Decision Making and Mental Models
Disclaimer: This is my opinion and does not reflect the view of any entity that I trade time for cash with. Everything is meant for educational food for thought and you should always “follow your protocols.”
I recently watched a vlog about decision-making and how experience shapes our process of assessment. This had me thinking about habits and how to change them for the better. It has been said that a bad habit is more difficult to adjust than adding a new habit. So as clinicians, we need to have experiences that mold our thinking and sometimes we need a bad outcome to subvert the algorithm to forge a new process. Conversely, if we don't have that bad outcome, we sometimes fail to improve processes as they have not "led us astray" so to speak. An example of this is when you treat patients using the same prime decision-making process for an unconscious patient and give Narcan initially when it could be a stroke. You would hopefully reach that same endpoint of going to a stroke center but had you considered all the options, you might have not performed unnecessary treatments along the way.
So, how do we improve our processes? As stated, experience is a great motivator. As you progress as a medic you recognize patterns and create shortcuts to essentially run on autopilot. Just like when you have a call that ran so smoothly and no one has to speak. This serves many functions. You have to be careful though, just because 2 or more outcomes from the same process have occurred, does not mean they are correlated. Might just be that you haven't tried enough times to elicit a different result. The vlog mentions when you get bradycardia the 2 attempts on an RSI might not mean it will always happen.
In addition to our mental models, checklists and resources are another tool that you can use to reference complex algorithms or data for later. You can't be expected to remember everything in medicine, but you can be expected to know where to look. Protocols, guides, phone-a-doc, and coworkers are all good resources at your disposal if they provide timely and correct information.
Your salty 30yr veterans might be a wealth of knowledge, but on the same token, we have a bit of 30yr anniversaries of someone's first year on the job. Or even something more true to life, leaders feel the need to not keep up with skills since "it's not their job" anymore. Always be skeptical and ask for a references if you think something sounds off. Case in point these blogs, I don't expect you to take my word for it. I would love for you to check my sources and research the data for yourself. You might pull something I didn't see or you might have a better understanding of the information by reading it from the source.
Speaking of resources, guides are a great way to gather information for quick recall. The employers provides those ALS Guides, but it's a bit of information overload that can't be easily referenced in a timely manner. I would suggest making your own that you are familiar with or finding something that you can use with ease. I personally made a drug reference book just for that reason. Knowing I have a fetish for excel spreadsheets, it was a great project. Granted something like a Handtevy system is a bit more than just the book I made, but it serves as a guide to reduce med errors in our smallest populations. Dr. Peter Antevy is a great pioneer in EMS and especially in pediatrics as a Board certified Pedi ER Physician and a medical director for a sprinkling of counties/cities. You should really check out his stuff.
Dr. Antevy talks about System 1 / System 2 thinking and its direct use in EMS. System 1 being that quick decision-making that is most of our jobs. If you see a hole, plug it. They are not breathing?; ventilate them. And so on. System 2 is more of that long process of thinking in pediatric drug calculation. You need to find the Broselow tape, then measure head to heel, then calculate the mg (math), then find the concentration of the drug, then calculate the mL (math), then give the medication. All while the child is doing the funky chicken on the ground in the case of a seizure. So resources make the difference in these cases.
Lastly, I would like to talk about online medical control. Historically, consultation is used as a final resource of knowledge in case you have to go fish or you want to deviate from the guidelines. Our physician is supposed to know our protocol and the reasons why we might need to call. I believe calling the medical director should not be necessarily a last resort, but should help steer the clinician in a direction that they might not have necessarily gone or consider options unbeknownst to them. For example, when treating for shock, when is the best time to start a vasopressor after volume replacement depending on the type of shock you think is occurring? If you think it is cardiogenic, you might start dopamine faster than if you thought it was septic shock. Sometimes with our limited tools and information, it might not be as clear cut as you think. We can't check for fluid responsiveness to know that the container is full but actually needs more squeeze. The hospital can check for things like systemic vascular resistance, central venous pressures, and left ventricular diastolic pressures and have medications that more selectively target the needs of the heart. We on the other hand don't have such wizardry.
To wrap all this up, please don't stop learning and improving your process. You don't need to memorize everything, just know where to look. Use your peers, but don't take everything you hear for a fact. Lastly, make checklists for processes to reduce inadvertent errors in high-acuity / low-frequency tasks to better improve outcomes. If you happen to have a checklist you like and currently using, I would love to see it.
