Paramedics use both intuitive and analytical thinking processes in clinical decision making. Errors often arise due to cognitive biases that influence thinking under pressure. Strategies can be applied to reduce errors, such as thoroughly investigating initial impressions, identifying red flags, ruling out worst-case scenarios, and using clinical decision tools. History taking is especially important, as it can lead to the right diagnosis 80% of the time.

1. How Paramedics Think
Tom Fearnehough - YAS Paramedic in Sheffield

2. Learning objectives

To understand the thinking processes
paramedics use in clinical decision making.

To understand how clinical decision making
errors arise.

To understand how errors in clinical decision
making can be reduced.
BE CHALLENGED TO THINK ABOUT HOW YOU THINK!

3. A bat and a ball cost £1.10
The bat costs £1 more than the ball.
How much does the ball cost?

4. Errors in Clinical Decision Making
An Australian study (Wilson et al, 1999) found:

Over half of adverse events in a hospital
involved errors in clinical decision making.

These errors led to death or permanent disability
in at least 25% of patients.

Three quarters of these events were deemed
highly preventable.

5. Errors in Clinical Decision Making
WHY?
'Most errors in clinical reasoning are not caused
by incompetence or inadequate knowledge but
due to the frailty of human thinking under
conditions of complexity, uncertainty and
pressure of time' (Scott, 2009).

6. Paramedic Clinical Decision Making

The environment in which paramedics work
encourages them to make intuitive decisions
based on first impressions (Croskerry 2009).

An intuitive approach can be useful in reducing
reaction time and avoiding 'paralysis by
analysis' (Croskerry 2009).

However this approach is also prone to error.

7. Dual Process Theory
Dual process theory recognises the role of two
different thinking processes:

System 1 – intuitive (e.g. 2+2)

System 2 – analytical (e.g. 1824 / 8)
Both of these interact with each other and play an
important role in clinical decision making.

8. Dual Process Theory
(adapted from Coskerry 2009)
System 1 System 2
Cognitive style Intuitive Analytical
Speed Fast Slow
Effort Low High
Awareness Low High
Reliability Low High
Scientific rigour Low High
Bias High Low

9. Scenario

I had recently attended a number of patients
who had mechanical falls with no injuries and
had pressed their alarm pendant.

All of these patients had been left at home and
referred to the falls team.

Terrafix flashed up the message '82 year old
male – fallen – the patient is still on the floor'

10. Clinical Impression – mechanical fall
System 1 System 2
Cognitive style Intuitive Analytical
Speed Fast Slow
Effort Low High
Awareness Low High
Reliability Low High
Scientific rigour Low High
Bias High Low

11. Scenario (continued)

I was met at the door by a very apologetic lady
who says she only wanted the alarm company
to help her husband off the floor.

The patient was sat on the floor by the bed. He
said he slipped off the bed whilst trying to put
his socks on.

12. Clinical impression – Mechanical fall
System 1 System 2
Cognitive style Intuitive Analytical
Speed Fast Slow
Effort Low High
Awareness Low High
Reliability Low High
Scientific rigour Low High
Bias High Low

13. Scenario (continued)

I requested assistance to help lift the patient.

PMH – sciatica, arthritis

Medications – paracetamol

History
− increased sciatic type pain and lower back pain
since yesterday which prevented him doing his daily
walk to the newsagents.
− slipped off the bed whilst trying to put socks on.

14. Clinical impression – Mechanical fall
System 1 System 2
Cognitive style Intuitive Analytical
Speed Fast Slow
Effort Low High
Awareness Low High
Reliability Low High
Scientific rigour Low High
Bias High Low

15. Scenario (continued)

Observations – within normal parameters

Respiratory – normal

Abdominal – normal (no urinary symptoms*)

Cardiovascular – normal, ECG - NSR

Musculoskeletal – no injuries / normal range of
movement. Back pain and bilateral sciatic pain.

16. Clinical impression – Mechanical fall
System 1 System 2
Cognitive style Intuitive Analytical
Speed Fast Slow
Effort Low High
Awareness Low High
Reliability Low High
Scientific rigour Low High
Bias High Low

17. Scenario (continued)
Neurological assessment

FAST -ve / PEARL / CN II – XII intact.

