Paramedic decision-making and the influence of bias: a case study
David (Spud) Tory, Paramedic, South Western Ambulance Service, Blandford Forum, UK; Iain Darby, Programme Lead, Paramedic Science, Bournemouth University, Bournemouth, UK. Email: email@example.com
Background: Prehospital clinical decision-making is a complex, evolving skill. Typically, there are multiple possible diagnoses and several potential treatment pathways to be considered, and usually prehospital clinicians have to base their decisions on imperfect information. Biases will inevitably compete to influence clinicians as they attempt to weigh the probabilities of diagnoses, degrees of certainty and permissible risks in their decision-making process. With experience, as intuition and tacit knowledge develop, paramedics will depend less on explicit knowledge and algorithm-based decision-making tools. Paramedics must strive to strike the right balance between the intuitive and analytical aspects of clinical decision-making, while maintaining an awareness of the human factors that will influence them in this process if optimal clinical decisions and therefore patient outcomes are to be achieved. This case study illustrates complex decision-making in the prehospital setting, with a focus on the influence of bias. Key words l Clinical decision-making l Emotional bias l Irrational deductive process l Rapid deduction process l Probabilities of diagnosis l Permissible risks
Accepted for publication:1 April 2022
This critical analysis will evaluate the clinical decision-making process during an incident that I attended but was led by another paramedic, where there were several possible patient diagnoses and three potential treatment pathways. The probabilities of diagnoses, degrees of certainty and permissible risks will be analysed during the assessment, consideration of diagnoses and treatment stages of this incident. Particular attention will be paid to the influence of emotional biases on our deductive process throughout.
This analysis is anonymised in accordance with the 2018 Data Protection Act and the Health and
Care Professions Council Standards of Conduct, Performance and Ethics (2016).
The incident This incident was assigned to us at 22:25, 35 minutes before our shift was due to finish. We were tired, and our desire to finish on time made us acutely aware of how close this was to the end of our shift.
The patient, who was in his 80s, was sent an ambulance because of an episode of confusion during the evening, which had now resolved. He had a 2-month history of a cough and had had his influenza vaccination 30 hours before this incident. The patient was tachypnoeic, but my impression was that he appeared otherwise well; he was self-mobilising, fully orientated and reported no pain or impairments at that time. The patient’s wife, also in her 80s, was in attendance and mobilising using a frame. However, it was apparent that the patient and his wife were dependent on each other for their personal care, with no relatives or friends able to assist them.
On examination, the patient had a peripheral body temperature (PBT) of 38.6°C and a respiration rate (RR) of 26 breaths per minute (bpm). All his other baseline observations were unremarkable and his chest was clear of adventitious sounds on auscultation. We were attending the patient in his home, which was unkempt but warm. We considered that, alongside his overall presentation, the patient’s elevated PBT and RR were primarily indicative of infection, sepsis or an adverse reaction to his influenza vaccination. Without further tests, possible only in definitive care, we could not be certain of the his diagnosis.
Vol 14 No 6 • Journal of Paramedic Practice