When all you have is a hammer, everything looks like a nail.
The real world is a messy place, it is a million shades of gray and clear cut boundaries are often lacking. Patients do not easily fit in to one specific category. A large amount of patients are going to end up in a gray area between being designated as sick and not-sick.
It is easy to be a good EMS provider when things are black and white; it is in the gray areas where the expert EMS provider excels and the poor EMS providers falter.
EMS needs to embrace the notion that reciting a memorized algorithm is the minimum level of competency not the mark of a great EMS provider. EMS education fails by teaching providers to classify patients according to a false dichotomy of sick or not sick, and stable versus unstable, symptomatic versus asymptomatic.
Make no mistake here, I am complicit in this as well, asking countless third riders over the years if the patient is sick or not sick, running students through scenarios and asking them if the patient is stable or unstable. Lately I find myself asking providers to walk me through their though process on their treatments and I encourage all of you who are in that role to do it as well. Make it a dialogue, an exploration and see where their clinical judgement is at.
Strict adherence to protocols is another facet where black and white thinking is employed. Stealing from the legal world here, it is vital providers can understand the difference between the spirit of the protocol and the letter of the protocol.
I do the QA for the service I work at and people try to argue with me all the time, invoking a Nuremberg-esque defense about how the protocol says one specific thing and they were just following protocols.
Honestly, I don’t give a shit what is in the protocols. I know that is a weird thing for a QA person to say but it is the truth. I care about the thought process that goes in to treating the patient; I care about doing the right thing for our patients.
There was a recent Facebook post about an elderly woman that really drove this point home.
The patient had atrial fibrillation at 180-190 per minute, her blood pressure was 82/54 and she was complaining only of dizziness upon standing, not much else is known, how would you treat this?
Some people wanted to go directly to immediate cardioversion while others were on the opposite end of the spectrum and wanted to give her a ride to the hospital and do nothing else.
Is she sick or not sick? Stable or not stable? Arguments ensued arguing both points. Some folks wanted to give fluids, some wanted to give calcium channel blockers or beta blockers, some wanted to give adenosine (not sure why they wanted to for AF, but it is Facebook) and some talked about amiodarone.
I think synchronized cardioversion without sedation for a bit of dizziness is a bit aggressive and I would prefer fluids and some titrated diltiazem if I were the patient.
People eventually started posting pictures of their protocols and using that as an appeal to authority that you must cardiovert her. If you go to straight to cardioversion here you’re not technically wrong, you could make a case that because her BP fit in one box on a flow chart you were justified in shocking her without sedation.
If you were to do this you’re not wrong… you’re just an asshole.
So…how do we get good at working in the gray area? I am by no means an expert on decision making. I make bad decisions more frequently than I should. But I try to be aware of them and learn from them. I try to not make the same bad decision twice.
What do I do when presented with a patient that does not fit neatly in to the false dichotomy of stable or not stable? I have an in depth inner monologue, knowing none of this happens in a vacuum, a million things go in to my decision making that day.
Did I have a discussion about this type of patient recently? Did I read an article or blog about it? Did I sleep enough last night? Do I have to pee? Have I met the patient before? Did I have a bad experience with a procedure last time? Do I know what doctor is in the ER?
Am I aware of my bias going in to this?
Here are some of the thoughts, in no particular order, that go through my head when I find myself in a gray area with a sick-ish patient.
1. What else could be going on with this patient? A perfect example is compensatory atrial fibrillation in sepsis. Is the patient having an issue from the atrial fib or is it a compensatory response to poor perfusion and slowing down the heart rate could be deleterious by lowering cardiac output.
2. What happens if I do nothing? If the answer to this question is “nothing” it does not mean two wrongs make a right and that you should in fact do nothing, but it should give you pause and make you reconsider your treatment plan.
3. What negative outcomes can I expect from this treatment? What are the side effects of my drugs? If I have a hypokalemic patient with a COPD exacerbation do I want to give them a bunch of albuterol? What are the risks of this treatment? What can happen even if I am right? Am I dooming an elderly patient to spend their few remaining days on a vent if I intubate them?
4. What is the benefit of my treatment? You should be able to clearly explain this if you are proposing it.
5. What is my gut feeling? Does it feel right or wrong? Trust your gut but make sure you follow up and find out if your gut was right or wrong.
6.What else is acceptable treatment here? Come up with what options you have for treatments and debate the merits of each of them.
7. Why do I want to do this treatment? Are my intentions honorable or am I worried that I will get busted for not following a procedural rule? If I have a patient with chest pain and I don’t believe it to be cardiac, do I give them nitro just so I do not have to talk to the QA people about why someone with chest pain did not get nitro?
8. How sure am I? Is this a mistake I have made before? Are those crackles really pulmonary edema or could this be pneumonia? What if I am wrong here, what will happen? Am I practicing type 1 versus type 2 thinking here (coming up in the next post)?
Conclusion
It is 4am right now and I have had my ass kicked this shift, and tonight’s failings by me will be discussed in a post in the near future. I want to post something witty here and tell you to go out in the world and do good or something like that, or I don’t know, just try not to be an asshole when treating patients.
emsqaqi 
We have gotten away from EMS practitioners that think to many that follow a protocol or algorithm blindly because that’s what they are “supposed” to do. We need to take back out profession and start using our brains.
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I’m one of the more aggressive folks in treatment, but there is a reason for that.
Most medical errors are errors of omission and errors of non-performance. Most of us are fairly conservative in our general practice, and when we have a patient with potential to decompensate but who is currently hemodynamically functional and “stable” to the point we can handle it, we as a whole tend to avoid intervening. For patients with vague presentations or whom we can do nothing for, that is an appropriate mentality, but in some cases, it needs to be recognized that a patient who seems “stable” is anything but. Sadly, a Facebook post is often not a complete enough medium to make great decisions.
I think that the core of the QA process is that it is important to recognize that each provider has a different vision of that patient and a different comfort level with the management of that patient and even a different understanding of the expectations and reaction of QI. These are challenging for providers precisely because they are a dichotomy, and the perception becomes that QI will either hang them out to dry if they do do something or if they don’t.
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Your dead right ! The real issue as far as I can see is that the format in how Paramedics are trained needs to be revised. The Emergency Medical Technician concept is what is wrong. To train someone as a technician means you educate them well in a very narrow band. This is what leads to the big issues as you discussed. The EMT presumes that the therapy prescribed by the SOP or CPG is morally and ethically sound and feels justified in its deployment regardless of holistic complications.
An example from my days was the traction splint, were we were taught to undertake traction before analgesia. This is morally and ethically reprehensible to current thinking but then it was deployed and endorsed. Similarly when a CPG or SOP changes medication and equipment are taken off the vehicle, which may have potential benefits to another patient group, and reenforces this narrow scope of practice
The Irish, Austrailians and the British, not to mention most of Europe are adopting a policy for paramedics to undertake an undergraduate three/four year BSc honours degree.
The degree allows for a broad clinical knowledge with an appreciation for evidence based practice and ultimately could dilute the valid issue of blind SOP adherence.
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If you listen to physicians discuss treatment, they don’t talk about “right” or “wrong,” you constantly hear whether the treatment was “reasonable.” They recognize the shades of gray, but that’s what you get when you have a high baseline of underlying knowledge, which unfortunately is not possible for paramedic programs following the bare minimum standard.
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Spot on – critical thinking is something that I TRY to teach in the classroom, and you took the thoughts right out of my head. Thank you!
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