There is no greater enemy to a paramedic than time. We are constantly fighting the clock, whether it be response, assessment, treatment, or transport times. We are taught from day one that we are racing the clock, that patients benefit the most from arriving at the hospital as quickly as possible. We are taught the importance of rapid assessment, decision-making and treatment. In such a world, idleness or inaction are our enemy and we must constantly be doing something. But how rapid is rapid? Do all situations require split-second decision-making and action? Or is there room for thought, discussion, and debate? Is a fast treatment better than a slower, but more precise, treatment?
Thinking of decision-making concepts such as the Observe, Orient, Decide, Act (OODA) Loop, there is a definite benefit to the ability to rapidly take in information, orient resources, make a decision, and act. The OODA loop, however, was designed with an aerial dogfight in mind, so there are limitations to how accurately it reflects EMS practice. If we frame the enemy as a disease process, then we must also adjust the amount of time necessary to act before it starts to out-act us. On the one hand, we have the obvious examples of split-second reactions needed for a cardiac arrest, where seconds and minutes will have significant impacts. But what about grayer examples, such as a heart attack, stroke or infection? These patients will still require timely care, but what if we are rushing our expectations for what a timely response actually is? Can we permit ourselves a few extra seconds or a minute to assess the patient, work through our differentials and treatment plans, and make a plan?
Scenarios, whether simulated or live, suffer from significant time restrictions. Treating or stabilizing a patient can take a significant length of time, whether in a pre-hospital or inter-hospital setting. It would take significantly longer to test each student if scenarios were real-time, especially as we move to more advanced scopes of practice, so the focus is instead on the decision-making at critical junctures - a change in patient condition, a response to a treatment, a lack of response to a treatment.
By focusing on these critical junctures, however, we miss the periods of time between them. Deciding to act is (relatively) easy, but orienting resources ahead of time to enable the action is not. It may take seconds to realize that a patient needs a treatment, but the treatment may take minutes to prepare, minutes that may now be in short supply. Identifying these needs ahead of time and preparing for them is something that scenarios often fall short on.
We also miss out on developing the patience needed in practice. Depending on the treatment, we may need to wait for quite a while to see an effect. I can recall many times when, in a scenario, we are rapidly prompted with the response after initiating a treatment. “No effect”, we are told, immediately afterwards, or “5 minutes later, no change.” We may be implying the passage of time, but 5 minutes is very different in practice, especially if we are hoping for a significant change.
Most problematic, it creates a reactive mentality. Rather than anticipating complications, practitioners wait until they are prompted, acknowledge the issue and then begin to orient a response. Depending on the scope of practice or patient condition, this may be an appropriate way to react, but with a more critical patient or a higher scope of practice, there is less room and more consequences for reactivity.
We can improve decision-making in practice by providing students with longer, more accurate scenarios, allowing practitioners time to conduct an assessment, put the pieces together, and make a plan at their own pace. We should also prioritize forward thinking, preparing equipment for a situation that may or may not come to pass, to create a better understanding of how long procedures may take to orient prior to acting.