Heuristics are nothing more than decisional shortcuts and we use them all of the time. Heuristics are practical, but they are not always optimal. They help you make quick decisions, but they come at the cost of potential inaccuracy and bias. Many different types of heuristics exist, and you use them more often than you might think. In the Fire/EMS industry we have to make quick decisions every shift. Think about a time in your personal or professional life when you may have done the following:
Made a decision based on the information readily available to you at the moment, rather than ALL of the possible information?
Made a decision based on emotions, rather than objective information?
Based your opinion of someone based on what things OTHERS have said about an individual?
Take a familiar route to the hospital, even though there may be another way that is faster?
Attempting to guess or forecast how a patient may do, based on previous experiences?
You guessed it - all of the above bullet points are great examples of heuristics.
This blog will explore their place in the complex medical decision-making process.
You are a pre-hospital clinician - don't let anyone else dispute that fact. You've earned it.
As a clinician, you must make diagnostic treatment decisions using a large body of probabilistic information and process this information under the pressure of time and workload. Many times, you are in the back of the ambulance by yourself. The pressure of this task is thought to result in mental shortcuts, otherwise known as heuristic decision-making. The same could be said of a busy ED physician, or an intensivist in the ICU ward.
Revert back to your initial education and training. You learned a bunch of algorithms to help assist you with decisions. These decisions could have been related to the best definitive destination to send a trauma or stroke patient. Based on the example below, you could have also used heuristics to triage many patients in an MCI scenario.
These heuristics can be considered a tool and like any other tool they come with risks and benefits. Contrary to popular belief, sometimes less information is more. I once had a veteran ED doctor tell me to quick looking for the zebra in a field of horses. Fortunately, when somebody gets sick, the trouble is usually something common, not one of those exotic diseases they dramatize in medic schools.
I would just caution you though -- don't overuse them or rely solely on them as they can burn you. Always keep an open mind as even those frequent fliers can get sick too. Be able to step away from the heuristics on occasion to avoid catastrophe. So -- what can you do to prevent cognitive errors from resulting in actual medical mistakes?
Be more analytical and less intuitive in your thinking.
Explicitly consider and rule out three alternative diagnoses, even if all evidence seems to agree with the first differential diagnosis that comes to mind. (Maybe the hypotension and tachycardia are being caused by something other than internal hemorrhage)
Reconsider the problem when we find ourselves repeating the same therapeutic maneuver 2-3x with no improvement in the patient condition. Maybe the 3rd dose of Narcan isn't the answer -- they could be hypoglycemic right??
Do not discard or minimize the value of your repeat/ongoing patient assessments. Maybe your first impression isn't quite right and that's OK if you as the provider realize it and switch gears. Don't always stereotype clinical presentations
Summarize OUT LOUD
Feel safe in verbally collaborating with your colleagues both at the station and at the hospital. Asking for help can provide us immediate relief -- both with physical and mental tasks.
Utilize checklists and content relevant cognitive aids (Handtevy) as they can help us deliver the best care to our patients in times of crisis.
August 19, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC
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