Professional Development--Part 11: Reflecting on Actions and Decisions

   Many years ago, I responded with my partner to a home in southwest Philadelphia. We were called to a reported fall. When we arrived we found a birthday party winding down. There were balloons, the remains of a cake and ice cream in the kitchen, little kids running around in sugar freak-outs, and a homemade banner hanging in the dining room that said Happy Birthday, Pop Pop. One of the family members took us to some stairs that led to a finished basement set up as a family room. At the bottom of the stairs we could see an old man lying on his back, his feet still on the steps, another family member holding him. As we walked down to him, it was clear he had been incontinent of urine. We determined Pop Pop had been celebrating with a bit of wine and ouzo. When we asked him what happened, he said he'd tripped on the stairs and fallen. His speech was slurred, but he was otherwise alert and oriented. We continued our assessment and found no significant injuries other than a bruise on Pop Pop's forehead. He had no complaints and denied loss of consciousness. His vital signs were mostly normal, but his blood pressure was a bit high. We wanted to board and collar Pop Pop, do a cardiac workup and take him to the emergency room for evaluation.

   The family did not want us to initiate treatment and did not want us to transport. I had a long conversation with Pop Pop's daughter and son-in-law about what could have happened to Pop Pop, and what might happen if he did not get evaluated. I told them he could have had a stroke or some kind of cardiac event that triggered the fall, or that he may have suffered a serious head, neck or back injury in the fall. The family was adamant that Pop Pop was fine, that he maybe just had a bit too much to drink. I tried to convince them to allow us to treat and transport Pop Pop. I told them there was small chance something was seriously wrong, but we couldn't tell for sure without further evaluation and tests that could only be done at the hospital. I told them Pop Pop needed to see a doctor to be certain. If he had a serious problem that went undiagnosed, Pop Pop might die. They said they would take him to the emergency room themselves later if I really thought it was so important for him to be evaluated, but they absolutely refused to allow us to transport at the time.

   I called the medical command physician on duty and explained the situation. Then I asked the family if they would talk to the doctor. They did, and when I got back on the phone, the medical command doc told me to let them sign a refusal against medical advice, and make sure the police officer signed as a witness. The call, like all medical command calls, was recorded.

   I didn't feel right about the situation. We got the signatures and made one last attempt to convince the family to let us take Pop Pop to the emergency room. They said thanks, but they'd take him later. We documented the call completely, had family and the officer sign the patient care report, and then we left.

'POP POP DIED?'

   About a month later I got a call from one of the medical command physicians at our systems resource hospital. They handled the department's quality improvement activities. He asked me if I remembered the case of an elderly man who had fallen down a staircase. He wanted to know what had happened and why we didn't transport. I said I remembered the case. He started to grill me about the details. I got aggravated and asked him, "Have you read my report or listened to the medical command tapes?" He said he hadn't. I replied, "Everything you need to know is in my report and on those tapes." Then I asked why he wanted to know. He said the family had waited until the next day to take the man to the hospital--after they couldn't wake him up for breakfast--and that he'd died seven days later after being admitted. He had suffered a subdural bleed. The family was threatening to sue.

   I was shocked--Pop Pop died? I felt awful and wondered if we could have handled the case differently. I was also concerned and a little scared I might get sued.

REFLECTION IN EMS

   I never heard anything more about the case after that phone call. I suppose my documentation and the taped conversation between the family and medical command physician made everything clear. As far as I know, there was never any lawsuit. But though the system outcome was OK, the fact was that Pop Pop had died.

   Over the years, I thought about that case, wondering what we could have done differently that night, what we might have said to change their minds. Wondering if it would have mattered if we'd been able to convince the family to let us do the job we'd been trained to do. Would Pop Pop have survived to another birthday?

   Later, as an instructor, I used that case as an example of the importance of thorough, accurate and complete documentation. Because the case was well documented and because we had the medical command tapes, we were never called in to testify because there was likely never a lawsuit. But I still look back and wonder if we might have been able to intervene in some other manner.

   The point of this story is to lead us to the last of Dr. Herbert Swick's professional behaviors. Swick contended that "physicians reflect on their actions and decisions."¹ EMS providers should too. We cannot change the past, but we can learn from it. There have been several recurring themes throughout this series. One has been the need for each of us to honestly evaluate ourselves--to look at our actions and decisions with critical eyes. I've made plenty of mistakes in my life. Some I've made more than once. But I try not to fall into the trap of thinking I'll get a different outcome from repeating the same actions. The definition of insanity, variously attributed to Albert Einstein, Ben Franklin, Rita Mae Brown and an ancient Chinese proverb, is doing the same thing over and over and expecting different results.

   What exactly is reflection? According to leadership guru Donald Clark, "Reflection is thinking for an extended period by linking recent experiences to earlier ones in order to promote a more complex and interrelated mental schema. Reflection normally involves looking for:

• commonalties
• differences
• interrelations beyond their superficial elements."²

   Reflection is a major component of critical thinking. Critical thinking involves a wide range of thinking skills leading toward desirable outcomes, and reflective thinking focuses on the process of making judgments about what has happened. Reflective thinking is important in prompting learning during complex problem-solving situations, because it provides students with an opportunity to step back and think about how they actually solve problems and how a particular set of problem-solving strategies is appropriate for achieving their goal.³

   As we discussed last month, we deal with complex problems in our practice. Reflection can help us to break down how we proceeded to solve these problems and how well our solutions worked, and let us examine the process and our choices to determine if there may have been a better, more efficient or more effective course of action.

   The process of reflection is also a significant dimension of experiential learning. Just as reflecting on actions is important in assessing performance in actual practice, reflecting on situations and problem-solving in the learning environment helps facilitate the translation of learning to practice.

   Common methods of group reflection used toward problem-solving in EMS and public safety include the "hot wash," after-action report or postincident critique. This process of reviewing an incident or drill brings to the fore areas that worked well and those that need improvement. In medicine, there are morbidity and mortality reviews. In sports, teams and players watch video of past games to assess how well they played. These are all forms of reflective activity used to improve performance.

CONCLUSION

   What does all of this mean to our practice of EMS? It means we should contemplate and reflect on our performance, our practice and our lives. It means we should participate honestly in group activities used to critique performance. It means we all must recognize that we will always be able to improve, we will always have something to learn, and we will all be better for this type of thinking. Ultimately, if we continue to improve, our patient care will improve, our workplace will improve, and the lives of those we serve will be better, and our own lives will too. What do we have to lose? Ignorance, arrogance and complacency. On the other hand, we have everything to gain.

References

1. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612-616, June 2000.

2. Clark D. Big Dog & Little Dog's Performance Juxtaposition, www.nwlink.com/~donclark/hrd/development/reflection.html.

3. Reflective Thinking: RT. Hawaii Institute of Geophysics & Planetology, www.higp.hawaii.edu/kaams/resource/reflection.htm.

   Michael Touchstone, BS, EMT-P, is chief of EMS training for the Philadelphia Fire Department. He has been involved in EMS since 1980 as an EMT, paramedic and instructor. Contact him at m-touch@comcast.net.