Paramedic clinical decision-making: results of two Canadian studies Abstract

Paramedic clinical
decision-making: results of
two Canadian studies
Jan Jensen is a Provincial Research Leader, Emergency Health Services and Lecturer, Dalhousie University.
Email for correspondence: [email protected]
Paramedics make many decisions while caring for patients in the out-of-hospital
setting, including clinical judgments, such as assessment, treatment and transport
decisions. As the decisions paramedics make can have an impact on patient safety
and clinical outcome, it is important to focus on which clinical decisions are most
important, when paramedics are required these, and how paramedics make clinical
decisions, that is, what thinking strategies they rely on. This article will present
the results of two recent Canadian studies, and will discuss the implications for
paramedic clinical practice, education and research on this topic.
Key words
l Clinical decision-making l Paramedics l Scene management l Think aloud
Accepted for publication 2 February 2011
aramedics are responsible for treating and
transporting patients in need of urgent care.
In North America, paramedics have been
referred to as the backbone of the out-of-hospital
emergency care system (Institute of Medicine (IoM),
2006), and the safety net of healthcare (Ross, 2010).
The decisions paramedics make while assessing and
treating patients can have a major impact on the
care delivered and the resultant clinical outcome
(morbidity and mortality) and safety of the patient
(IoM, 2006). This is especially true as the diagnostics
and interventions paramedics administer become
more complex and their scope of practice continues
to evolve and expand (Paramedic Association of
Canada, 2001; Emergency Medical Services Chiefs of
Canada, 2006).
EMS in Canada
In most Canadian emergency medical services (EMS)
systems, clinical protocols or medical directives
direct paramedic care. EMS medical directors
create these documents, based on existing norms
and standard practice, using their judgment on
what will be most successful in the local system.
Protocols are often presented in algorithm format,
and are analogous to ‘practice standards’, which are
definitions of the correct practice, with few treatment
options, intended to be followed explicitly (Eddy,
1990). Adherence to protocols often a main measure
of the quality of care delivered.
Patients who require assistance from EMS
are found in a variety of locations, making the
practice of paramedicine more unpredictable
than in-hospital settings, including the emergency
department. In some situations, paramedics have
fewer clinical resources, including a lack of other
skilled practitioners, incomplete patient medical
histories, and even the events that precipitated the
emergency call may be unclear. In combination with
this, many EMS patients have high acuity, timesensitive conditions, whether medical or trauma.
These and other factors are why EMS is often called
an ‘uncontrolled setting’ (Nelson, 1997). Given this
context, it is essential to learn more about paramedic
clinical decision-making (CDM).
This article will focus on paramedic clinical
decision-making, specifically, the judgments
paramedics make that pertain to assessment,
treatment and transport decisions. Two recent
Canadian paramedic research studies will be
discussed, along with the implications of this work
on paramedic clinical practice, education, and future
research. The goal of these projects was to learn
more about what clinical decisions paramedics
make that are most important for patient safety and
clinical outcome, and how paramedics make clinical
decisions. There has been little work done on
paramedic CDM to date, so this work was intended
to generate interest on this topic and be a catalyst for
future research.
Emergency call scene management
Caring for a patient in the out-of-hospital setting
can be challenging. What distinguishes paramedics
from other health providers are not the diagnostics
international • Journal of Paramedic Practice
Table 1. Important clinical decisions made by paramedics during high
activity emergency calls.
