Technology A help or a hindrance?
Charles E. Truthan, D.O., F.A.C.O.F.P.
President & Medical Director, F.D. Doc ®
Copyright 1999 by FD Doc®
The science of medicine has literally exploded in just the past 30 years. Daily, our technological abilities are growing. Just yesterday, I read where there has been another "breakthrough" in the Human Genome project (decoding of the human DNA). Yet in another article, there was more discussion on the high costs of medical care today, and how we need to " contain the rising costs of healthcare ".
To this I respond, "Just because we have the technology does NOT mean that we HAVE to use it.". The working diagnosis for a patients presenting complaint, is based upon the history of the present illness and the initial physical examination of the patient. Then you select which tests are needed to confirm your diagnosis, or which tests are needed to rule out other diagnoses. The selection of tests is based upon your clinical judgement. You do not order every test in the book. Rather, you select the test(s) which will aid you in making the final diagnosis and rendering definitive care. The decision to use a test must be based upon the medical need, not the legal or "documentation" need, for the test. If the answer the test will provide you with will change your treatment plan, then by all means run the test. If it will only confirm our diagnosis and NOT change the treatment, then why are you running it?
This is the mind set that a physician must consider every time a test is ordered. We used to order a "Chem-20" on everyone, because it was less expensive to order a panel than ordering just the 3 tests you really wanted. Then the problem becomes, what do you do with the "abnormals" that have come back on the other 17 tests you didn't want to begin with. Medico-legally, these abnormals must be followed up. Usually, on retest, they are normal. So, to save money, we had to run a panel of tests, then we had to run it again with or without 4 additional tests to confirm the normalcy of the abnormals. What have we saved? What has changed in the treatment of the patient (remember them)? If the answer is "Nothing", then the question remains, why run the test in the first place?
As an EMT or Paramedic, you do this on every call. Lets walk through one to illustrate. You start your differential diagnosis upon receipt of the call; "Medic 7 respond to ABC Business, 1234 Anywhere St. on a 32 year old male with Shortness of Breath (SOB)". You start thinking of what the causes for SOB are in a 32 y/o male. You start with the worst possible ones and go down from there. This is, after all, an "EMERGENCY". What will kill him first and fastest? Cardiac problem, aortic aneurysm, pulmonary embolism, status asthmaticus, spontaneous pneumothorax, laryngospasm, epiglottitis, pneumonia, rib fracture, bronchitis, upper respiratory infection (URI), are all part of the initial differential diagnosis. You start thinking of what equipment you will need to initially bring in with you. Drug box, O2, IV kit, Medical kit, Cardiac monitor. You arrive on scene in front of an office building, so you start ruling out any trauma as an etiology for this SOB male (but there could still be the fall down a flight of stairs, etc.). You lug in all your equipment and find a 32 y/o white male who is laboring hard to breathe, is diaphoretic, slightly cyanotic, and you do not hear any wheezing or other noises as you enter the room. You notice he takes in a breath, then seems to hold it for a second or two before letting it out. Your immediate thought is that this IS a VERY sick patient. You have also eliminated the URI, bronchitis, laryngitis and epiglottitis before you have even opened a single kit or put on your stethoscope. Status asthmaticus and aortic aneurysm have moved lower down your diagnostic list, but are not out yet. You have NOT needed ANY tests so far either.
You now start asking him questions, and note the difficulty he has in answering. He can only say 2 or 3 words before taking another breath.
Are you having any pain? No. (Aortic Aneurysm ruled out, pulmonary embolism way low on list, and probably not cardiac in origin)
When did this start? A day or two ago. (Spontaneous pneumothorax ruled out)
How did this start? Just kind of crept up on me. (Rib fracture ruled out)
What makes it worse? Any kind of movement like walking, or laying down. Really bad when I try to sleep at night.
What makes it better? Sitting up helps a bit.
What have you done for this? Took some aspirin and some "Cold and Flu" syrup.
Did it help? No.
Been having fevers, sweats and "bone rattling teeth chattering chills" at all? Oh yes, terrible chills.
Been coughing a lot? Yes.
Bringing anything up with it? All kinds of green and yellow junk. (BINGO! Pneumonia! Probably heading for sepsis and septic shock if this continues untreated)
Now while you have been asking questions, your partner has already gotten the O2 hooked up and running at 100% on a non-rebreather mask. Vital signs are being taken by her as well. You have NOT needed ANY tests so far either. Working strictly off of your clinical skills you have successfully diagnosed and started effective treatment. What else MUST you do for this patient? Lets go back to the ABCs. Airway is open, Breathing is being supported by high flow oxygen, circulation is normal (cyanosis is improving with the added O2). Transport in position of comfort is the final MUST DO item. What else CAN we do? Well, we can draw blood work and blood cultures as we start an IV, start a cardiac monitor, start a pulse oximeter, administer a nebulizer treatment, even start IV antibiotics, providing we are trained and equipped to do these. But, do we HAVE TO? Are these "MUST DO" items, or "NICE TO DO" items. Sure, the more we can do in the field, the better. But, what if we cant start IV antibiotics. Surely this patient needs them. Are we harming the patient by delaying transport 5 to 10 minutes so we can run a 12 lead EKG, start that IV, or administer that nebulizer? Maybe yes, maybe no. If you can do it all while transporting, fine. But, is an EKG in a 32 y/o with obvious pneumonia essential? Not really, and especially not in the field. Is the nebulizer essential? Not really, it might help but it might also worsen the probable tachycardia he has due to the infection itself. What does the pulse oximeter change in your treatment? You already have him on 100% O2. Are you going to reduce his O2 flows, or take him off O2? I certainly hope not! Will you have done any harm to the patient with these extra items? Possibly, but probably not. Will these extra items have helped this patient? Probably not. So the question goes back to "Why do these things if they are not going to be of any benefit to the patient?". Just because "We can." is NOT an acceptable answer.
In the ER, we could run an MRI on the patients chest, but we dont. We may take a Chest X-ray, even though it takes 3 to 4 days for a pneumonia to show on X-ray because it can make a difference.