title: Performance of experienced versus less experienced paramedics in managing challenging scenarios: a cognitive task analysis study.
abstract: OBJECTIVE
  Out-of-hospital care is becoming more complex, thus placing greater reliance on the cognitive abilities of paramedics to manage difficult situations. In adapting to the challenges in their work, paramedics develop expertise. We study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges.
  
  
  METHODS
  We conducted a "staged-world" cognitive task analysis to explore paramedics' handling of cognitive challenges related to sense-making and to resource and task management. A mixed-fidelity simulation was used to present paramedics with 2 challenging scenarios: a pulmonary embolism initially presenting as a myocardial infarction and a 2-person shooting with limited resources available.
  
  
  RESULTS
  Participants were 10 paramedics, 6 more experienced and 4 less experienced. Analysis involved comparing the performance of the 2 groups to identify strategies associated with expertise. The more experienced paramedics made more assessments, explored a wider variety of presumptive diagnoses, and identified the pulmonary embolism earlier. They switched attention between the 2 shooting victims more, used their emergency medical technician-basic level partners more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care.
  
  
  CONCLUSIONS
  Our findings correspond to general cognitive attributes of expertise: greater cue gathering and inferential reasoning, and more functional and strategic thinking. These results suggest potential areas and methods to facilitate development of expertise, as well as ways to better support use of expertise. Future studies should expand on these findings through larger sample sizes and more complex scenarios.
authors.affiliation: Cognitive Systems Engineering Laboratory, Institute for Ergonomics, Ohio State University, Columbus, OH; Houston VA HSR&D Center of Excellence and the Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX. Electronic address: ms6@bcm.edu.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Smith
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Bentley
authors.forename: Antonio R
authors.initials: AR
authors.lastname: Fernandez
authors.forename: Gregory
authors.initials: G
authors.lastname: Gibson
authors.forename: Sharon B
authors.initials: SB
authors.lastname: Schweikhart
authors.forename: David D
authors.initials: DD
authors.lastname: Woods
mesh_terms: D022561:Advanced Cardiac Life Support / Q000523:psychology; D002637:Chest Pain / Q000175:diagnosis / Q000209:etiology; D002983:Clinical Competence / Q000592:standards*; D006259:Craniocerebral Trauma / Q000175:diagnosis / Q000628:therapy; D004630:Emergencies / Q000523:psychology; D004634:Emergency Medical Technicians / Q000523:psychology / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000628:therapy; D013647:Task Performance and Analysis; D013898:Thoracic Injuries / Q000175:diagnosis / Q000628:therapy; D014948:Wounds, Gunshot / Q000175:diagnosis / Q000628:therapy