Recognize potential hazards (e.g., people, animals, environment, chemical/radiological/biological risks) - Scene safety
Decide to check for/triage patients at scene with several patients
Initial assessment: is patient critical or not; level of distress/acuity, decide whether to start treatment right away, or complete assessment
Recognize signs of life-threatening trauma
Decide if patient has capacity to refuse or consent
Decide when to leave scene vs. manage/tx on scene (load & go vs. stay & play)
Deciding on appropriate treatment
Determine if patient requires immediate treatment or can wait til en route, arrival at ED
Recognize contraindications/reason to withhold therapy
Reassess patient after giving a treatment - decision on next action (stop drug, change, give another dose, etc)
Decision to change care plan (switch protocol/med directive) based on patient changes
Decide how to manage labour & delivery
Provide ASA
Give epinephrine for anaphylaxis
Give epinephrine for severe asthma
Give epinephrine for pediatric shock
Decide to give TNK for STEMI
Provide bronchodilators
Decide to use drugs to facilitate intubation (sedation, opiates, paralytics)
Decide on drug for tachycardia (amiodarone/lidocaine/adenosine)
Decide whether to administer vasopressor
Decide on manual airway positioning - if necessary and how (head tilt, jaw thrust, etc)
Decide to insert airway adjuncts (OPA, NPA)
Decide to use supraglottic device (King LT, Combitube, LMA), ETI or BMV
Provide positive pressure ventilation with BVM in respiratory distress
Decide whether to attempt intubation in pediatric patient
Decide whether to attempt intubation in major trauma patient
Decide to use CPAP
Decide to perform chest needle decompression
How to clear obstructed airway (Heimlich maneuver, suction, forceps)
Start CPR
Begin chest compressions on decompensated child (shock)
Remind/correct chest compressor on CPR quality; have chest compressors switch
Decision to defibrillate
Analyze cardiac rhythm (3 or 4 lead strip)
Interpreting 12 lead ECG
Decide on electrical cardioversion or medications for SVT
Decide how to confirm intubation
Decide to extubate if unsure of placement
Failed attempt at intubation - try again for ETI or switch to supraglottic device or BVM
Decide whether to perform cricothyroidotomy
Decide most appropriate destination (trauma, heart, stroke centre, community ED, other)
and interventions they use to assess and treat
patients, but rather where they practice (Campeau,
2008: 286). Campeau (2008), a Canadian paramedic
who conducted research on paramedic scene
management, commented:
‘Paramedics must ‘fit’ medical procedures
Journal of Paramedic Practice • International
into their work context; consequently,
paramedic practice is a unique type of care.
Paramedics achieve the remarkable objective of
transforming everyday, uncontrolled locations
where emergencies occur into settings that can
be used to effectively deliver emergency care’
(Campeau, 2008: 286).
Table 2. Characteristics of dual
process theory
Type I
Cognitive style
Conscious control Low
Vulnerable to error
Predictive power Low
Emotional valence High
Detail on judgment process Low
Scientific rigour Low
Type II
Few but large
From: Croskerry, 2009b: 214
A schema, a concept from cognitive psychology,
is the general information an individual acquires
and organizes in their mind about an experience
(Matlin, 2003). Schemas provide a cognitive template
for what to expect when entering into a particular
situation. Paramedic students quickly learn the
schema of a typical emergency call: receive dispatch
information, arrive on scene, conduct an assessment,
perform initial treatment, move the patient to
ambulance, perform repeated assessments and
treatments en route, arrive at destination, give report
and transfer care of the patient.
These phases form the major events that occur
in an emergency call. Process mapping allows for
events that occur during a particular situation to
be viewed in a linear fashion, which can increase
understanding of the factors at play during a
particular process. They are valuable not only to
recognize areas where errors currently occur, but
more importantly, to prospectively identify processes
most vulnerable to adverse events (DeRosier et
al, 2002). Process maps have been created to find
areas susceptible to clinical error in the emergency
department (Croskerry et al, 2006), and to outline
the sub-processes required during out-of-hospital
rapid sequence intubation (Blanchard et al, 2009).
Consensus on paramedic clinical
decisions during high acuity
emergency calls: results of a
Canadian Delphi study
The objective of this study was to learn more about
the most important decisions paramedics make
during emergency calls, in terms of clinical outcome
and patient safety, and to visualize those decisions
on a process map of an emergency call (Jensen et al,
2009; Jensen et al, 2011). Advanced care paramedics
and EMS medical directors (emergency physicians
who provide clinical oversight to paramedics
working in the EMS setting) from across Canada
participated in this multi-round online Delphi survey.
The purpose of the survey was to achieve consensus
among the group on the most important clinical
decisions paramedics make.
In round I, participants listed all the clinical
decisions made by paramedics during high acuity
emergency calls they believed to be important for
patient safety and clinical outcome. In Round II,
participants scored each decision on a 1–5 scale
on its importance for patient outcome and safety.
In rounds III and IV, participants could revise their
scores. If 80% or more of the panel scored a decision
important or extremely important, it was included in
the final list of important clinical decisions. Included
decisions were categorized and plotted on a process
map of a typical emergency call.
