Show Notes
Decision-making is one of the defining skills of pre-hospital practice. Every shift requires clinicians to interpret incomplete information, navigate uncertainty, balance competing risks, and make consequential decisions, often under intense time pressure. But does faster decision-making necessarily lead to better decisions? In this compilation episode of the Pre-Hospital Care Podcast, we explore the anatomy of decision-making under pressure, examining the cognitive processes, mental models, and human factors that influence how emergency responders think, assess, and act. We explore the limits of working memory through Miller’s Magic Number 7, the role of heuristics and intuition, inattention bias, cognitive overload, and the critical role of metacognition in recognising and improving our own decision-making. We also consider how stress, leadership, teamwork, experience, and limited resources shape decisions when the stakes are high. Featuring insights from Olly Sapsford, Firefighter, Commander and Lecturer in Disaster & Emergency Management at Coventry University, alongside discussion of Radu Venter’s research into EMS decision-making, this compilation challenges the culture of constant urgency in emergency medicine and asks whether rushing decisions actually makes us better clinicians. From the fireground to the ambulance and the clinical environment, we examine the OODA Loop, reflective practice, expertise, ethical decision-making, and the potential for technology and artificial intelligence to support, not replace, human judgement. Ultimately, this episode asks a fundamental question: what does it take to make sound, timely, and patient-focused decisions when every decision counts? These are the individual episodes: The Anatomy of Decision Making Under High Pressure Situations Listen on Apple Podcasts Decision-Making Under High Pressure Situations – Part 2 with Olly Sapsford Listen on Apple Podcasts EMS Decision-Making: Rushing the OODA Loop with Radu Venter Listen on Apple Podcasts
More from Pre-Hospital Care Podcast
What does the future of pre-hospital care look like, and what can we learn from the people leading its development? As we build towards the EMS2027 Congress in Ireland, taking place from 13–15 April 2027, I’m delighted to be joined by Cathal O’Donnell, Clinical Director of Ireland’s National Ambulance Service, for a conversation about the evolution of Irish EMS and the challenges and opportunities shaping our profession. We’ll explore Cathal’s journey in emergency medicine and clinical leadership, the development of advanced paramedic practice, and the importance of governance, research and education in delivering better patient care. We’ll also look beyond Ireland to consider the future of EMS across Europe and how greater collaboration can help move our profession forward. About Cathal O’Donnell Cathal is an Emergency Physician who has served as Clinical Director of the National Ambulance Service of Ireland since 2011. A graduate of University College Cork, he trained in Emergency Medicine in Ireland before completing a Fellowship in EMS and Emergency Medicine at the University of Toronto. He also holds an MSc in Leadership from the Royal College of Surgeons in Ireland and is Treasurer of EMS Europe. With EMS2027 on the horizon, this is an opportunity to hear from one of the key clinical leaders in Irish EMS about where we’ve come from, where we are now, and where pre-hospital care needs to go next.
