The need for EMS physician involvement in clinical education and critical decision-making became apparent to me a few years ago. I was working a football game at Rice University in Houston, Texas, alongside my EMTs from Rice EMS and my residents from Baylor College of Medicine. A female patient in her 20s presented with lower abdominal pain, was evaluated by an EMT and a resident, and transported to the hospital by a contract EMS service.
After the call, the EMT pulled me aside quite concerned because the resident didn’t follow the EMS protocol for evaluation and management of patients with abdominal pain.
I explained there’s no protocol for doctors and described the concepts of “differential diagnosis” and “standard of care” and the guidelines for physicians. At that moment I realized the way we educate our EMS providers is in conflict with how we train clinicians, and that we may be programming our paramedics for clinical failure.
Physicians must be active in paramedic training and quality improvement to integrate prehospital providers into the house of medicine. Photo Mark Escott
The way we’ve historically trained our EMTs and paramedics is centered on heuristics, or pattern recognition—a sort of “if, then” analysis of the presenting problem. If you recognize a pattern, then follow the prescribed guideline, or protocol, for that pattern.
This type of training is common for technical-based roles and is designed to limit the need for individual judgment. Additionally, at the advent of EMS, there was limited data input to analyze and limited interventions that made higher-level decision-making less important.
Pattern recognition and protocols are an important part of clinical education and patient management. We look at standardized training such as advanced care life support, which, through its algorithms, is designed to generate a way to organize thoughts and a reproducible method of managing patients. This approach is essential early in the education to develop a framework on which to build the clinician. But at some stage, pattern recognition fails and those making critical decisions need education and guidance to develop and refine their clinical skills.
In the age of 12-lead ECGs, capnography and prehospital ultrasound, paramedics have much more data input than ever before, making decision-making increasingly challenging. I once reviewed a case that involved a male in his 60s who presented with lightheadedness and had a sinus bradycardia of around 50. The seasoned paramedic recognized this pattern as symptomatic bradycardia and decided to externally pace the patient. The problem? The patient’s blood pressure was 240/150!
Why did heuristics fail in this case? Because the paramedic didn’t develop a differential diagnosis for this patient.
The development of the differential diagnosis is the quintessential method of problem-solving used by clinicians to determine the course of action for evaluation and management of patients. Instead of looking for one pattern and then anchoring on that (referred to as “anchor bias”), the astute clinician must, from the moment of first contact, begin to develop the list of possible diagnoses for the patient. This differential diagnosis is then further developed and refined based on the data input from the history, physical assessment and data monitoring.
In this case, there was a conflict between the diagnosis of symptomatic bradycardia and the patient’s hypertension. In order to be symptomatic from the bradycardia, the individual has to be hypoperfused, which is unlikely with a blood pressure that high. Despite that piece of data, the medic anchored on the diagnosis and wasn’t able to transition to the more likely diagnosis of hypertensive urgency.
When we train our EMTs and medics, we follow the standard curriculum for patient evaluation. Although this is a useful tool for examination purposes, it’s far different than the investigative approach to patient evaluation used by doctors and clinicians.
The key assessment questions we burn into the memory of all our providers aren’t meant to be a checklist to memorize for an exam, they’re meant to be a skeleton on which to develop a clinical investigation. That history then develops into a physical examination. The standard head-to-toe exam is designed to create a pattern that’s followed as the basis of the physical examination. That examination has to then be modified and enhanced based on the differential diagnosis that’s been developed.
To paraphrase John Knox in the book The Humanity and Divinity of Christ, it’s useless to know the facts unless you can also walk amongst them. In order for paramedics to make the transition to clinicians, or “paramedic practitioners,” we must create systems that are independent of the individual EMS service.
We do a good job in our education programs having students memorize facts, but we fail when it comes to teaching them how to use those facts in a way beneficial to the patient.
Physician-Based Bedside Teaching
Although some paramedics obtain clinician-style diagnostic skills through experience and outside education, they aren’t uniformly found even among our most senior personnel. Therefore, the EMS physician must be actively involved in this second phase of training.
We began an effort two years ago to transition our paramedics at Montgomery County (Texas) Hospital District to think like clinicians. We defined a mental process that must take place when caring for patients in the field in order for paramedics to develop a differential diagnosis. Interactions between physicians and paramedics in the field became much more like the interaction between an attending and resident in the hospital.
Bedside teaching is largely unfamiliar in EMS and can be met with resistance by medics, often due to the paramedic’s perception that they’re no longer students and therefore shouldn’t be questioned in front of patients or their peers.
As subspecialists, the EMS physician must be an active participant not only in case reviews, but also as a safety net at the bedside. It’s impossible to train paramedics to develop clinician-level critical decision-making without an engaged EMS physician to refine these thought processes in real time.
Imagine training an emergency medicine resident by chart review alone. You can certainly learn a great deal from retrospective review, but this method alone is incomplete and is done at the cost of patient lives.
In the new age of EMS as a physician subspecialty, the clinical practice of EMS medicine has to change. Our communities shouldn’t be satisfied with the response, “We did the best we could.”
We must demand improvements in paramedic education and understand the criticality of increased physician support in education and quality improvement so paramedics are better aligned with the rest of the house of medicine.