The panel (17 paramedics, 7 medical directors;
mean 16.5 years experience) achieved consensus
on 42 important clinical decisions, grouped into six
categories: airway management (n=13 decisions);
assessment (n=3); cardiac management (n=7); drug
administration (n = 9); general treatment (n=6); and
scene management (n=4). The airway management
and cardiac management categories had the highest
mean scores (4.49/5). Table 1 displays the list of
included important clinical decisions.
Decision density is the number of decisions
that must be made simultaneously or over a short
period of time (Croskerry 2009c: 408). The on-scene
treatment phase of the process map of a typical
emergency call appears to have the highest decision
density (Appendix 1). For paramedics, scene
management is an essential component of their
Metz stated, ‘the measure of a man or woman
doing paramedic work is always decided at the
scene (1981: 93). Identification of areas of high
decision density brings into focus point(s) of the call
that have an increased susceptibility to near misses,
adverse events and errors (Chisholm and Croskerry,
2009). The on-scene treatment phase is the period
of a typical emergency call when paramedics deal
with variable settings (outside the ambulance) and
are likely to have the least amount of clinical support
(e.g., when paramedics arrive on scene and then
call for another crew for assistance). While not all
of the decisions on the map happen during each
emergency call, the map is valuable for increasing
awareness of when paramedics are likely to be
international • Journal of Paramedic Practice
Table 3. Thinking strategy
Event driven
Pattern Recognition
Hypotheticodeductive II
Algorithmic II by proxy
Rule out worst scenario
II by proxy
Treat symptoms and then re-evaluate with further evaluation, depending on response to Decisions made without conscious thought
Combination of salient features establish likely diagnosis with corresponding evaluation and management plan
Accumulate facts indiscriminately and then sift through them for diagnosis
Inference based on preliminary findings, idea modification based on subsequent findings, response to therapy & exclusion of competing possibilities
Preset diagnosis or treatment pathway, based on pre-established criteria
Consideration of pre-existing ‘can’t miss’ list of diagnosis for presenting condition
From: Sandhu and Carpenter 2006: 716
inundated with many decisions. This process map
was not intended to be a representation of the
thinking process that occurs in a paramedic’s mind
(consciously or subconsciously), as decision-making
itself may not occur in a linear fashion. However, the
main events of an emergency ambulance call (call
dispatched, paramedics en route, patient contact,
etc.) are generally predictable, and in most instances
an emergency call is a linear process through time.
Thinking about clinical decisionmaking
In many EMS systems, paramedics use clinical
protocols to help guide the care they deliver. A
traditional assumption has been that paramedics
make most of their clinical decisions by choosing
the most appropriate protocol and following it
from memory (i.e., algorithmic thinking), but this
is probably not a sufficient explanation for how
paramedics actually make decisions in practice
(Bigham et al, 2010).
Clinical decision-making has been explored
by other health professionals and disciplines of
study. The dual process theory is the predominant
decision-making theory in cognitive psychology
(Table 2). The theory divides decision-making into
two processes. Type I thinking, often referred to
as subconscious thinking, is reflexively employed
when mental short cuts are used to make decisions,
without conscious thought, and is essential for
minimizing thinking effort (Evans, 2008). Type
2 thinking underlies the decisions that require
purposeful contemplation and analytic thought.
Although Type 1 processes are more prone to
error, they are effective in minimizing reaction time,
avoiding ‘paralysis by analysis’ (Croskerry, 2009a).
Journal of Paramedic Practice • International
For example, a novice paramedic may feel unsure
about how to approach an unresponsive trauma
patient, but as they gain experience, the cervical
spine is immediately held still without conscious
Type 2 processes are engaged in more complex
situations, when a decision cannot be made
quickly. In this mode of thinking, the thinker must
weigh the pros and cons of each option and make
a conscious decision on the best fit. A paramedic
may decide a patient’s chest pain is cardiac in
origin, rather than musculoskeletal, after they have
conducted a physical exam, a patient interview and
collected diagnostic data such as electrocardiogram
and vital signs. The paramedic may make the
decision with purposeful deliberation between the
competing possibilities (using Type 2 processes),
or it may be instantly made by recognizing the
combination of presenting symptoms as likely
cardiac (such as crushing retrosternal pain, nausea,
sweating). Subsequent actions are based on this
pivotal decision.
