The decision is yours

The paramedic role requires pre-hospital clinicians to make countless sound, logical and sensible decisions. In any healthcare setting, these decisions are related to the welfare, treatment and safety of a person, and this should not be forgotten. Sometimes paramedics may be faced with decisions that they feel less confident about making. However, concluding that not having the necessary skills, knowledge, or information to do so is not being indecisive; rather, it is sensible and safe, and shows good clinical judgement. Judgement is a term that is almost synonymous with the process of decision making, and is associated with carefully considering a situation before arriving at a course of action. It is something that is required in the vast majority of clinical scenarios.

Decision making is a cognitive process, and no matter which model is adopted, the judgement is almost always based on sound reasoning: that is, it is rational. One approach to decision making is rule based or algorithmic. Here, choices are made using a set of rules, policies or protocols. The decision maker must select the correct rule to apply based on the specifics of the case presented to them. The use of algorithms should reduce risk and inconsistency, and ensure relevant information is used when making a judgement (Thompson and Dowding, 2002). There can, however, be concern that the rules are not flexible enough, or that the wrong rule could be applied. The algorithm approach is safe as long as the patient is not atypical or misread by the clinician. It does not allow for any deviation from the prescribed course of action, and clinician thinking or exploration is limited. Hadorn et al (1992) even relate algorithmic use to rigidity and the production of robots who do not think for themselves. To be clinically valid, algorithms need to be rooted in actual data and have an ability to deal with inherent uncertainties (Kassirer and Kopelman, 1990). Risk is addressed using strategies such as clinical assessment tools or decision trees, which encourage logical processing of available data.