An essential series on clinical decision-making on scene




Back in 2004, the Emergency Medicine Journal (EMJ) created a series entitled ‘The ABC of community emergency care’, which was designed to update general practitioners who were experienced in the field and to serve as an introduction to those new to emergency clinical decision-making.

The aim of the series was to describe the management of non-traumatic emergencies commonly encountered in community emergency care. It was aimed at doctors because it was generally GPs who managed patients with urgent care needs in the community.

However, following the changes to GP contracts that came into effect on 1 April 2004, many GPs opted out of providing certain services such as out-of-hours cover. NHS ambulance services became the first port of call for many patients who would previously have contacted their GP, and paramedics were being asked to provide a different level of service to non-emergency patients.

Today, paramedics are the first point of contact for a high number of patients with urgent care needs and it is reasonable to argue that clinical decision-making has never been so important and so challenging.

Paramedics are at the forefront of making decisions about patients with complex care needs and the consequences of incorrect decisions can be catastrophic for patients and paramedics alike.

Over the past 16 years, much has changed in terms of guidelines, technology, equipment and education for paramedics so it is apposite to offer an updated series to help with clinical decision-making in the face of ever-changing demands.

Throughout the series, key areas of clinical practice will be explored, taking a case presentation approach to replicate the information that is normally available en route to a case. Rather than dealing specifically with the management of a patient with an acute myocardial infarction, the series will adopt the approach to management of a patient with chest pain.

A growing body of evidence is available to support paramedic practice, although there are still large gaps in knowledge. Recommendations will be based upon the best evidence available and will be extrapolated from other professions or other fields of practice where necessary. Some areas still lack rigorous research evidence so recommendations here will be based on published consensus opinions.

Back in 2004, the EMJ said the key principle was doing ‘what is right for this patient, in this setting, with my skills, at this time’. Although 16 years have elapsed, we see no reason to change that mantra and strongly advocate that position. Just because an intervention can be made in the community setting does not mean that it should be undertaken. All decisions need to be taken in the best interests of the patient, not the clinician.

Scope of the series

The series will endeavour to address the key aspects of emergency and urgent care in the community setting, including an overview of trauma. Topics are set out in Box 1.

Box 1.Some series topicsPrimary survey positive patientEndocrine emergenciesChest painAcutely disturbed patientAssessing trauma: ABCDETransient loss of consciousnessRespiratory problemsCardiac arrhythmia emergenciesFalls and the elderlyNeurological emergenciesPoisoningDermatological conditionsGynaecology and obstetricsFever, nausea and vomitingDrowning emergenciesUnwell childPaediatric emergenciesMusculoskeletal problemsDisaster managementSystems design, communicationa and ethicsPreventing avoidable use of urgent care servicesRelieving pressure on A&E with technologyArtificial intelligence and health coachingAnd more!

Format

The format will reflect the approach adopted by the EMJ as little has changed in that respect; however, additional topics will be included. Most patients normally fit into three groups:

  • Those with an immediately life/limb-threatening illness/injury who require resuscitation and immediate transportation
  • Those with a condition requiring urgent transportation to hospital with essential treatment provided en route/on scene
  • Those where a fuller assessment is needed to decide on the most appropriate course of management.

The priority is to identify patients in the first categories, then move to a deeper assessment of patients for whom immediate transportation to hospital is not indicated. The majority of patients do not present with immediately life/limb-threatening conditions so a thorough assessment will be required on most occasions.

It is worth noting that there may be no single correct answer to any particular situation as variables such as clinician experience, access to clinical support, distance to hospital and availability of other services will influence any decision. The principles outlined in this series need to be applied in the context of each individual situation.

Each case presentation will be explored in the following manner:

  • Identification and management of the ‘primary survey positive’ patient
  • Identification and management of the patient who obviously requires hospital treatment
  • Assessment and decision-making for patients for whom transportation to hospital is not immediately indicated.

While this series presents a systematic approach to patients, it is not the only approach that can be adopted. Clinicians need to apply all of these principles in the context of their own experience and education, and within the wider context of healthcare within their particular area of practice.

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