Another category of thinking strategies exists,
which don’t readily fall into either Type I or Type
2 processes. The term ‘Type 2-by proxy’ refers to
situations in which clinicians use thinking ‘tools’
to speed decision-making. These tools, such as
algorithms, clinical prediction tools, and differential
diagnosis lists, have been developed by experts
using Type 2 processes, typically by heavily referring
to research evidence. Clinicians memorize the tool
and during the patient encounter, the steps or list
is recalled. An example of this would be working
through a resuscitation guideline while managing
a cardiac arrest (i.e., algorithmic thinking). Several
thinking strategies have been proposed on how
emergency physicians make decisions (Sandhu and
Carpenter, 2006) (Table 3). Each of these strategies
Table 4. Thinking strategies used by paramedics
Total decisions
Trauma decisions
Medical decisions
I (event-driven, pattern recognition, intuition)
II (hypotheticodeductive, exhaustive)
II-by Proxy (algorithmic, ROWS)
ROWS = rule out worst scenario
can be categorized as employing Type 1, Type 2 or
Type 2-by proxy processes.
Clinical decision-making by
Canadian advanced care
paramedics: a think aloud study.
In this study, Canadian advanced care paramedics
(ACP) verbalized their reasoning while working
their way through two scenarios of emergency
calls (one trauma and one medical) ( Jensen et al,
unpublished observations, 2010). The Think Aloud
technique was used to identify the decisions made
and thinking strategies used by the participants
during the verbal ‘paper patient’ scenarios.
Purposeful sampling was used to create an
equally mixed sample of novice (less than two
years experience at the ACP level) and experienced
participants (greater than two years experience at
this level). Following the Think Aloud technique,
participants were encouraged to stop and explain
why they made each assessment, treatment and
transport decision during the audio-recorded
scenarios (Fonteyn et al, 1993). The clinical
decisions made and thinking strategies used were
identified in the interview transcripts.
During analysis, investigators matched the
participants’ explanation of their decisionmaking and the context of each decision to one
of seven predefined thinking strategies (Table 3,
hypotheticodeductive, exhaustive, algorithmic, rule
out worst scenario (ROWS), event-driven, pattern
recognition and intuition) (Sandhu and Carpenter,
Eight ACPs with a mean 9.6 years of overall
paramedic experience (SD 6.7) participated.
Twenty-nine decisions were made in the trauma
scenario. Eighteen decisions were made in
the medical scenario. In the trauma scenario,
participants used Event-driven and Algorithmic
thinking most frequently. In the medical scenario,
Algorithmic and ROWS were employed the most.
Event-driven thinking was used more often in the
trauma scenario compared to the medical scenario
(45 decisions vs 0, t-test, P<0.001), otherwise no
differences in thinking strategy used by scenario
types were found. Decisions in both scenarios were
made most by using Type 2-by proxy thinking
strategies (Table 4).
The novice paramedics failed to verbalize a
significantly larger number of decisions than the
experienced paramedics in both scenarios (mean
8.50 decisions not made per participant versus
mean 4.12 decisions not made per participant,
t-test, P< 0.05). Differences in thinking strategies
used were not found between the novice
and experienced ACPs. It is possible that the
thinking strategies paramedics use do not change
significantly with more experience.
A major limitation of the Think Aloud study
is intuition cannot be directly measured. The
requirement to think aloud and verbally report on
decisions may bear no direct relationship to any
intuitive thinking that might have occurred, and may
even change it (Hogarth, 2005; Nisbett and DeCamp
Wilson, 1977). Therefore, it is possible paramedics
rely on Type 1 processes to a greater extent than
could be detected in this study.
Some health professionals do not believe
algorithms and clinical prediction rules can outperform clinical judgment (Paley, 2007), and may feel
these are a threat to their decision-making autonomy
and lead to inflexible care plans. However, several
reviews and one meta-analysis comparing clinical
judgment to clinical predication rules found that
these tools are almost always more accurate, and
often require less clinical information than individual
clinician judgment (Grove et al, 2000).
