Table 1 Quotes Describing our Model of Paramedic Decision-Making

Constructing a Malleable Model

Revising the model

Situation Specific Action

Prepatory cognition

Sometimes you can tell what this is going to be; you know just based on the location, based on a couple of the notes, you know how this is going to be nothing. Or you read the notes and you go this is going to be a STEMI (ST-elevation myocardial infarction). I can tell this is going to be a STEMI. (Participant #4)

Looking for clues

You look for things like alcohol. You pay attention to if there are any smells. Is there a pleasant odour or a fecal smell. Are there any drugs? You essentially use all your senses. All this happens in the first few milliseconds. It is not a step by step process. There are things you recognize and pay attention to. You notice what you hear, see, and smell. You have already assessed the environment as you meet the patient and you have already started to evaluate what might be going on. (Participant #13)

Initial impression

I look at colour, how are they breathing, what is their work of breathing, is their breathing distressed, are they conscious, are they tracking with their eyes, their facial expression, do they look distressed? (Participant #7)

Initial determination

I consider whether the diagnosis is supported by the signs and symptoms, the environment and the history and then I go with the most likely. If I don’t have enough information I go with the most responsible diagnosis. (Participant #10)

You look for clues about how they’re living. I can’t walk. You’re on the second floor of your house in the bedroom. How have you gotten around all day? Well, I walked up here. (Participant #4)

Reasoning about treatment decisions

If I think they already have drugs onboard and they are already drowsy and say they have 10/10 pain I won’t give drugs, but I make sure I can justify it if I get called in. Things like they were already drowsy, there was pot in the home, I was concerned they had something else onboard (Participant #8).

Working with protocols

Okay, in this given situation, this is what you’re going to have to do. And the way they’re written, they’re kind of written in a linear form and box A followed by box B and box C. That doesn’t always work depending on the patient. Sometimes you’re going to have to mix and match around a little bit. (Participant #2).

Seeking medical advice.

I have always stayed within my scope of practice and where it is appropriate call online medical back up But we know that could take 10–15 min. And when someone is hypoxic and you need orders you need them now. You don’t have 20 min to tell the Dr. the story when you wake him up in the middle of the night. This is what I have, this it what I need, can I go ahead. The Drs. also don’t like being asked if they don’t know who you are. (Participant #7)

Initiating treatment

We had an adult woman with a dislocated shoulder up in the far corner of a kids jungle gym, 30 ft in the air and there was no moving her as we had to crawl and weave through obstacles, walls etc to get her down. We had to use the fire department to help us, we got orders from our physician to sedate her with fentanyl and ketamine and attempt to reduce her shoulder there on the spot. We were 30 ft in the air a long ways from our ambulance so we had ALL of our equipment there, all of our airway management stuff, medications, monitor etc just in case things went poorly. (Participant #4)