Dissecting Decisions

      The content at EMS EXPO is always cutting-edge. To help promote this important content, we feature Q&As with selected speakers about their topics. Here we speak to Jeff Beeson, DO, RN, LP, associate medical director for the Emergency Physician's Advisory Board, which provides medical oversight for the MedStar system in Fort Worth, TX. Jeff spoke with Dr. Ray Fowler on critical thinking and decision-making with critically ill patients at the 2010 EMS World Expo.

   What does your talk with Dr. Fowler concern?

   It's kind of a cognitive autopsy, trying to dissect how we think and make decisions. In emergency and prehospital medicine, the way we think can often lead us down the path to make mistakes. Our focus is to identify the things that lead us to make mistakes--to kind of unmask our cognitive misperceptions.

   The study itself is called heuristics. It's looking at the way people think. We know that in prehospital medicine, choosing a bad path can be detrimental to your patient. So if we can show you, "OK, these are some of the things that make you make mistakes," then when you're next in that situation, you'll hopefully think to yourself, Whoa! Stop a second. Let's reevaluate here and think critically.

   What kinds of things actually lead to our mistakes?

   Most of the mistakes we make in prehospital emergency medicine are from inadequate patient assessment. We take shortcuts: "I've seen this 100 times. You're short of breath, you're a COPD patient." We jump to conclusions, and fail to do a thorough history of the present illness and a thorough physical exam. Then our diagnosis attaches to the patient and becomes a label: "Oh, this is a drunk guy." And that follows the person all the way into the emergency department. So maybe the emergency department puts that "drunk" patient in a back hall to let them sober up, and maybe gets a set of vital signs every 12 hours. Then, 12 hours later when they go and check on the patient, the patient's dead, because what they were actually suffering was an intracranial hemorrhage or traumatic head injury. But he was altered, he smelled drunk, he looked disheveled--therefore "just some drunk guy." People trust our medical knowledge, and that diagnosis, once the momentum starts, follows a patient all the way into the ED.

   What are some other problems?

   Another example is cherry-picking. Say I have a COPD patient who's short of breath. I'm doing my history and physical exam: You're short of breath, it's been going on a couple days. I find your right leg is swollen, your calf is tender, the pain suddenly onset, you've never had this before, your lungs are clear--but you're a COPD patient. What I've done is cherry-picked certain things out of your physical exam that confirm for me the diagnosis of COPD. And I've failed to accept the things that don't go along with that: the sudden onset, that it's never happened before, the hot right swollen calf. What you actually have is a pulmonary embolism that I've missed because I was too focused on thinking it was COPD.

   What can we do in the educational process to better instill and enhance critical-thinking abilities?

   We need to teach differential diagnosis. When you walk in to a patient who's short of breath, you need to think of five possible causes of the shortness of breath. Then let your history and physical exam make things either more or less likely. I run calls all the time, and I'll get in the ambulance and look at the paramedic and say, "OK, give me five possible causes for this patient's presentation." That helps them think in this differential mode.

   Right now I think there's a difficult balance in prehospital emergency care. We teach people to take and pass the National Registry exam. Well, what does that exam provide you? All your National Registry certification gives you is a license to learn--that's it. There's no way you, fresh out of school with a brand-new card, have the knowledge and experience of a paramedic who's been on the street 10 years.

   We need to teach people that this is just the beginning of their training--it's not the end. You do not know everything. And when you walk in on a shortness-of-breath patient, you start thinking, What causes shortness of breath? Asthma, COPD, pulmonary embolism... Start the differential, and let the hospital know what you've ruled out and what's still possible. Don't just attach a label and let it go.

   What kind of system support do providers need to practice this kind of critical thinking?

   You need a supportive medical direction team, and a supportive operational team. You have to have an operational director running the system who's supportive, because this kind of care takes time, on scenes and at hospitals. And, finally hospital support. In Ft. Worth, we function as an emergency physician advisory board, so I work for a board of hospital ED directors. As physicians, that gives us ownership of the EMS system. These are our paramedics and our patients--even if they're not in the hospital, they're in our house. So these issues affect the emergency system as a whole, not just the ED vs. EMS. It's all interconnected.