VitalNotes

Paramedic Thinking. Essential Ideas. One Page at a Time.

Mastering Directive Decision-Making

Think Beyond the Checklist. Apply with Confidence

ALS PCS directives aren’t difficult to read—but they’re easy to misapply. It’s not that students forget the rules. It’s that they struggle with when a directive applies, when it doesn’t, and how to confidently justify their choices.

This page gives you a framework to approach directives as a thinking clinician—not just a protocol follower.

Why Directives Can Be Tricky

Most directive errors don’t come from lack of memory. They come from:

  • Failing to recognize the clinical triggers that activate a directive
  • Confusing conditions with contraindications
  • Over-focusing on memorized wording instead of patient context
  • Freezing under pressure or defaulting to habit

Learning to apply a directive isn’t about checking boxes. It’s about linking presentation to decision.

Step 1: Know the Directive Anatomy

Every ALS PCS directive follows the same structure:

  • Indications → Why you’re using it
  • Conditions → What must be true (age, vitals, LOC, etc.)
  • Contraindications → When it’s unsafe or not authorized
  • Treatment → What to give, how much, how often

Tip: Memorizing the structure helps you scan for what matters. Every directive can be broken down this way.

Step 2: Watch for Triggers

Directives aren’t “on” all the time. There’s usually a clinical trigger that should make you stop and ask:

Does this directive apply right now?

Examples:

  • Chest pain with pressure? → Consider ASA / Nitro Directive
  • SOB with wheezes? → Consider Bronchoconstriction Directive
  • Low GCS + pinpoint pupils? → Consider Naloxone Directive

As you build your clinical pattern recognition, triggers become intuitive—but in the beginning, look for them intentionally.

Step 3: Use a Thinking Template

When you think a directive might apply, walk through this:

  1. What directive might apply here?
  2. Do they meet the indication? (e.g., “Suspected ischemic chest pain”)
  3. Do they meet all required conditions?
  4. Do they have any contraindications?
  5. What’s the dose, route, and frequency?
  6. What’s my judgment—would I proceed or withhold? Why?

You don’t need to overtalk it. Just think it clearly.

Step 4: Break Down an Example – ASA Directive

Let’s walk through it step by step:

  • Indication: Suspected cardiac ischemia
  • Conditions: Age ≥18, able to chew/swallow
  • Contraindications: ASA allergy, recent GI bleed, no prior use (if asthmatic), CVA/TBI in past 24 hrs
  • Treatment: 160–162 mg PO, chewed, one-time dose

Real-Time Thought Process:

  • Chest discomfort radiating to jaw? → Yes → Proceed
  • Age 54, alert, can chew? → Yes
  • Any GI bleed or ASA allergy? → No
    → Give 160 mg PO, chewed, and document clearly

If they’re asthmatic with no history of ASA use? → Withhold, document the contraindication

Step 5: Practice the Decision-Making Loop

Try walking through different directive-based calls using this same mental checklist.

Scenario A:
54M, crushing chest pain, BP 110/70, no known allergies.
→ Apply ASA? → Yes

Scenario B:
82F, mild chest pressure, Hx of GI bleed last week.
→ Apply ASA? → No. Contraindicated.

Scenario C:
24M, pinpoint pupils, agonal breathing, unknown history.
→ What directive? → Naloxone (if opioid OD suspected)

Step 6: Reinforce It

Make 1 Anki card when a directive surprises you:
Q: “ASA contraindications?” → A: Allergy, GI bleed, no prior ASA use in asthma, CVA/TBI in last 24 hrs

Write a Permanent Note when you miss a cue:
Note title: “ASA: When Not to Give” → Link it to [[Chest Pain MOC]]

Run a Five Whys if you made the wrong call:
Why didn’t I give ASA?
→ I thought they had a contraindication.
→ Why?
→ I assumed “history of ulcers” = GI bleed
→ Why didn’t I clarify that?
→ Because I didn’t ask…

That’s how you learn from it once.

Final Thoughts

Using directives well isn’t about having a good memory. It’s about having a clear process.

Slow down. Look for the trigger. Walk through the structure. Think clearly. Then act with confidence—and document like you meant it.

That’s the shift from memorizing medicine to practicing it.

I. Learning Foundations

Build a strong system for thinking, studying, and remembering in high-pressure fields.

II. Practical Application

Move from theory to field-ready practice. These tools help bridge simulation, lab, and real calls.

  • Scenario Days – Make Learning Stick
    How to get more from scenario practice using repetition, debriefs, and learning loops. Turn repetition into retention.
  • Mastering Directive Decision-Making
    A breakdown of how to use directives in real-time, with pattern recognition, logic triggers, and threshold thinking.
  • Reflecting Without Journaling
    Not everyone journals—this guide offers quick, low-resistance alternatives to build metacognition through regular reflection.
  • Lab Integration Guide
    Use lab sessions to build decision-making habits, not just check off skills. Includes scenario prep, debriefing, and error capture.

III. Clinical Reasoning

Develop clarity under pressure. These pages train your diagnostic eye, pattern sense, and mental workflow.

IV. Resources

Your support tools: guides, summaries, templates, and setup walkthroughs.

  • Summary
    Recap of the big ideas behind VitalNotes: learn reflectively, study actively, and build a system that supports decision-making under pressure.
  • Helpful Resources
    Downloadables and quick-reference tools: directive cue sheets, Anki decks, debrief templates, and scenario aids.
  • Anki Setup & Use Guide
    Step-by-step instructions for downloading, customizing, and optimizing Anki for long-term retention.
  • Obsidian Setup & Use Guide
    How to build a clinical note vault in Obsidian: folder structures, templates, and linking strategies.
  • Sources and References
    A list of research and literature that supports the methods taught in the blog, with commentary on their application to clinical learning.