Analysis Paralysis

For those who choose to study prehospital medicine, the many challenges that lie ahead quickly become obvious. For the EMT-B course, that’s more than 1,000 pages of reading spread over one single quarter. And what we read we need to not only remember, but be able to recall upon demand, under the duress of an emergent moment in another human being’s life.
If that isn’t challenge enough, folded in with that come the various skills, all unrelated to each other but still required to be mastered. Spinal immobilization is nothing like airway management, which in turn is nothing like CPR or extremity splinting. Lastly, without question the most important challenge is that of having the ability to take knowledge and turn it into practical application.
Believe me, this is far easier said or written than done. The dynamics of the world of prehospital care are unique to a fault: a perpetually unstable platform, coupled to limited physical and technological resources, but still with expectations of excellent medicine. Call after call, day in and day out, we gather and sift through piles of information, each time needing to extract that which will allow us to identify and remediate the problem(s) plaguing our patient.
It is at this point where the problem of “overthinking” comes into play. On one side of the equation, the provider continues to believe they need more information before they can act. On the other side, they continue to run the “what if?” scenario, resulting in a circular thought pattern: Well, it could be this, or it could be that. Then again, it could be this as well, or maybe even that. This process continues to produce more and more possible working diagnoses, thus taking the person right back to square one. With these added possibilities comes the need for more information before they can act. Analysis paralysis sets in. If there isn’t another team member who can step in and take the lead, the call simply freezes in place. It’s the equivalent of going to the firing range, pointing a gun at the target and then: “Ready, aim…aim…a-i-i-i-m…” and never pulling the trigger.
Of course, if overthinking becomes a chronic performance matter and can’t be corrected, it can be a career-ending condition. Patients don’t just call us because of what we know; it’s because of what we can do for them.
I’ve listed below what I believe to be helpful suggestions to treat analysis paralysis before it becomes fatal:

1. Know your stuff. You must have an adequate fund of knowledge to draw from to make good care decisions.

2. Work to separate what is “relevant” from what is not. We generally ask open-ended questions to gather lots of information. Focus on that which does or may apply to the problem at hand.

3. Understand Occam’s Razor, which basically says the most likely answer to any question or solution to any problem is usually that which is most obvious.
Most of medicine unfolds in a reasonably lucid and logical fashion. For example, the progression of angina to unstable angina to MI makes sense. Irrespective of whether you take too many opiates or too may opioids, in the end you will breathe slowly and shallowly, and as a result you will become hypoxic and hypercarbic.

4. Develop confidence and courage. Developing confidence in your medicine takes time and practice. There is no other way. Going from average to good does not happen magically in medicine. As you increase your knowledge base, your confidence grows. As you master your skill set and polish it to a master craftsman-like level, your confidence grows even more. With more patient contacts and experience, you put your knowledge and skills to use, and that takes your confidence to continuously higher levels.
That being said, you must still have the courage to put your working diagnosis into play and start doing something for your patient. Don’t just aim—pull the trigger!

5. Own and learn from your mistakes. One reason people overthink may be that they believe they can avoid mistakes. But keeping on thinking rather than doing is the biggest mistake of all: being unable to make a decision for your patient.
Working to think more logically and become more decisive means that for a while, you will see an increase in the volume of your mistakes. That’s OK and to be expected when going from indecisive to decisive. Just do the right thing and own your mistakes, avoiding the temptation to buff them off on someone else.

Every EMS provider has certain subtleties and nuances of practice that arguably are part of what “makes them them.” For the most part, though, our similarities are more common than our differences, with the most important commonality being the ability take theory and turn it into practicality.
As for those who suffer from analysis paralysis, theirs is not an easy road to hoe. They must have both the capability and desire to change, or there will be no resolution, and their time in EMS will come to an end.
Until next month…

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.