Today on the Pre-Hospital Care Podcast, we’re tackling a topic that challenges one of the most deeply embedded concepts across Pre-hospital care. For decades, we’ve taught clinicians to think in binary terms: STEMI or not STEMI. Spot the ST elevation, activate the pathway, and move the patient toward reperfusion. It’s a model that has transformed care and saved countless lives. But what if that framework is also causing us to miss patients? Increasingly, there’s a growing conversation around the idea that acute coronary occlusion doesn’t always read from the textbook. Significant coronary artery blockages may not meet traditional STEMI criteria, while subtle ECG findings, evolving patterns, and clinical context can point toward a patient experiencing a true occlusive myocardial infarction, or OMI. The argument isn’t simply about changing terminology; it’s about changing how we think. So today we’re asking some big questions. Has STEMI become too narrow a lens? Are we over-relying on algorithms and thresholds? And what does this mean for clinicians making real-world decisions in the back of an ambulance, under pressure, with imperfect information and time-critical choices? You can read Mike's Substack piece here: https://emsdrmike.substack.com/p/beyond-stemi-in-ems
Some of the most important diagnoses in pre-hospital care are the ones we least expect, conditions that challenge our assumptions, present outside familiar clinical patterns, and can be missed when we rely too heavily on traditional assessment tools. In this episode, we revisit two important conversations from the Pre-Hospital Care Podcast that highlight the consequences of diagnostic overshadowing and the need for clinical curiosity. First: Spontaneous Coronary Artery Dissection (SCAD) SCAD is an important, often under-recognised cause of acute coronary syndrome. It can affect patients, particularly women, who may have few or none of the traditional cardiovascular risk factors associated with myocardial infarction. Through the perspectives of a survivor, the clinician who treated her, and an advocate raising awareness, we explore how SCAD presents, why it can be overlooked, and how pre-hospital clinicians can improve recognition. 🎧 Listen to the original episode: Spontaneous Coronary Artery Dissection (SCAD): The Condition We Often Miss Second: Posterior Circulation Stroke FAST has an important role in stroke recognition, but it does not identify every presentation. Posterior circulation strokes can manifest through dizziness, imbalance, visual disturbance, impaired coordination, and difficulty walking, sometimes without the classic signs of facial weakness, arm weakness or speech disturbance. Joining us in the original conversation, paramedic and researcher Shane Devlin explores the clinical and research challenges of recognising posterior circulation stroke. My brother, Ronan Walker, also shares his experience of suffering a posterior stroke in his late thirties, highlighting what can happen when symptoms don't fit the expected picture. 🎧 Listen to the original episode: Not So FAST: Rethinking Stroke Recognition in Pre-Hospital Care with Shane Devlin and Ronan Walker The key message: The patient doesn't have to fit the textbook for the diagnosis to be real. Whether we're assessing a potentially life-threatening cardiac event or a stroke that falls outside traditional screening criteria, careful assessment, clinical curiosity, and a willingness to challenge our initial impression can make a critical difference.
Today, we’re exploring a critical challenge in stroke care: identifying patients with large vessel occlusion (LVO) and getting them to the right hospital as quickly as possible. Mechanical thrombectomy can transform outcomes, but access depends on rapid identification and appropriate prehospital triage. Current clinical assessment and stroke severity scales have limitations, making it difficult to reliably distinguish LVO from other strokes and stroke mimics. Professor Christopher Price, Professor of Stroke and Applied Health Research at Newcastle University, has been investigating whether rapid, lateral-flow blood tests detecting stroke biomarkers could complement paramedic assessment and improve prehospital identification of patients suitable for thrombectomy. Could point-of-care testing help clinicians make better destination decisions, reduce delays from inter-hospital transfers, and get the right patients to treatment sooner? We’ll explore the evidence, the limitations, and what this technology could mean for the future of prehospital stroke care. Could the next major advance in stroke care happen before the patient reaches hospital? Find out more about the research: https://www.ncl.ac.uk/press/articles/latest/2026/07/standardtemplate/
A good clinical handover sounds simple. But when the environment is noisy, time is limited, cognitive load is high, and the stakes are significant, communicating the right information and ensuring it is understood becomes much harder. In this compilation episode, we explore the relationship between trauma handover, human factors, simulation and performance under pressure, bringing together two conversations that approach the problem from different perspectives. We revisit our conversation with Andrew Pearce to explore what makes an effective trauma handover and the challenges of transferring critical information between pre-hospital and hospital teams. We look at communication, structure, information loss and the human factors that can influence how information is delivered and received. We then turn to Neel Bhanderi and the science of high-fidelity simulation. Neel explores how we can move beyond simply practising clinical skills and instead create training environments that reproduce the cognitive, environmental and interpersonal pressures clinicians experience in the real world. His discussion takes us into stress, task loading, communication, handover, environmental distraction, and the importance of effective debriefing. High Fidelity Simulation with Neel Bhanderi Originally released 15 May 2023. Listen to the original episode on Apple Podcasts Trauma Handover with Andrew Pearce Listen to the original episode on Castro