Creative adapting in a fluid environment: an explanatory model of paramedic decision making in the pre-hospital setting

Abstract

BackgroundParamedics work in a highly complex and unpredictable environment which is characterized by ongoing decision-making. Decisions made by paramedics in the prehospital setting have implications for patient safety, transport, treatment, and health resource utilization. The objective of this study was; a) to understand how paramedics conduct decision-making in the field, and b) to develop a grounded theory of paramedic decision-making in the prehospital setting.MethodThis study was conducted using classical grounded theory. Paramedics (n = 13) with five or more years’ experience, who worked in a large urban center in Western Canada were interviewed. Field observations were conducted, each lasting 12 h, with five different ambulance crews. The data were analyzed and coded using the constant comparative method.ResultsThe resultant theory, Creative Adapting in a Fluid Environment, indicates paramedic decision-making is a fluid iterative process. Unpredictable and dynamic features of the prehospital environment require paramedics to use a flexible and creative approach to decision-making. The model consists of the three categories constructing a malleable model, revising the model, and situation-specific action. Two additional components, safety and extrication, are considered at each stage of the call. These two components in conjunction with the three categories influence how decisions are made and enacted.ConclusionParamedic decision-making is highly contextual and requires accurate interpretation and flexible cognitive constructs that are rapidly adaptable. Evaluation of paramedic decision-making needs to account for the complex and dynamic interaction between the environment, patient characteristics, available resources, and provider experience and knowledge.

Cognitive skills of emergency medical services crew members: a literature review

“…Prehospital emergency situations, which can change very fast and at any moment, frequently require the development of situation awareness, both rapidly and on-the-spot [53], while synthesizing information about one's surroundings into a big picture/model of the situation [34,43,44,47,50,54]. Reay et al [47] highlights constructing a malleable/flexible model, determined to be continuously revised and adapted to a changing situation [59]. The synthesis combines information from focused assessments that are here separated, yet in EMS professionals' minds, they tend to overlap.…”

“…They can be valuable sources of information to manage the emergency situation to a satisfying conclusion. It also emerged that it was crucial for those in a high-risk EMS profession to assess the environment and the safety of patients, bystanders, and personnel on scene and in the ambulance [31,33,34,38,40,41,47,48,55,57]. This means assessing clues and significant objects in the environment that can give a notion of what happens and to assess potential risks and threats.…”

“…This can provide initial pertinent information to construct a malleable model of the call. As EMS crew members approach and enter the scene, looking for clues related to the patient's situation in the environment can add information to the model [47]. It is also important to observe the scene [54] and note (state) any environmental hazards to the self and the patient [38].…”

“…On the scene, the necessity is to focus and concentrate [43] what an expert can do quickly and directly to the problem at hand [60]. Usually, gathering information centers on history taking and physical examination of the patient [42], which should be conducted systematically [54,57], promptly [41,47,48], effectively, thoroughly, appropriately to a given situation [54], and via perception and active/careful listening to information provided from the dialog with the patient [35,36,59]. Although the patient is a key information source, the information provided from bystanders' behavior and communication [37] is irreplaceable, especially when the patient is unconscious or unable to talk.…”

“…Studies highlight being open to a variety of causes for the patient's clinical representation (to accept the general and not to have to arrive at a specific diagnosis) [60], the ability to absorb, process, and combine a variety of information and information sources simultaneously [35,47,60], and making quick, sound judgments [60]. When an element of incongruent information appears, the necessity is to reconcile information [34], or to look for consistency among various information sources and to question inconsistent variables [47]. More noticeable markers of good interpreting information are responding to changes in the patient's state, verbalizing observed trends and their meaning to other team members, increasing frequency of monitoring in response to patient condition [44], and interacting with team members that enable to correct potential misunderstanding [35].…”