. No abstract available.
PMID: 22754120 [PubMed]

Free Full Text from PubMed Central.

[5] Prehospital hypoglycemia: the safety of not transporting treated patients.
Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D.
Prehosp Emerg Care. 2003 Oct-Dec;7(4):458-65.
PMID: 14582099 [PubMed – indexed for MEDLINE]
 

CONCLUSIONS:
Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

[6] Outcome of diabetic patients treated in the prehospital arena after a hypoglycaemic episode, and an exploration of treat and release protocols: a review of the literature.
Roberts K, Smith A.
Emerg Med J. 2003 May;20(3):274-6. Review.
PMID: 12748153 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

Read the whole paper (both pages) – especially the recommendations for limitations on refusals.

[7] Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport.
Vilke GM, Sloane C, Smith AM, Chan TC.
Acad Emerg Med. 2003 Aug;10(8):893-6.
PMID: 12896894 [PubMed – indexed for MEDLINE]

Free Full Text Download in PDF format from Academic Emergency Medicine.
 

RESULTS:
There were 998 out-of-hospital patients who received naloxone and refused further treatment and 601 ME cases of opioid overdose deaths. When compared by age, time, date, sex, location, and ethnicity, there were no cases in which a patient was treated by paramedics with naloxone within 12 hours of being found dead of an opioid overdose.

[8] No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose.
Wampler DA, Molina DK, McManus J, Laws P, Manifold CA.
Prehosp Emerg Care. 2011 Jul-Sep;15(3):320-4. doi: 10.3109/10903127.2011.569854.
PMID: 21612385 [PubMed – indexed for MEDLINE]
 

CONCLUSION:
The primary outcome was that no patients who were treated with naloxone for opioid overdose and then refused care were examined by the MEO within a 48-hour time frame.

[9] The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting.
Cantwell K, Dietze P, Flander L.
Resuscitation. 2005 Jun;65(3):315-9.
PMID: 15919568 [PubMed – indexed for MEDLINE]
 

CONCLUSIONS:
The concurrent use of alcohol with heroin resulted in the use of greater than standard doses of naloxone by paramedics in resuscitating overdose patients. It is possible that the higher dose of naloxone is required to reverse the combined effects of alcohol and heroin. There was also a link between initial patient presentation and the dose of naloxone required for resuscitation. In light of these findings, it would appear that initial patient presentation and evidence of alcohol use might be useful guides as to providing the most effective dose of naloxone in the prehospital setting.

[10] The diagnosis and management of seizures and status epilepticus in the prehospital setting.
Michael GE, O’Connor RE.
Emerg Med Clin North Am. 2011 Feb;29(1):29-39. doi: 10.1016/j.emc.2010.08.003. Epub 2010 Oct 15. Review.
PMID: 21109100 [PubMed – indexed for MEDLINE]
 

Such patients must demonstrate to providers the mental capacity to make an informed medical decision to refuse care. In patients who have just had a seizure, it is unlikely that they will demonstrate intact mental status and capacity for medical decision making.12,13 Because the risk of seizure recurrence is approximately 6%, prehospital care providers and medical command physicians should ensure that patients understand the risks of refusal.14

 

Pediatric patients present unique challenges in prehospital seizure management. Galustyan and colleagues15 studied the care of 1516 pediatric EMS calls with a chief complaint of seizure. Of those calls, 189 (17%) refused transport.

[11] Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation.
Mechem CC, Barger J, Shofer FS, Dickinson ET.
Acad Emerg Med. 2001 Mar;8(3):231-6.
PMID: 11229944 [PubMed – indexed for MEDLINE]

Free Full Text Download in PDF format from Academic Emergency Medicine.
 

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Comments

  1. On the larger point, you know I agree. The difference between medics and docs is that, while medics tend to have well-thought out arguments regarding who can diagnose, most doctors would just be confused by the question. Seriously, only philosophers and historians of medicine talk about the definition of diagnosis. Working doctors are just trying to “figure out what is probably going on with the patient” – call this process Susan, if you want.

    Regarding a narrower point, I probably wouldn’t be so quick to suggest the safety of refusals for pediatric anaphylaxis. Yeah, most of these kids do fine, regardless of what we do, but a good period of observation is pretty well accepted in practice. My favorite anaphylaxis study sent basically all their (adult) anaphylaxis patients home, but they waited until 2 hour after the epi drip had been shut off. (http://www.ncbi.nlm.nih.gov/pubmed/14988337 – open access) A recent study in Annals of EM demonstrated that biphasic reactions are rare, but their anaphylaxis patients still had an average LOS in the ED of about 2 hours. (http://www.ncbi.nlm.nih.gov/pubmed/24239340)

    No one feels real anxious to discharge these patients right off the bat, and observation is cheap, with few side effects!

    • Okay, one more though, this time about refusals by hypoglycemic patients. The problem with using a lot of the EMS literature on the safety of refusals is that they were mostly (all?) done before the ultra-long acting insulins (e.g. Lantus) were released.

      Now, if someone took their Lantus injection 18 hours ago, that’s probably fine. But if it was 6 hours ago, that’s a bit more dicey. I don’t know of any evidence to directly support the concern of recurrent hypoglycemia, but it’s a real limitation of the older data.

      • I’d personally ask hypoglycemic patients that recover to eat something with more complex carbs before I leave, but if they really push the issue, it’s their medical care and their decision once they’re alert, oriented, and can make an informed decision about it.

        • I agree that patients should be allowed to make an informed decision about refusing transport. The problem is when we don’t have the data to responsibly inform them.

          For example, what would you tell the family of a child who just had an EpiPen injection for anaphylaxis, if they asked you “Is it safe to stay at home?” What do you tell the wife of a diabetic patient who just took 60 units of Lantus 2 hours ago, and is recovering after getting a bag of D10 – is it safe for him to stay at home? How do we know? What do you document about the conversation?

          That being said, I think the standard of care for post-hypoglycemia food isn’t complex carbs, but a peanut butter sandwich!

  2. There’s also a difference between “diagnose” and “Diagnose”. The first is an action which is taken by medical practitioners of all stripes and is what EMS providers do. The second is a legal term which incurs legal liability and can only be done by Doctors (and other specific health care providers).

  3. So, wouldn’t it be helpful on the front end with new medics if those in charge didn’t demonize allowing someone to not be transported as a mortal sin? I see it only as a mortal sin if you’re not smart/educated/experienced enough to have any clue of what you’re doing.

    Like you say sometimes the best treatment is benign neglect, wouldn’t non-transport fall under that heading?