Outcome vs. Input Thinking

What makes an excellent clinician so good?

How do “rockstar” paramedics make resuscitating crashing patients look so easy?

As a paramedic educator, I spend a lot of time pondering these questions and looking for the “magic bullet” answers. We are gearing up for our paramedic course starting next month, and I was talking with our senior educator, Rob Atripaldi, about curriculum design differences for psychomotor versus cognitive knowledge domains. Rob had an epiphany—he identified that a key difference between the master paramedic and the typical paramedic was a difference of approach.

The master paramedic approaches resuscitation situations by identifying what outcome they want to see, while the typical paramedic instead starts by deciding what treatments are indicated.

Here’s an example: You respond to a 67-year-old female patient experiencing a severe COPD exacerbation. She’s been struggling to breathe and using her rescue inhaler for the past two hours, but her energy is just about gone, and she tells you, 1–2 words at a time, that she cannot breathe. Your initial assessment is not great—her airway looks good, Mallampati of +3, but her breathing is rapid, shallow, with severe wheezing in upper lobes and diminished breath sounds in lower lobes. Her vital signs don’t look too hot either: HR 122, RR 28, BP 160/80, SpO2 72% on room air, ETCO2 581.

Any competent paramedic is going to pretty quickly recognize that this is a sick patient who needs immediate treatment. The typical paramedic is going to begin thinking about the skills or interventions indicated for this patient—maybe thinking “Albuterol, Combivent, Solu-medrol…” and of course Oxygen, IV, 12-lead, monitor. As the patient continues to deteriorate, the medic may then start thinking about RSI and prepare to intubate.

The master paramedic is going to think differently, working backward from the desired outcome. She’s going to start by framing this respiratory failure patient as a ventilation problem leading to an oxygenation problem. The oxygenation problem can be temporarily patched by increasing FiO2 using an oxygen mask; her assessment will lead her to identify the causes of the ventilation problem—probably bronchoconstriction with or without excess mucus production2.

Next, she will choose the optimal tools to resolve the bronchoconstriction. Perhaps this will involve inhaled beta-agonists, maybe pressure-support from CPAP—the point is that she is picking tools not by matching their indications to the patient’s current condition but instead by matching their effects to the problems she is trying to fix. The master paramedic has a clear vision of the outcome she is aiming for, identifies the pathophysiologic issues keeping the patient from that outcome, and then picks the best tools to fix those problems.

In most cases, these two approaches produce similar treatment plans and similar results. However, in the critical patient with unexpected complications, an outcome focus better equips the clinician to react appropriately. A skills or treatment indication focus sets the paramedic up to fixate on the treatment, not on the result. This anchoring can lead the paramedic to ignore changes in patient status or fail to recognise treatment failures.

A prime example is in airway management: Let’s say that the patient above continues to decline, despite our intervention. Having passed the point of respiratory failure, she now begins to lose consciousness, and her breathing starts to slow. Recognizing this, our typical paramedic sets up for RSI, pushes the medication, and inserts a laryngoscope. The patient’s airway is challenging, but no worries—our paramedic has practiced intubation every morning at his station and is confident he can get the tube. However, after two attempts, the patient’s SpO2 is hovering in the 80s, her heart rate has begun slowing, and the paramedic can’t seem to get the equipment to cooperate. Anchoring leads the paramedic—and in fact, the entire team—to fixate on “getting the tube,” and they keep trying different tricks until finally, they use a bougie and a video laryngoscope to place an ET tube successfully. Just in time, in fact, because when they look up at the monitor they see V-Fib, and a quick pulse check reveals the patient has coded.

Now, this is not a typical case, but it is a typical response to an unexpected complication. The literature describes these types of scenarios and my personal experience reviewing hundreds of RSIs confirms it. Anchoring is dangerous—potentially fatal when performing RSI.

The outcome-focused paramedic is not immune to these biases, but a little more protected. She fixates on the desired outcome, which fundamentally is a patient with a patent and protected airway, adequate ventilation, adequate oxygenation, and adequate perfusion. When the patient begins to decline, our paramedic recognizes that the priority problem is now airway protection, and she can start picking treatments based on that goal. Her initial treatment choices might be the same as above, but being outcome-focused would predispose her to abandon futile intubation attempts when they are not getting her any closer to her outcome goal.

So how do you teach an outcome-focused approach, especially when paramedic curriculum is overwhelmingly skills-driven?

Stay tuned—some ideas for that are coming.

  1. If you aren’t monitoring ETCO2 right away in your respiratory patients, you ought to. An initial pre-treatment value < 28 or > 50 is a huge red flag.
  2. This is an important distinction to guide the use of an anticholinergic such as ipratropium (Atrovent). History and breath sounds are important information here.

3 thoughts on “Outcome vs. Input Thinking

  1. Gonna get real old-school here and float the “nasal intubation” boat on this + ghetto BiPap (or real BiPap, if we got a vent). Also worth considering IM epinephrine for this patient in order to get some rapid beta-2 agonist effects quickly, without having to rely on albuterol to maybe trickle into lungs.

    Epi + NIPPV + airway PRN FTW (we hope).

    On a conceptual level, I agree, and I detest paramedic educations that go ‘follow the acronym’ or whatnot (the V.O.M.I.T. method). I’m a big fan of education to the standard of identifying and fixing the problem, and empowering people to do that with all that it entails- meaning that we’re making field diagnosis, using tools/meds/procedures appropriately to manage those conditions to the best of our ability, and understanding when the ‘expected’ or ‘normal’ set of interventions isn’t necessarily helpful. I reckon that anchoring is a lot less likely to set in when there’s not a strong preconceived notion that some things ‘must’ be done in order to successfully treat a patient. If the overall objective is the priority, then people are at least anchoring on the right thing.

    • “If the overall objective is the priority, then people are at least anchoring on the right thing.” Very true.

      I think terbutaline is another excellent paraenteral beta agonist. You’re right about BiPAP—great therapy, albeit expensive to provide (compared to oxygen-powered CPAP).

      • BVM + CPAP mask + Peep valve = inferior but semi functional ghetto BiPap. Can also ghetto in a neb treatment, but by this point, we’re getting weird lol. Would also be doable with the vents the sups carry, assuming Creek kept their NPPV functions. With that being said, I’m not a terribly huge fan of the Zoll vent’s BiPap interpretation- seems like any one tiny thing blows the whole circuit into a constant ball of alarms. Really like the Draeger Oxy-log, HT70 and T1 vents for good BiPap, or the pneumatic Parapack with “BiPap functionality” even if it is an oxygen waster. The OTwo vents the Corps carries are ok too imo…

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