Here at St Emlyn’s we have often talked about decisions and decision complexity. Our belief is that one of the key attributes of the clinician who works in emergency care is the ability to make decisions on limited information, with significant time pressure. I have personally argued that this is perhaps the defining characteristic of a good resuscitation clinician. You can read more about our past musing on this here. Those thoughts were very much based on my observation of behaviours in the ED resus room and I’m sure that you can think of situations and clinicians who exemplify this need in practice. The key characteristic of time critical, information light decision making is that it takes place early in a patient’s journey and not through the eyes of an omnipotent retrospectoscope applied at the subsequent debrief.
The time pressure in decision making is further amplified when working in the prehospital setting where we see patients closer to the time of injury/onset. There is even less opportunity to use time, repeated observation, or clinical course to guide key decisions such as the need to deliver key interventions. One decision that is often debated amongst the clinicians I work with is the decision as to whether to give blood products in the prehospital setting. It’s a fascinating debate to be had with many moving parts influencing decisions, but despite the complexity and uncertainty a decision still needs to be made. You either give the blood products, or you don’t, but how do we decide is complex, or at least it is for me. How then do the expert and experienced decide?
This month there is a nice paper in the EMJ that explores expert decision making in prehospital care and it’s definitely worth a read if you’re interested in the blood transfusion in trauma, but also (perhaps more so) if you’re interested in expert decision making in emergency care. The abstract is below, but as always please read the full paper yourself and come to your own conclusions.
What kind of paper is this?
This is a qualitative paper examining decision making amongst senior clinicians. Many of us from a medical background struggle with qualitative papers as we come from a positivist background, but they are now rightly recognised as important contributions to the medical literature. My very basic belief is that whilst most papers seek to tell us ‘what’ is happening a good qualitative paper may have a better methodology to explain ‘why’.
There are many qualitative methodologies that can be applied to a question (as there are with quantitative studies), and in this paper they have used an inductive thematic analysis. This essentially means that they interviewed experts and then looked for themes to explain decision making, and that those themes were not predetermined, but were inducted as part of the process. The method description in this paper is worth a read for anyone interested in qualitative studies, it walks the reader through the process quite well (so a good one for your journal club). I particularly liked the declaration of researcher perspectives in the methods, and of course the shout out to Kahneman and (more importantly IMHO) Klein.
Who was studied?
The authors interviewed 10 experienced pre-hospital physicians defined as more than 5-year’s experience at two UK air ambulance services that carry blood products. The majority were from an emergency medicine background, and were 90% male. The authors used a semi-structured interview model with starting questions determined in advance. The questions were designed to explore decision making on administering blood products.
What did they find?
The authors found three main themes and a number of sub themes that influence decision making which (I hope) will be familiar to many of us.
- Recognition Primed Decision Making. The participants use past experience/learning/guidelines/expectations to guide decisions. There is a lot here to unpick about how the varied factors that influence that decision interlink and influence. I found it really interesting that some decisions are influenced by the potential for post hoc scrutiny. That’s true in all settings, but perhaps more so in PHEM where we discuss a much greater percentage of cases. However, in systems with imperfect feedback systems that might present challenges.
- Uncertainty. Participants expressed that decisions were complicated by a lack of clarity on the impact of transfusion on the patient and also on whether the patient would be the best candidate.
- Imperfect decision analysis. Participants do not have clarity on the true impact of interventions which in itself impacts the two themes above. An inability to close the loop on the impact of this (or any) intervention is of course a barrier to decision making in itself.
As with many qualitative studies there is rich data in the quotes and they are worth reading in the main paper (abstracts rarely do qual studies justice IMHO).
What does this paper tell us?
At first glance one might think that the conclusion here is that decision making is difficult, imperfect and uncertain, and the results do support this. However, there is more here that may help us think about how we train prehospital clinicians and how we explore and review decisions in practice.
The finding that clinicians use recognition primed decision making is in keeping with other work in this area, and reflects how expertise and experience is a factor in the time critical information light decision making processes we discussed earlier. Klein, who developed this approach talks of how such processes can be taught and developed using techniques such as ‘Shadow-Boxing’, something adopted by Scott Weingart on EMCRIT and by others in this area.
Decision making in uncertain times may be one of the more challenging areas for us to develop in ourselves and in our trainees, but I would argue it is one of the most important skills to analyse, develop and feedback on. This paper reinforces my belief that we really need to train ourselves and our future colleagues in complex decision making. It really is a key attribute of the emergency clinician.
References and further reading.
- Understanding pre-hospital blood transfusion decision-making for injured patients: an interview study Bagga R, et al. Emerg Med J Epub ahead of print: . doi:10.1136/ emermed-2023-213086
- Simon Carley, “Risk, probability and decisions in Emergency Medicine. St.Emlyn’s,” in St.Emlyn’s, November 16, 2017, https://www.stemlynsblog.org/risk-probability-decisions-emergency-medicine-st-emlyns/.
- Simon Carley, “Decisions, oscillations and damping. St Emlyn’s,” in St.Emlyn’s, October 5, 2022, https://www.stemlynsblog.org/decisions-oscillations-and-damping-st-emlyns/.
- Simon Carley, “Making good decisions in the ED. #RCEM15 #EuSEM15,” in St.Emlyn’s, October 13, 2015, https://www.stemlynsblog.org/making-good-decisions-in-the-ed-rcem15/.
- Scott Weingart, MD FCCM. EMCrit 314 – ShadowBoxing Case 1 – In the end, it’s always…. EMCrit Blog. Published on December 30, 2021. Accessed on December 7th 2023. Available at [https://emcrit.org/emcrit/shadowboxing-1/ ].
- Klein. Streetlights and Shadows. https://www.goodreads.com/book/show/6470232-streetlights-and-shadows