Setting the scene
So, you were trying to put a skeleton Santa Claus on your roof to knock out decorations for the rest of the year, but you fell off the ladder and broke your leg. The paramedics show up, scoop you up onto the stretcher, and load you into the back of the ambulance. As they get to work assessing your leg and giving you pain medication, suddenly it hits you: this is an information setting!
The inside of an ambulance is a small, high stress environment. Paramedics often have limited time and resources on the drive to the hospital. Information plays a key role in making sure the best possible treatment is provided to the patient. A variety of information flows between patient, paramedic, health records, the emergency department, and many other places. This challenging environment offers information professionals opportunities to improve in education, processes and tools.
Types of information
There are a number of different types of information at play in the back of an ambulance. These can be grouped into four broad categories: objective medical data, subjective reports and assessments, medical background information, and non-medical information.
Objective medical data are things like pulse rate, blood pressure, and the heart’s electrical rhythm. This information is collected directly or by use of technology in a repeatable, objective way. If two people check my blood pressure, they should get roughly the same values. This information is almost exclusively quantitative in nature, and is related to this specific patient.
Reports and assessments are information that comes through the lens of human interpretation. A patient might report a tight feeling in their chest, or a paramedic might note a crunchy feeling when assessing for a broken bone. During the course of treatment, paramedics will develop an understanding of the situation and the effectiveness of interventions. This information is almost exclusively qualitative in nature, and again is related to this specific patient.
Medical background knowledge consists of the information a paramedic carries in their head about how the human body works and which interventions might be useful for a given condition. It also exists in the mind of the patient, whether information they’ve learned about their chronic condition, gleaned from carrying for a family member, or their own past experience with similar emergencies. This also includes lists of allergies, current medications, and previous diagnoses and treatments. With modern communication technology, specialists at local health facilities can be contacted to request additional information. Ambulances are also typically equipped with instruction manuals and procedure guides to help guide the paramedic to provide the highest standard of care. Much of this knowledge is general, and isn’t specifically related to the emergency that the patient is experiencing in the moment.
Finally, there is non-medical information. This category includes things like health insurance information, emergency contacts, and even discussions of the weather and other topics of social interest.
Functions of information
The primary function of the information generated, collected, and exchanged in this setting is to inform the care provided to the patient experiencing the medical emergency. Different information sources are combined by the paramedic to form a cohesive understanding of the patient’s condition, which is then used to identify appropriate interventions to be performed in an effort to improve the patient’s condition. During and after interventions, more information is gathered to identify whether the intended positive effect was achieved, and to direct further care in an iterative fashion.
Medical background knowledge is useful to educate the patient, especially in cases of chronic illness management. This not only improves the outcome during the crisis, but can prevent future crises. Knowledge of non-emergency care options can serve to reduce the load on the healthcare system by redirecting patients to more appropriate levels of care.
Information about local non-medical resources, for example temporary housing options, can more holistically support patients. It can also serve as a distraction, for example talking about the weather so that a patient isn’t focused on the injury they’ve sustained.
Interactions between people and information
Paramedics don’t simply collect information. They have to combine it into a comprehensive understanding of the patient’s medical status, and then utilize that understanding to provide care. The synthesis of general medical knowledge (how bodies work in general, how interventions affect the body in general) and patient-specific knowledge (vital signs, reports, assessments, medical history) is essential to forming an adequate understanding to direct care.
Patients interact with this information as well. Every interaction they have with emergency services allows them to learn more about how they work by direct observation. They hopefully become more educated about how the body works, and any illness or injury they’ve sustained.
The documentation that paramedics produce during the encounter is often reviewed by experts for the purposes of quality improvement and research. When time is of the essence, information can be transmitted to the receiving health facility, allowing appropriate resources to be mustered and available immediately on the patient’s arrival.
Factors that facilitate and hinder information processes
The integration of technology has transformed the processing of information inside of an ambulance. For example, readings of electrical activity inside the heart can be obtained by machines and automatically included in the patient’s medical records. This can avoid forgotten or misremembered data, and saves the time of the paramedic who no longer has to note them on a paper form.
Clear labeling on medication packaging is another example; having the medication name, common doses, and other information at the point of use decreases the likelihood of error during administration. When two paramedics are present, they can each confirm the medication is correct by exchanging the medication name, dose, and other information, which further reduces the chance of errors.
Usually though, most care is provided by a single paramedic, and the back of an ambulance is far from an ideal clinical environment. Loud sirens can make it difficult to listen to breathing sounds with a stethoscope. Bumpy roads can interfere with heart electrical activity monitoring. The cramped space and lack of helping hands can make it difficult to assess the patient’s entire body. Diverse patient populations can result in cultural and linguistic barriers to information exchange.
Impact of technology
Electronic health record systems allow health providers out in the field to access a patient’s medical history and medications, as well as capturing the various forms of information generated during the encounter. The receiving medical facility can even watch as the paramedic documents assessments and interventions in real-time, thanks to cellular data connections.
Conversations with specialists are also possible via cell phone or radio. Whether it’s a patient’s primary care doctor to answer questions about a recent illness, or a cardiac surgeon at the receiving facility giving a second opinion about an ECG, technology allows expertise to be imported into the information context in real time.
Technology can also make medical background information more accessible. For example, with the explosion of drugs available for treating various conditions, it becomes impossible for any individual to remember all of the doses, or to remember the possible interactions between different medications. A laptop with a comprehensive drug catalog, integrated into the electronic health record system, can analyze the medications the patient is taking and help the paramedic choose appropriate drugs to utilize while minimizing complications.
This integration of technology is not without its downsides. Laptop batteries run out of electricity. Cellular data coverage is spotty, especially in rural areas. Various device manufacturers may be incompatible, limiting or preventing information sharing between them. It also requires additional technological expertise on the part of the paramedics using the devices, and can increase the cost to provide care.
Reliance on technology has also been shown to decrease critical thinking and hands-on skills. Paramedics can develop the habit of letting the machine take the blood pressure readings, instead of doing it themselves. If the heart monitor erroneously indicates the patient’s heart has stopped, they may deliver a shock to try to restart it, despite the fact that the patient is awake and talking to them.
Impacts and opportunities for information professionals
This assessment of the types of information, their function, and their flow between people and technology highlights several areas where better information management could be applied. Technology gets a lot of attention, and devising standards for communication between medical devices would greatly improve digital information flow. Instilling multicultural knowledge and humility during paramedic education would lower cultural information barriers. A well-informed public can better understand the available resources for receiving care and be more active advocates during healthcare encounters. We can devise strategies for addressing some of the challenges of providing care inside of a moving vehicle, such as applying hearing aid technology to stethoscopes. We can centralize the synthesis of patient information in the treatment process, helping paramedics remember to treat the whole patient instead of the numbers reported by devices.
Conversely, the back of an ambulance is a high-stress, high-stakes information environment, and I think information professionals working on tools and processes for this setting could benefit from riding along with an ambulance crew to see what the lived experience is like. Information becomes knowledge through experience and context.