Treatment Prioritisation
Treatment prioritisation is such an important part of being a paramedic. It’s not good enough to just be able to recite the management plan as per the CPG, you need to be able to identify what treatment options are most appropriate for your patient and what needs to come first.
A very straightforward example of this is anaphylaxis. Adrenaline is the treatment that will reverse the cause. There’s no point wasting time by hanging a bag of fluids for your hypotensive pt until AFTER you give the medication that will improve the patient’s blood pressure.
Of course, this is complicated by the individual patient presentations you may encounter. The critical APO patient with extremely poor perfusion and severe respiratory distress will benefit more from quick application of CPAP rather than delaying it to first try a non-rebreather mask and performing a 12 lead ECG.
Factors to consider when deciding how to prioritise treatment are:
1. Patient Trajectory- ie. without appropriate and timely treatment, what will happen to the patient? If there is a risk of the patient deteriorating, then interventions to prevent and prepare for this become more crucial. In the event of a patient going downhill, you want the patient positioned appropriately, IV access obtained and airway and respiratory equipment at hand.
2. Time Criticality- Does the patient need an intervention NOW, or do they need definitive care more? An easy example is airway management. If the patient’s airway is occluded, they are time critical. It makes zero sense to muck around with IV access or drawing up medications until the airway is patent and the patient can be oxygenated effectively. A clear understanding of assessment systems like the primary survey provide a good guide of what immediate life threats are. This makes it pretty easy to determine what treatment needs to occur at what point in time to treat the patient properly.
3.Treatment Benefits- Conversely, if the treatment holds little benefit to the patient pre-hospitally and they require more urgent management at hospital (either because they don’t require emergency care OR they are transport critical), then down the priority list it goes.
4. Ability to Manage the Underlying Cause- This goes hand in hand with treatment benefits. If you have the ability to manage the underlying cause, then depending on patient’s presentation treating the cause of their condition becomes the priority. A perfect example is hypoglycaemia. Once the underlying cause is addressed then the patient’s symptoms should resolve, making anything other than addressing their blood glucose levels irrelevant. The headache experienced as a result of a low BGL is not a priority until the sugar levels are managed to an appropriate level.
5. Length of Time Needed to Perform an Intervention- This is a tricky one to work out because it can be applied in different ways. An OPA is a good example of a quick airway adjunct that can effectively manage an airway. It can be done within seconds, allowing for other interventions to be started, making it easy to prioritise. However, in a different situation it may be more important to do the longer task first. Refer back to the APO patient. CPAP takes longer to set up than a non-rebreather, however for that critical patient it is more beneficial to spend longer setting up the CPAP mask and starting it ASAP than it is to start with a non-rebreather (which could be ineffective) and then move on to CPAP. This again comes down to how much benefit the treatment carries and how many people you have available to initiate treatment.
6. Patient and Paramedic Safety- It should always be on your mind but it never is until you are actually out on road making the decisions. If a patient is having a seizure in a bathtub full of water, is it more important to give Midazolam or to remove the patient from potential risk of drowning? Likewise, is it more appropriate to begin treating a patient with a non-life threatening problem outside in a thunderstorm or move them into the ambulance? It may be most appropriate to give analgesia and splint a broken leg in the rain, then move the patient and continue to treat minor injuries afterward. These are pretty clear cut examples, but they are legitimate considerations when prioritising tasks.
