Judgment Calls

   One definition of judgment in the dictionary is "the cognitive process of reaching a decision or drawing conclusions." To do this well in the prehospital setting is a challenge, because of the enormity of the consequences of our decisions and the short amount of time in which we have to make them. To use "good judgment" in the prehospital setting, one must first acknowledge the tremendous external forces that work to make this difficult.

   Today's EMS provider has an enormous amount of clinical information to remember and process with each patient interaction. More and more is expected of our EMS personnel in terms of new medicines, interventions and devices. It seems like just as soon as we get comfortable with King LTs, ResQPODs and vasopressin, we have to deal with LMAs, LVADs and Plavix.

   However, just as important as the technical side of patient care is the intangible element of establishing a rapport with the patient in a short amount of time. This is so crucial because the first 30 seconds of any patient encounter will usually dictate how the rest of the run will go. It is amazing how the art of connecting to patients in the prehospital setting is so critical and yet so ignored, as we seem to focus on our proficiency in doing particular techniques or administering new drugs. The really effective EMS providers are able to quietly and calmly put a patient at ease while determining in short order what the exact nature of their problem may be. This ability is what separates good EMS personnel from great ones.

The Right Foot

   In the vast majority of cases, people who call 9-1-1 do not enjoy the process. Sure, there are individuals who abuse the privilege of calling for emergency response for various reasons. But the motivating factor for most people is fear or anxiety, and in the back of their minds lies the lingering notion that maybe their call was frivolous or unnecessary. They worry their neighbors will be curious or concerned about your arrival with red lights and sirens. They may feel they are wasting your valuable time or resources. Your initial response to their call may either validate their anxiety or put them at ease, so that you may better evaluate their medical condition.

   So your initial demeanor toward the patient may encourage them to open up to you and be forthright with their symptoms and complaints. Or, if you act patronizing or demeaning to them, it might just make them clam up and make it difficult for you to get a proper appraisal. Once you have lost that rapport with the patient, it is almost impossible to recover it. Sometimes you just need to say, "You know, we got off on the wrong foot, and I apologize if my remarks or attitude were offensive to you. Can we start over? Let me introduce myself: My name is..." And hopefully you can "reboot" the entire interaction and begin a productive exchange of information.

What Patients Want

   Above all else, the patient usually wants you to tell them they are really OK and do not need to go to the hospital. In some instances, you may want to tell them exactly that, especially if you have been getting hammered all night long and it is just before shift change and that last transport to the hospital will get you back to your station way after quitting time. When the patient is having just "heartburn" and you are performing the 12-lead EKG, the words they want to hear are, "Well, I don't see anything specific showing a heart attack." And you wouldn't necessarily be lying when you said it. But you may be conveying a false sense of security to the patient by what you don't say.

   Try saying, "Our EKG will usually show some definitive changes that would indicate a heart attack. But in some instances the EKG may be normal and you could still be having a heart attack that's just too early to detect with an EKG. We cannot be absolutely certain unless you let us take you to the hospital, where they can perform specific tests we can't." Document in your patient care report that you said exactly that to them, especially if they still refuse transport.

   Also perform a self-evaluation before each patient encounter. Determine whether you can be an impartial and fair-minded caregiver at that point in time. You cannot let preconceptions and bias based on socioeconomic status, gender, time of day or any other factor cloud your judgment in evaluating patients in the field. It is really quite amazing how your state of mind can lead you to interpret the same situation so many different ways. Your state of mind can be affected by many things, including fatigue, hunger, home relations, a quarrel with your partner, even the physical resemblance of a patient to someone you detest. Any number of things can turn you from a compassionate and impartial caregiver to a biased, impatient and careless individual who just happens to have someone's life in their hands.

   Everyone has heard that you should look on each patient as your child, wife, husband, mother or father, and treat them in the same manner you'd like that person to be treated. This is sometimes difficult but pays off handsomely. Sometimes it helps to just put those words up in your vehicle somewhere, or stick them on your clipboard as a reminder. Just saying the words, "This could be my father. This could be my son. This could be my wife," etc., can reinforce in your mind that every patient encounter warrants the attention you would give to those loved ones.

Boxed Out

   Try to avoid building "boxes" that fit certain medical conditions and only considering patients who fit into those boxes to be "really sick" and worthy of treatment and transport. For example, patients with chest pain do not have to be over 50, obese, smokers or have just finished a heavy meal before shoveling snow off their driveway in freezing cold to be considered worthy of consideration for an MI. They could smell of alcohol, be thin, female, relatively young and fit and still be in the throes of a heart attack. Be humble enough to admit there are certain situations that may not fit into your preconceptions of true illness. Be flexible. You are at the disadvantage of evaluating these patients in the most uncontrolled setting with the minimal diagnostic equipment available. Your goal should be to think of the worst-case scenario with each patient interaction and proceed accordingly.

   Above all, know what your protocol says and the parameters within which it allows you to practice. The protocol and/or your base station should be readily available to guide you through your decision-making. However, be aware that not all situations are covered by protocols. Sometimes it is necessary to get input from other sources to come to good decisions. In these situations it may be necessary to call upon your colleagues, supervisors, base-station personnel or receiving ED physicians to get further insight. All unusual or difficult patient encounters must be meticulously and thoroughly documented on your PCR.

   In particular, refusals of transport should receive comprehensive and exhaustive documentation that you made every effort to get the patient to go to the hospital. And, yes, if the situation is appropriate, you may tell a patient that they may die unless you take them (chest pain is a good one), and document that you said that in your PCR. One of the most dangerous runs you will make is the patient you leave at home after they had enough concern to call 9-1-1 in the first place. Whether they refuse transport or you just don't think they deserve a ride to the hospital, your documentation should explain your actions in excruciating detail.

Conclusion

   Good judgment in EMS is learned over years of patient encounters and usually by making mistakes. Try to learn from those who have been doing the job for a while--pick their brains to learn tricks of the trade. You can probably name these individuals right now; most people working in EMS know who they are.

   Experience is something that cannot be taught in a classroom, but must be obtained by actually doing the job. Utilize all the resources available to you to develop the best methodology and style you can. And know your limitations, so you can anticipate potential problems and be prepared to overcome them.

   David P. Keseg, MD, FACEP, is medical director for the Columbus Division of Fire EMS in Columbus, OH.