Sensation / power / tone – both sides the same.

'Any numbness or tingling anywhere?'

18. Scenario (continued)
The patient replied 'I can't feel the toilet paper
when I wipe my bottom'.

19. Clinical impression – Suspected CES?
System 1 System 2
Cognitive style Intuitive Analytical
Speed Fast Slow
Effort Low High
Awareness Low High
Reliability Low High
Scientific rigour Low High
Bias High Low

20. Cauda Equina Syndrome

Cauda equina syndrome is caused by
compression of the nerve roots below the level
of spinal cord termination (L1/L2).

21. Awareness Test
How many passes does the
team in white make ?

23. 'History, History, History'

I could have become so absorbed in assessing
the patient that I missed a pertinent piece of
information from the patient's history. e.g.
saddle numbness.

Careful history taking can lead to the correct
diagnosis 80% of the time (Hampton 1975).

24. Premature Closure
Acceptance of a diagnosis before it has been fully
tested.
e.g. I could have diagnosed a simple mechanical
fall without further doing any further investigation.

25. Anchoring Bias
A tendency to fixate on first impressions and
select signs and symptoms that confirm this.
e.g. I could have focused on the fact that the
patient slipped onto the floor without feeling dizzy
or blacking out and ignored the back pain / saddle
numbness.

26. Availability Bias (type 1)
A tendency to accept a diagnosis based on a
number of recent cases that appear to be similar.
e.g. before even seeing the patient my instinct
told me 'it'll just be another patient who's had a
mechanical fall', because I'd attended a number
patients like that during the week.

27. Availability Bias (type 2)
A tendency to accept a diagnosis based of the
ease of recalling a memorable case.
e.g. I am at risk of diagnosing CES in every
patient with sciatica because I vividly recall this
case of CES.

28. Reducing Errors in Clinical Thinking
Test your initial diagnosis (hypothetical deductive
reasoning).
e.g. I think this patient had a mechanical fall and
does not require transport to hospital. Is there
anything in the patient's history, signs or
symptoms that prove or disprove this?

29. Reducing Errors in Clinical Thinking
Identify red flags.

e.g. if a patient complains of new or worsening
sciatic or back pain, enquire about saddle
numbness, difficulty passing urine and
incontinence.

commit red flags to memory!

30. Reducing Errors in Clinical Thinking
Rule out worse case scenarios.

e.g. you attend a patient who is hyperventilating
can you rule out the 8 differential diagnoses listed
in your aide mémoire?

Heart failure, acute asthma, chest infection, PE,
DKA, pneumothorax, drug overdose, MI.

31. Reducing Errors in Clinical Thinking
Use algorithms, clinical decision rules and scoring
systems (Type 2 thinking by proxy).

tools like these are proven to improve clinical
decision making (Grove et al 2000).

e.g. heart failure, PE, COPD, hyperventilation
syndrome, convulsions, sickle cell crisis...

32. And finally...

33. In Summary

Paramedics use type 1 and type 2 thinking
processes in clinical decision making.

Errors in clinical decision making are often
caused by thinking errors.

Strategies can be applied to clinical decision
making to reduce the likelihood of thinking
errors.

35. References

P Croskerry (2009). Clinical cognition and diagnostic error: Applications of a
dual process model of reasoning. Advances in Health Sciences Education:
Theory and Practice, 14 Suppl 1 , 27-35.

WM Grove, DH Zald, BS Lebow, BE Snitz, C Nelson (2000) Clinical Versus
Mechanical Prediction: A Meta-Analysis. Physiological Assessment, 2000,
Volume 12, No. 1, 19-30.

JR Hampton, MJG Harrison, JRA Mitchell, JS Prichard, C Seymour. Relative
Contributions of History-taking, Physical Examination, and Laboratory
Investigation to Diagnosis and Management of Medical Outpatients. British
Medical Journal, 1975, 2, 486-489.

I Scott (2009) Errors in clinical reasoning: causes and remedial strategies.
British Medical Journal, 2009, 338:b1860.

RM Wilson, BT Harrison, RW Gibberd, JD Hamilton (1999). An analysis of
causes of adverse events from quality in Australian health care study.
Medical Journal of Australia, 1999, 170:411-415.