Therefore, in chaotic or time-sensitive situations,
it is preferable for paramedics to use decision
tools, rather than rely on Type 1 processes, which
can be influenced by bias, the emotional state of
the thinker, and inappropriate use of mental short
cuts (Croskerry, 2005, 2010). It is also preferable to
taking too much time deliberating each competing
hypothesis or decision option using Type 2
processes before acting (Croskerry, 2009b).
Although small and exploratory, this study
contributed evidence to dispel assumptions that
may exist that paramedics solely rely on algorithmic
thinking to make clinical decisions. This finding
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provides us with new challenges: if paramedics
use more than one thinking strategy, which are
the best for which situations? Also, how can we
teach paramedics to recognize their own thinking
Implications of clinical decisionmaking research
Implications for future paramedic research
The two studies have generated further research
questions about paramedic CDM. This is a complex
topic, and many studies are required to build a
cohesive body of knowledge in this area, as it
applies to paramedic practice. Future paramedic
research questions that can be asked with the Think
Aloud technique include: the impact of paramedic
variables on thinking strategy, such as paramedic
level, call volume (rural compared to urban service),
work setting (ground ambulance versus air), and
type of paramedic education (full-time diploma, parttime diploma, undergraduate degree).
Think aloud studies could be conducted in a
simulation lab, to give participants a more realistic
sense of an emergency call. Further, it would be
possible to have paramedics think aloud while
they are working the ambulance setting, in order to
determine thinking strategies in real time (Fonteyn
and Fisher, 1995; Aitken and Mardegan, 2000).
Other aspects of clinical reasoning can be explored,
including the use of mental short cuts by paramedics.
Finally, paramedics make decisions during emergency
calls that are unique to that profession. These factors
may include timing (how long to spend on scene,
how many interventions can be done in the time it
takes to get to the hospital) and clinical support (do I
have the time or hands to call the medical director for
advice, should I call for another paramedic crew or
medical first responders to help?).
Studies like these are important for developing
the field of clinical decision-making further, in order
to understand more about how CDM varies, and
the impact on patient outcome and safety. The field
of decision-making is multi-faceted, and includes
theory and research from psychology, philosophy,
neuroscience, statistics, computer science and others
(Croskerry, 2000). The academic work of these
scientific disciplines needs to be interpreted and
applied to the real time setting of paramedics.
Implications for paramedic
Through didactic learning, and even more so,
during their clinical preceptorship, student
paramedics learn how to manage an emergency
call in a routine fashion. This occurs with the
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establishment of an emergency call schema in their
memory. This seems to happen naturally over the
course of preceptorship, which involves bridging
the theory to practice gap through observation,
repetition, and following the actions of experts
(their paramedic preceptors) (Boyle et al, 2008).
While students may quickly learn the process of
an emergency call, it is more difficult to develop an
understanding of how decisions are made. Much
has been written about medical education and the
importance of teaching quality clinical reasoning
through examples (Kassirer and Kopelman, 1989).
In typical paramedic education, students learn
and are tested extensively with simulation. These
scenarios should test thinking strategies, not just
clinical conditions and treatment paths (Kassirer
and Kopelman, 1989).
Paramedic educators should feed information
(such as past medical histories) to the student
slowly, to replicate how it is uncovered in real
life (Kassirer, 1983). Every time a student asks a
question, requests more information, or performs
an assessment or treatment task, the scenario
should pause and the student explain why they are
making the decision, recognizing the benefits and
pitfalls of the process used. Through this type of
exercise, students can learn how to use different
thinking strategies (Banning, 2008b). For instance,
they can increase their ability to tap into Type 2
processes by pausing, developing hypotheses, and
ruling them in or out as new information becomes
available. This would be a departure from the
tradition of teaching decision-making by following
Similarly, when paramedic students are in the
clinical phase of their training, their preceptors
should probe them about why they are making
each decision, and discuss different thinking
strategies. If this is not possible to do in real-time
during the call, the questioning and discussion
should ensue immediately after the call is complete.
