For Every Proposed Intervention, a Risk-to-Benefit Analysis MUST Occur
Reaching the heights of Bloom’s taxonomy (application, analysis, evaluation type skills) is challenging both for the educator and the learner. Our responsibility to teach clinical judgment becomes abundantly evident when we hear that EMS graduates feel “under-prepared” to practice specifically in the so-called “soft skills”. And now, educators have another motivator: the NREMT Clinical Judgment questions on the cognitive exam.
The title really sums up a straight-forward practice: always, always, always ask your EMS students to compare the risks of a proposed intervention against the risks of NOT doing the intervention. If the risk seems too heavy, then examine the expected benefit(s). I’ll refer to this as “risk-to-benefit” analysis, but the process is MUCH easier on newbies if you start with a simpler “go, no-go” comparison–once they gain clinical experience, they’ll better be able to predict benefits and can then slot that info in to their analysis.
I’ve successfully utilized this simple process for decades, and the key to success if consistency. Teaching a mental process is EXACTLY like teaching a physical one: instruct, observe the student do it, give feedback. Routinely practicing analysis naturally molds a clinician who does not just do an intervention “because it is in the protocol book” but because it is the best decision for the patient. When the risks are too heavy, we do NOT do the intervention. When the benefits are critical, we MUST do the intervention.
Clinical Judgment is never “black and white” or “if this, then do this” which makes students VERY uncomfortable…perhaps you feel that same discomfort? It is SO much easier to teach things which only require regurgitation. However, teaching HOW to think is where YOUR skill as a facilitator is critical: as we mentioned in our first Clinical Judgment article (HERE), you must master the art of keeping your mouth shut long enough for students’ brains to engage but not so long that they get discouraged and give up. Think of a small child learning to ride a bike–YOU are the training wheels which guard against full bloody falls.
How it Works
Habits–we want to build good (and virtually inescapable) habits. As stated in our “Gimme Five (DDx)” article, by approaching patient cases and scenarios the same way every time, we establish a process. Once built, this becomes the default by which students (graduates) think about care…whatever the educator forms in the early (“formative”) stages of curriculum will be very difficult for the student to break or escape (in law enforcement they call early instructional errors “training scars”). And THAT is why WE must be so careful and prepared.
Establish the Mental Model and Procedure
First, you’ll need to introduce and establish the mental model–this can be done well before the students have any idea of possible treatments. Remember, students don’t yet realize that they’ve signed up to make the critical decisions with minimal and incomplete information–the mystery factors which can produce unexpected complications is a unique part of the EMS equation which must be considered by EMS providers.
Risk-to-benefit analysis can be applied to any number of non-medical situations. This helps students get the flow and rhythm before adding in the challenges of medical vocabulary and complex physiology. When we’re engineering our curriculum, we must focus on baby steps and digestible bites.
- Your fresh home-baked cookies are not quite done when the timer goes off. Consider the “intervention” of leaving the cookies in the oven. What is the benefit? What are the risks? Would it be better to NOT intervene (and take them out at the prescribed time)? What are the risks of NOT leaving them in (undercooked might have salmonella from the eggs or simply a mushy center)? Are there benefits to not intervening (no chance of burning)?
- You’re on the freeway driving 75 MPH. You are imminently about to pass a car in the right-hand lane ahead of you going significantly slower and weaving some.
- What are the possible interventions? (Slow down? Notify authorities?)
- Complete a risk-to-benefit analysis of each intervention as well as the risks/benefits of non-intervention (keep going as you presently are and pass).
- Which do you choose and why?
In this way we’re already establishing the analytical thinking required to develop excellent clinical judgment. You could develop a whole series of these non-medical risk-to-benefit analytical activities to allow students to establish the pattern within familiar contexts before trying to do it in medicine.
Establish Working Field Diagnosis
Next, you’ll want to establish a pattern of always considering the differential diagnoses (DDx) and choosing a “working field diagnosis.” This is the FIRST step in assessing risk-to-benefit probability–how certain are we that our field Dx is correct? A low-certainty working field diagnosis means an increased allowance for risk. That is, the more uncertain we are that our mental model accurately reflects what is wrong with the patient, the greater the “unknown risk” cushion we must work into our analysis.
Proponents of “assessment-based management” may argue that the condition doesn’t need a “name” to be effectively treated. I agree. However, if one cannot hypothesize about the underlying pathophysiology, then treatments cannot be precisely targeted nor can expected responses be predicted.
Therefore, when I say “working Field Dx” I mean not a Merck Manual name of condition but rather a mental model of the underlying mechanics producing the observed patient condition.
As a side note: this step can be used to stress how critical it is that students master the physiology and pathophysiology of common medical and trauma issues. If you don’t have a catalogue of possibilities in your head, you have already failed the first need: finding a direction. The DDx is our compass which helps us navigate a pathway to improving the patient’s condition. Without it we fall prey to common clinical errors.
