Your Captain Speaking: Say It Out Loud

“Samantha, there are many examples in aviation where a pilot thought they detected a problem and the other pilot sitting right next to them saw something completely different. It led to running the wrong checklist and bad outcomes.”

“Dick, why do I have the feeling the same thing happens in EMS? What can we do about it?”

Many years ago there was an aviation accident where the cockpit voice recorder was recovered but didn’t give any clue what went wrong or triggered the problem. The conversation recorded was pretty much, “Hey, did you see that?” “Yeah, weird.” But ultimately the investigation concluded the pilots came to believe very different problems were occurring—they were not on the page. It happens. I once had a jet engine quietly flame out, and the only warning light that illuminated was that the electric generator failed. The other pilot started to open the checklist for electrical failures. When I mentioned the low exhaust gas temperature and RPMs, he quickly responded with the right procedure. The key was that I spoke my perception of the problem out loud.

EMS can easily fall into this same trap. When we respond we’re given a location and chief complaint. Dispatchers are skilled at asking the right questions, but they can only decide the chief complaint based on what they’re told. Patients and family members may withhold or be reluctant to provide details or may even be misleading. My personal best misdirection was a call for “My grandfather fell down.” When the family met us at the door, they seemed nervous. When we asked, “What do you need help with?” They responded only with “Hurry, hurry!”

Suspiciously I entered the house and rounded a corner and saw grandpa supine on the kitchen floor with a male straddling him and both holding the handle of a long kitchen knife, the blade of which was deep into grandpa’s abdomen. I paused for a moment to process the scene when, to my surprise, grandpa turned his head to me and said, “I should have used a gun!” What I’d thought was a simple fall rapidly became a domestic violence, then a suicide attempt, with the family member trying to stop grandpa from harming himself further.

Expectation bias is what we encountered. While it was very true and accurate that grandpa did fall, the family used that alone in the call to 9-1-1—as it later turned out, to avoid having the police respond. Surely you’ve also responded to calls that turned out very different than you expected.

Expectation Bias

Aviation and EMS have so many factors in common, it is astounding. Expectation bias is often a precondition to many aviation incidents and accidents. One way is through poor communication. In the example above clear, accurate communication between the 9-1-1 caller and dispatcher did not occur. We don’t know if the 9-1-1 call-taker asked about a reason for the fall, but certainly on an EMS call we would dig deeper into this question.

Expectation bias is a sneaky and subtle factor to deal with. It does not show as clear sign or symptom but rather blends in quietly. Here are some of the conditions that might lead to expectation bias in EMS:

• Fatigue—We all can be affected by fatigue shaping our judgment.
• Prior EMS calls of a similar nature. For example, the last 5 calls were the same scenario, so my mind-set is that this one will be the same.
• Different levels of training and experience. Subtle signs and symptoms may point a paramedic toward a specific problem that’s not recognized by other members on the scene. Maybe the patient’s ECG has some funny little beats the medic has seen before but the new EMT partner hasn’t.
• Time pressure. This could be external (the family insisting you move faster) or internal (we’re due off soon and have things planned after work).

What to do about it? First, recognize that expectation bias can happen and give us tunnel vision as to problems and solutions. It can happen to anyone. For me, I restart my scene survey from the top to include personal protection, scene safety, initial triage, and mechanism of injury (see “Your Captain Speaking: An Acronym for Every Call.”1). This allows you to re-evaluate what you’ve observed and your thinking process.

“Dick, I know where you’re going next. Say out loud to your partner or the other responders what you see as the problem and what your actions will be next.”

“Samantha, you nailed it. Say it out loud so everyone’s on the same sheet of music.”

Reference

1. Blanchet D, Greene S. Your Captain Speaking: An Acronym for Every Call. EMS World. Published May 23, 2021. www.hmpgloballearningnetwork.com/site/emsworld/article/1225859/your-captain-speaking-ems-acronym-every-call 

Dick Blanchet, BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Missouri and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years. He is a graduate of the US Air Force Academy with an MBA from Golden Gate University.

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia EMS in Illinois, and a full-time paramedic at the St. Louis South City Hospital emergency department. She was recently recognized as a GMR Star of Life.