BIAS ISSUES OF ANOTHER KIND
July 27, 2015
By Art Braunschweiger
There is a fundamental principle of EMD at the core of what we do: “EMDs don’t diagnose.” Most EDs know that but frequently do it without realizing it. Today I admit to a certain feeling of smugness in having proved that this principle is a sound one. Recently, it might have saved a life.
The call was from a woman who dialed 9-1-1 for her 92-year-old father suffering from a panic attack. She volunteered that he had a history of these. Awake and Breathing? Yes to both. Completely alert? Yes. Breathing normally? “Yes, but a little bit rough.” “What do you mean ‘a little bit rough?’” “Well, his breathing is a little labored, but that’s just because he’s panicked.” The EMD correctly sent an Advanced Life Support (ALS) unit anyway, in addition to the Basic Life Support (BLS) ambulance. It was a good thing he did, because the BLS crew reported CPR in progress within a minute of their arrival.
In my world, BLS and ALS are separate resources, and an anxiety attack with difficulty breathing requires both. It’s not uncommon to hear dispatchers gripe about sending resources when they “know” they’re not needed, and I’ve yet to meet a paramedic who responds enthusiastically to that kind of call. Most of the time, the BLS crew cancels the ALS providers. On this particular call, with those odds and the patient’s history, it would have been easy to agree with the caller’s diagnosis and dispatch a BLS ambulance without paramedics. Good thing we didn’t.
Some diagnoses are very tempting to make, such as the patient who’s not fully alert after he’s been drinking alcohol. “He’s just intoxicated.” Dispatch an ALS responder for him, and some dispatchers practically scream “waste of resources” or mutter about ProQA being flawed because it “overcodes” those calls. There’s no question that certain calls have a very high cancellation rate. At the same time, symptoms like difficulty breathing or a decreased level of consciousness aren’t things an EMS system—or an EMD—can afford to take chances on. We’re supposed to focus and base our dispatch decisions on the presence or absence of critical symptoms. Unfortunately, it doesn’t always happen that way.
Human nature seems to predispose us to drawing conclusions that may be in error. In his espionage novel “Red Cell,” author Mark Henshaw wrote, “Evolution, or God depending on your preference, has left us with brains that latch on to the first explanation that seems to fit the facts and our own mindsets and biases when we face a puzzle. Even smart analysts develop shallow, comfortable ruts.” Being biased by the caller’s diagnosis is a trap we fall into very easily. We think, “I’m not there, and the caller is, and he/she knows the patient, and I don’t.”
Another bias to guard against is being unduly influenced by the patient’s history. Every dispatch center has its “frequent flier.” The term is uniquely American and borrowed from the early days of the commercial airlines’ mileage rewards programs. A frequent flier is a repeat patient who calls in for the same thing all the time. You know him (probably by his first name), the responders know him, and he almost always declines transport to the hospital. The next time he calls, it’s very tempting to withhold the resources he would get if he was a new and unknown patient.
Every dispatch has to be based on clinical criteria and not influenced by fear of being labeled overcautious by our responders or fellow dispatchers. If you withhold a resource that should be sent, you’re betting your job that you won’t be wrong. Are you willing to make that bet? I bet you’re not.
Henshaw, M. Red Cell. Simon & Schuster; New York. 2012.