In addition to teaching paramedics how to
appreciate different thinking strategies, paramedic
educators should specifically discuss which clinical
decisions are important, and require deliberate,
conscious decision-making, versus those decisions
safely and effectively made with intuitive or
unconscious thinking strategies. Given that the
decisions paramedics make can have a major
impact on some patients’ outcomes, it is important
for all students to learn about how decisions are
made. A rigorous study should be conducted,
comparing student decision-making between a
group that has received a module on CDM and
those who have not. The outcome might determine
if paramedic CDM should become a mandatory
competency for paramedic education.
Key points
llThe highest density of important decisions paramedics make occurs during the
on-scene treatment phase of an emergency call.
llParamedics likely rely on several different thinking strategies, each of which fit
into either Type I processes (intuitive, subconscious thinking), Type 2 processes
(conscious, deliberate, analytic thought), or Type 2-by proxy (using a thinking
tool) of Dual Process Theory.
llIt appears paramedics rely on Type 2-by proxy thinking strategies most
frequently, which includes algorithmic thinking and ruling out the worst case
llParamedic clinical decision-making should be a focus during paramedic
research, education and clinical practice.
focus on the events of the call and the decisions
made, and also what they were thinking and
feeling at the time. This metacognitive exercise
would inevitably lead to improvements in clinical
practice as paramedics learn more about how they
make decisions during emergency situations. This
information is at least as important to share as the
clinical details. Further to this, paramedics should
be encouraged to write up case reports of calls
that required challenging decision-making.
As an example, Campbell et al (2007) published
a case report that included a detailed analysis
of cognitive biases that resulted in an important
diagnosis being missed in an emergency
department patient. Perhaps through the incentive
of continuing education credits, paramedics should
be encouraged to submit and share case reports of
this nature.
Implications for paramedic practice Conclusion
Croskerry et al (2000) proposed that each health
discipline should identify meaningful patterns in
their own practice that are prone to error. The
on-scene treatment phase of emergency calls
was found to have the highest decision density,
and therefore increased vulnerability to error
and subsequent adverse events (Croskerry and
Sinclair, 2001). This knowledge has important
repercussions. Continuous quality improvement
(CQI) paramedics and medical directors are tasked
with ensuring the quality of care is high and risk
of error is low. It would seem important that they
work closely with paramedics who have made
clinical errors, and encourage them to reflect on
their thinking and try new strategies, instead of
only focusing on the clinical aspect of the error.
It is imperative for CQI paramedics to be aware
of the decisions that were found to be the most
important for patient outcome and safety, and
seek these out while conducting clinical audits of
emergency calls.
Morbidity and mortality (M&M) rounds have a
long-standing tradition in EMS. In these sessions,
paramedics and medical directors gather to discuss
emergency calls that were challenging or resulted
in an adverse event (Cosby, 2009). The operational
and clinical aspects of the call are discussed, and
consensus is reached between the presenting
paramedic and his or her colleagues on what the
most ideal actions would have been. It is rare
for a presenter to discuss the thinking strategies
they used. Presenters should be encouraged to
conduct a cognitive autopsy as soon as possible
after the call, in order to maximize recall. Cognitive
autopsies are ‘a form of cognitive and affective root
cause analysis’ (Croskerry, 2005: 10).
During M&M sessions, the paramedic should
High quality care is achieved when practitioners
make clinical decisions that are safe and effective.
Paramedics often make decisions while working
in variable settings, unique from other healthcare
providers. The on-scene phase of an emergency
call has the highest important decision density;
it is important for paramedics to be aware of
this in order to minimize adverse events. In their
work, Paramedics engage a spectrum of decisionmaking strategies in their work that include Type
1 processes, Type 2 processes, and Type 2 –by
proxy tools, that typically involve the use of
algorithms, clinical decision rules, and practice
guidelines. CDM is a topic of utmost importance to
the development of the paramedic profession.
Conflict of interest: The studies described in this
article were supported by a studentship grant from
the Canadian Patient Safety Institute.
Acknowledgement: The authors acknowledge Dr.
Sam Campbell for his thoughtful feedback on the
research, and the paramedics and EMS medical
directors who participated in the studies.
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Appendix. Process map of an emergency call
Ambulance call dispatched
Paramedics en route
Paramedics arrival on scene
Patient contact
On-scene treatment
En route treatment
Patient hand-over
No transpoprt
Scene management
General treatment
Airway management
cardiac management
Drug administration
Terminal (start, end)
international • Journal of Paramedic Practice