[Patients' declared intentions and emergency medicine]

[Cognitive errors in diagnostic decision making]

Approximately 10-15% of our diagnostic decisions are faulty and may lead to unfavorable and dangerous outcomes, which could be avoided. These diagnostic errors are mainly caused by cognitive biases in the diagnostic reasoning process.Our medical diagnostic decision-making is based on intuitive "System 1" and analytical "System 2" diagnostic decision-making and can be deviated by unconscious cognitive biases.These deviations can be positively influenced on a systemic and an individual level. For the individual, metacognition (internal withdrawal from the decision-making process) and debiasing strategies, such as verification, falsification and rule out worst-case scenarios, can lead to improved diagnostic decisions making.

[Limb salvage and amputation after trauma : Decision criteria and management algorithm]

The clinical decision-making process for patients with severe trauma of the extremities for primary amputation or to initiate extensive reconstructive measures for limb salvage in the best interests of the patient can be complex and difficult. The many factors influencing the decision-making process, such as local anatomical, pathomechanical, physiological, psychosocial and general factors are demonstrated and discussed. In the past, the role of scores supporting the decision-making process for amputation or limb salvage has been overestimated. In the LEAP study it could clearly be demonstrated that none of the sometimes highly complex scores could fulfill the expectations to predict successful limb salvage or the need for amputation. In this article it is shown that initiators and authors of scores achieved much higher sensitivity and specificity in the inaugural studies compared to the standardized and controlled conditions used in the LEAP study. For a long time, a lack of feeling in the feet was considered a safe and reliable criterion for amputation but the LEAP study has made a substantial contribution to demythologizing this as a lead symptom. Patients with severe trauma of the ankle or foot requiring a free flap or ankle arthrodesis have a significantly worse outcome compared to patients with a below knee amputation. Taking all these influencing factors into consideration, a comprehensive algorithm is presented that facilitates, strengthens and standardizes decision-making for amputation or limb salvage. This algorithm consists of four modules: 1) decision-making, 2) emergency treatment, 3) definitive treatment and 4) fine tuning. In the decision-making module not only local and general injury severity are addressed but the expected result, the general condition, comorbidities, compliance and the will of the patient are also included.

[Medicolegal aspects in emergency medical care : Analysis of the frequency of advance health care directives and the influence on decision making in emergency medicine]

BACKGROUND

Medical decisions in an emergency medical services (EMS) situation are always extremely time- critical and sensitive, potentially leading to medicolegal consequences. Advance health care directives (AHCDs) are crucial components in the patients' participative decision making. When a patient refuses resuscitation, and/or other life-extending treatments, emergency physicians face possible ethical, medical, and medicolegal conflicts.

METHODS

As part of the RIMANO II Study [Risk Management Präklinische (prehospital) Notfallmedizin (emergency medicine)], all 18 "emergency physician bases" of the Berlin Fire Department were polled regarding the influence of AHCDs in regard to emergency medical decision making. The assessment was based on anonymous questionnaires. Furthermore, emergency medical suggestions for improvement of AHCDs were gathered. Descriptive statistics and qualitative methods were used for evaluation.

RESULTS

A total of 112 responses from emergency physicians could be incorporated into the study. Anesthesiologists represented the largest group (n = 55, 49 %), followed by internists (n = 40, 36 %). The median length of experience in EMS was 7 years [interquartile range (IQR) 4-14 years]. Patients' "do not resuscitate" orders were obeyed in 78/112 cases (70 %, 95 % CI 69-78 %). In 49/112 cases (44 %, 95 % CI 34-53 %), the request to not be hospitalized was granted. The length of EMS experience, type of medical specialty, the number of EMS cases and ways in which AHCDs were handled were all contributing factors to the various emergency medical interventions.

CONCLUSION

AHCDs appear to have an influence in the emergency medical decision process. However, it is presently unclear as to what a standardized and universally comprehensible AHCD should look like, in order to provide a framework that is both acceptable and necessary in a prehospital emergency medicine environment, ensuring medicolegal certainty for the parties involved.