The Paramedic Practitioner Andrew Merelman

In this episode I talked with Dr. Quinn Cummings (@resus_bae) about the topic of
cognitive bias and some ways we can reduce the influence of biases in our
practice. Quinn is an emergency physician with a special interest in this
topic.




During an average shift an emergency medical provider makes
hundreds to thousands of decisions. To make these decisions, our brains use a
combination of conscious and subconscious information. We tend to think that all
our decisions are made objectively but, in fact, much of our decision making
comes from knowledge or ideas that we are not even aware of. This is the
concept of cognitive bias. A cognitive bias is a systematic error in thinking
which can skew our ability to process information properly and accurately. This
can lead to an improper diagnosis or treatment path for our patient. There are
numerous examples of specific biases such as anchoring bias, confirmation bias,
premature closure, etc. We discuss a few examples in the podcast but we
encourage you to research more to see which ones you may be more susceptible to
(see resources below).




As always please feel free to share feedback, comments, or
questions!




Twitter: @amerelman




Instagram: @paramedicpractitioner
 




Facebook: The Paramedic
Practitioner Podcast




Email: amerelman@gmail.com






References and other resources:




https://www.nuemblog.com/blog/cognitive-bias




https://first10em.com/cognitive-errors/

https://criticalcarenow.com/criticalcarecares-25-cognitive-biases-every-doctor-needs-to-know/





Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to
Minimize Them. Academic Med. August 2003, 1-6.




Croskerry, P et al. Patient Safety in Emergency Medicine.
Lippincott Williams & Wilkins, 2009.




Thomas, D. D., & Mustafa, Y. Design for cognitive bias.
Jeffrey Zeldman / A Book Apart. 2020.




Croskerry P. Cognitive forcing strategies in clinical
decision making. Ann Emerg Med 2003;41(1):110–120.




Croskerry P. The feedback sanction. Acad Emerg Med. 2000
Nov;7(11):1232-8. doi: 10.1111/j.1553-2712.2000.tb00468.x. PMID: 11073471.




Caplan R.A., Posner K.L., Cheney F.W.: Effect of outcome on
physician judgments of appropriateness of care. JAMA 1991; 265: pp. 1957-1960.




Abraham Kaplan (1964). The Conduct of Inquiry: Methodology

On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see.








Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM.








A Law Enforcement Approach to ExDS



References and Resources





a href="https://smacc.net.au

This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.




Facebook: https://www.facebook.com/paramedicpractitioner/ Instagram: @paramedicpractitioner Email: amerelman@gmail.com Twitter: @amerelman




Image: PulmCrit



References and Further Reading UpToDatehttps://emedicine.medscape.com/article/296301-overview https://canadiem.org/management-of-severe-asthma/ http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/ https://rebelem.com/rebelcast-crashing-asthmatic/ https://emcrit.org/ibcc/asthma/ https://asthma.net/treatment/prevention/ https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/ https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/ https://err.ersjournals.com/content/22/129/227.full https://www.ncbi.nlm.nih.gov/books/NBK430901/ https://www.ncbi.nlm.nih.gov/pubmed/11406055 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/ https://www.ncbi.nlm.nih.gov/pubmed/23235634 https://www.ncbi.nlm.nih.gov/pubmed/22479740 https://www.ncbi.nlm.nih.gov/pubmed/26033128 https://www.ncbi.nlm.nih.gov/pubmed/25447559 https://www.ncbi.nlm.nih.gov/pubmed/27289336 a

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.




Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.




Facebook: https://www.facebook.com/paramedicpractitioner/ Instagram: @paramedicpractitioner Email: amerelman@gmail.com Twitter: @amerelman




Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.












img src="https://www.paramedicpractitioner.net/wp-content/uploads/2019/12/3-939x1024.jpg" alt="" class="wp-image-2271" srcset="https://www.paramedicpractitioner.net/wp-content/uploads/2019/12/3-939x1024.jpg 939w, https://www.paramedicpractitioner.net/wp-content/uploads/2019/12/3-275x300.jpg 275w, https://www.paramedicpractitioner.net/wp-content/uploads/2019/12/3-768x837.jpg 768w, https://www.paramedicpractitioner.net/wp-content/uploads/2019/12/3-500x545.jpg 500w, https://www.paramedicpractitioner.net/wp-content/upload

http://www.cmaj.ca/content/188/17-18/E466



Mechanism of Slow-Fast AVNRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/



AVNRT versus AVRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/



Sinus tachycardia with P waves at the end of the T-wave. Theses can be less obvious and the EKG can be mistaken for AVNRT or AVRThttp:// https://litfl.com/sinus-tachycardia-ecg-library/



img src="https://www.paramedicpractitioner.net/wp-content/uploads/2019/10/5-1024x561.jpg" alt="" class="wp-image-2250" srcset="https://www.paramedicpractitioner.net/wp-content/uploads/2019/10/5.jpg 1024w, https://www.paramedicpractitioner.net/wp-content/uploads/2019/10/5-300x164.jpg 300w, https://www.paramedicpractitioner.net/wp-content/uploads/2019/10/5-768x421.jpg 768w, https://www.paramedicpractitioner.net/wp-content/uploads/2019/10/5-500x274

This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful.




Airway Checklist Examples















Anything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.com



Grade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized.



Reference:
EMCrit Checklist page
SALAD Airway
Rich Levitan on epiglottoscopy
Video discussion