Evaluate RISKS of Proposed Interventions
Every medical intervention has inherent risk. We can forget that. Think about the routine starting of IVs. Unless we rigorously apply the risk-to-benefit analysis, we may not think twice about, say, stabbing a cancer patient on heavy chemo with a depressed immune system. If the patient is not in imminent need of fluid or pharmacological support, is exposing them to this procedure in the back of an ambulance truly worth the risk of introducing a bacteria they are unable to fight off?
Our “Medical Risk Analysis” chart is an adaptation of what exists in the literature though with a different X-axis. Basically, we’re comparing the risks of doing some selected intervention against the risks of NOT doing that intervention.
Wait! What if we have 5 possible interventions? Shouldn’t we compare them against each other?
Eventually, yes, but in the beginning it is too much cognitive load for a student to try to consider all possible interventions at once. We must focus on making the initial exposure manageable for our students: is this intervention worth the risk to this patient?
If we discard it due to too much risk, we can always revisit it later if we fail to find a suitable (safer) alternative intervention.
It should be conveyed that time (and decline in patient condition) can alter our analytical outcomes. An intervention which might be considered too risky early in patient contact might suddenly be unavoidable as the patient approaches arrest or even peri-arrest.
The list we’ve provided here of “Factors to Consider During Risk Analysis” is incomplete, but it is a sufficient starting place when introducing the concept of risk-to-benefit analysis to students.
We’ve already considered how greater uncertainty of field Dx increases the “black box mystery” of any interventions we consider. Severity of the patient’s present condition will help us determine how aggressive we need to be–the sicker the patient, the greater risk is justified if the benefit might just save them. It’s like we say when teaching CPR and someone worries about “hurting” the pt–they’re already dead; impossible to hurt them.
Provider (in)experience with the intervention should generate quite a robust discussion. Examples of procedures which generate significant provider anxiety would be drug-assisted intubation (DAI; or RSI depending on your region), initiation of intraosseous access on an awake patient, and administration of narcotics. Here, we can discuss when, why, and how we can be forced to gather up our courage and “just do it” when a patient life is on the line...and when that same decision is irresponsible.
Adequate number of personnel might include both the number needed to initiate an intervention as well as “best practice” when attempting riskier things. For example, some services require that a supervisor be on scene for a DAI as a backup safety-net; sometimes even the “airway gurus” have an off day! In the same vein–does the “backup equipment/resources” provide adequate ventilation should the DAI fail?
And finally, if we have some other option which is stronger (less risk, greater benefit) then we should opt for that one.
What Are the Expected Benefits?
I consider “Interfering with end-organ damage” to be THE number one goal of prehospital interventions. It is a simple and clean goal applicable to all patients. It helps student think about the physiological benefits of any proposed intervention. It also builds in a consideration of where the patient is on their march towards death (also known as stages of shock or shock progression).
As society learns more about anxiety and pain, the management of these increases in necessity. Keep in mind that your students may struggle with “old-timers” who maintain that, “Nobody ever died of pain,” but the science is showing us that is not necessarily the best metric. Again, all interventions come with risk–in these cases, though, provider ignorance is actually one of the most significant risk factors…ignorance to the benefits might mean that the provider gives their own fear and/or misgivings undeserved weight.
Kicking the Ant Pile...
Should we consider “Distance to Destination” in our analysis? When I asked this question on social media, my feed was filled with terrible stories of lazy paramedics who didn’t want to do interventions for one reason: “the hospital is SO close.” This “rationale” makes every dedicated provider want to crawl under a table in embarrassment.
That said, perhaps we educators can actually make a difference in future attitudes by ensuring the DELAYS of the ED are routinely considered. In this way, we offer the flipside of the coin that inexperienced students need to understand. Furthermore, when considering the actual “transport” and destination decision as interventions, distance is a critical factor. For example, can you justify bypassing a closer facility seeking to reach the closest stroke center if your stroke patient has an unstable airway? For these reasons we cannot neglect distance as a factor–just so long as it is never the sole deciding factor for not doing something of benefit to our patients.
Medicine-proper could use more of this type of thinking. I said what I said. It seems that folks who practice “brick and mortar” medicine have become so reliant on tests and images that they’ve forgotten how some things actually work. Maybe some day I’ll tell you about the EIGHT different ED docs and countless nurses who could not even speculate about an answer to a question regarding respiratory rates in metabolic acidosis…
Stay tuned: this is the second in a planned series of articles on development of clinical judgment in EMS students. Look for our next article which will have some samples of our “Critical Thinking” in-class discussions which have been reversed engineered to develop clinical excellence WHILE teaching the biological, assessment, and interventional material using experiential learning! You can find the first in the series (utilizing differential diagnosis as a starting point) HERE.