One of the biggest fears I hear paramedics talking about is of discovering that a patient they discharged on-scene has just been rushed to hospital in cardiac arrest— and the subsequent investigation. With complaints against health professionals on the rise and paramedics featuring in the top two league tables for fitness-to-practise cases, this concern is easily understandable (Bright, 2012; Gallagher et al, 2018).
Decision Making in Paramedic Practice attempts to arm the paramedic with the confidence to make sound decisions while raising awareness of the associated pitfalls. The foreword is written by Andy Newton, chair of the College of Paramedics, who claims that ‘the time is right for this book’ mainly because of the rapidly changing epidemiologic context of our time and the fact that patient complexity is increasing—ultimately requiring the paramedic to be able to treat and discharge at scene. However, I would suggest this book is ahead of its time.
The decisions that paramedics are able to make are still somewhat restricted within some ambulance services. The requirement to apply rational decision-making tools such as Pathfinder or the Manchester Triage System have been found to reduce flexibility and be time-consuming (Woodford, 2015).
The author, Andy Collen, progressed to the position of consultant paramedic via the traditional route, as well as having embarked on higher education by achieving a Masters degree. He clearly has a wealth of experience both within the ambulance service and primary care. This experience is evident from the first chapter, which explores the development of the profession.
Objectives at the start of each chapter link to reflective exercises at the end. This structure runs through the book, providing the opportunity for the reader to complete continuing professional development (CPD) evidence.
The Health and Care Professions Council (HCPC) is also addressed and this section attempts to provide some reassurance should you happen to be called to a hearing. Although this subject is not covered in depth, there is enough information to give a comprehensive overview. There are a few familiar quotes cited such as ‘listen to your patient, they're telling you the diagnosis’, crews being ‘unconsciously incompetent’, and discussing the patient's best interests compared with the crew's best interest. These are terms and phrases you may have come across before. However, there is a good reason for this reiteration—they are true and paramedics should consider them.
The author makes a stand-out comment early on in the text which really made me stop and think. He claims it's a privilege that we have to save lives, but poses the question: ‘is this something we take for granted?’ I think it probably is. Many of you reading this have indeed saved a life—and that's quite a spectacular thing to have done.
Critical thinking is a crucial aspect of decision-making and the chapter covering this topic starts with a loud ‘CAUTION’ warning. As you read, you may find yourself challenging what you believe with regards to making decisions. This is a little melodramatic, but what follows is a detailed chapter using non-paramedic examples ranging from the Klu Klux Klan (KKK), Humpty Dumpty and a recipe for meringue! The first example is used to challenge our notion of what we believe to be true, accurate and correct: this is achieved by explaining that the families born into the KKK had no moral frame of reference to allow them to form a reasonable balanced alternative view. For the latter two examples, the reader is asked to find an obvious link, that being the ‘eggs’. We are then requested to think critically in an attempt to demonstrate that if we challenge our instinctive responses, we can be confident when looking for red flags—in other words, we must look for them until we can prove there aren't any.
If you have not come across human factors and its implications in the clinical world, this is a good starting point. The example used may be familiar and relates to Martin Bromley's work. It is the tragic story of a ‘routine operation’ which sadly ended in the death Martin Bromley's wife. Following this event, Martin embarked on a mission to change the safety culture within the NHS by focusing on human factors. It is a fine example and now features in some of the mandatory training delivered by the North West Ambulance Service. The take-home message is that we are encouraged to create a learning culture rather than a blame culture.
Many of the points raised appear to be common sense but the text gives them academic backing and reasoning. Finally, the theories behind bias, optimism and anchoring are explored. Again, real-life examples are used to explore 13 different kinds of bias.
We are asked to consider if a white male from Los Angeles who has committed two murders is more likely to be a Hell's Angel or a lawyer. We are then presented with statistics to make us consider both options. This demonstrates that, like in health care where rare things happen (rarely), the most likely outcome is most likely.
Despite the reassurance at the beginning of the book around the HCPC and its potential involvement in investigations, we are presented with the HCPC standards during a discussion around the ‘garden path test’: if you are immediately doubting yourself when you leave your patient and considering the consequences if things go wrong, you have made the wrong decision. This feels a little like a warning, and a reminder of the potential consequences.
Before we are presented with five detailed case studies to apply what we have learned, the author drives home the message that we should be making decisions based on enquiry, testing the method: retest, reject or accept. The simple reason is that we are human and have the potential to be wrong. An interesting example is given on the statistics of base jumping (jumping from very tall buildings with a parachute on): those who make mistakes tend to be novice or very experienced as opposed to those in between. This is explained well and supported by a chart demonstrating the Dunning Kruger effect, showing that there are significant dangers of being unskilled and unaware of it. It is vital to recognise one's own incompetence and not allow it to lead to inflated self-assessments.
The five case studies which appear at the end of the book are well-structured. They enable the reader to consider bias and fallacies, which link back to chapter four; what would happen if the correct or wrong decision was made; and concludes with ethical and legal aspects. Despite not being a clinically-focused book, the case studies hold some interesting and thought-provoking clinical aspects. This is a really nice touch and assists the reader to apply the decision-making process.