Chapter 14Chapter 14

Critical Thinking and Clinical Decision Making

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Assessment

Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.

IntroductionIntroduction

• Paramedics must be able to:− Identify problems.

− Set patient care priorities.

− Develop a care plan.

− Execute the plan.

IntroductionIntroduction

• Cookbook medicine can lead to ineffective care.− Patients may present atypically.

− The scene may be unstable.

• You are expected to provide quality patient care.

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Gathering, Evaluating, and Synthesizing

Gathering, Evaluating, and Synthesizing

• You must be able to communicate and obtain information from many types of patients, including:− Different age groups

− Different educational backgrounds

− Different abilities to communicate

− Patients who have consumed drugs or alcohol

Gathering, Evaluating, and Synthesizing

Gathering, Evaluating, and Synthesizing

• Assess and evaluate gathered information to develop a treatment plan.− Check the validity of information using your

judgment and communication skills.

• Be as objective as possible in the decision-making process.

Gathering, Evaluating, and Synthesizing

Gathering, Evaluating, and Synthesizing

• Evaluate the information you obtain from:− The scene

− The patient

− A bystander

• Determine what is valid and invalid.

• Synthesize the information.

Gathering, Evaluating, and Synthesizing

Gathering, Evaluating, and Synthesizing

• Example: 64-year-old man reporting chest pains; history includes type 1 diabetes since childhood; long-time smoker; COPD

Developing and Implementing a Patient Care Plan

Developing and Implementing a Patient Care Plan

• Treatment plan guided by:− Patient care protocols

− Standing orders

• Protocols or standing orders define the essential standard of care.

Developing and Implementing a Patient Care Plan

Developing and Implementing a Patient Care Plan

• Protocols and standing orders specify:− Performance parameters

− When medical control should be contacted

• Protocols promote a standard approach and quality of care.− They do not cover atypical presentations.

Using Judgment and Independent Decision Making

Using Judgment and Independent Decision Making

• You must immediately recognize and treat life threats.− Circumstances

determine the treatment plan.

− Use critical-thinking and decision-making skills.

© Jones & Bartlett Learning. Courtesy of MIEMSS.

Thinking and Working Under Pressure

Thinking and Working Under Pressure

• To avert disaster, you must have:− Knowledge

− Excellent psychomotor clinical skills

• You must be able to:− Work under extreme pressure

− Think and perform quickly and effectively

Range of Patient ConditionsRange of Patient Conditions

• You must be able to determine if the patient is sick or not sick.− If a patient is sick,

quantify how sick.

• Clear thinking in an emergency starts with triage.

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Range of Patient ConditionsRange of Patient Conditions

• Critical patients

• Serious patients

• Mortally wounded or dead

• “Walking wounded” or minimally injured

• Critical life threats include:− Major multisystem

trauma

− Devastating single-system trauma

− End-stage disease presentations

− Acute presentations of chronic conditions

Range of Patient ConditionsRange of Patient Conditions

• Serious conditions include:− Serious multisystem

trauma

− Acute presentations of “first-time” medical events

− Multiple disease etiologies

• Non-life-threatening injuries include:− Simple abrasions

− Partial-thickness burns of an extremity, with less than 5% body surface area

− Small lacerations with only capillary bleeding

Concept FormationConcept Formation

• First stage in prehospital care

• Gather information from your senses and diagnostic tools.

• Begins as the paramedic arrives at the scene© Craig Jackson/InTheDarkPhotography.com

Concept FormationConcept Formation

• Primary assessment identifies medical condition and threats.

• Secondary assessment determines: − Pertinent medical history

− Any medications the patient is taking

− The patient’s affect

• Vital signs are then taken.

Data InterpretationData Interpretation

• Second stage of the critical-thinking process

• Evaluate all gathered information.− Understand how the body works.

− Have a background in anatomy, physiology, and pathophysiology.

− Have a good attitude

Application of PrincipleApplication of Principle

• Third stage of critical-thinking process

• Initial field impression becomes a working diagnosis

• The treatment plan is determined by patient care protocols, or standing orders.

Reflection in ActionReflection in Action

• Fourth step

• Treat patients while monitoring intervention effects.− Avoid tunnel vision. © Craig Jackson/InTheDarkPhotography.com

Reflection on ActionReflection on Action

• Last stage

• Occurs after the call is over

• Reflect on and learn from the decisions and actions taken on each call.

Reflection on ActionReflection on Action

• Elements that contribute to critical thinking:− Knowledge in medical sciences

− Ability to gather and organize data

− Ability to focus on specific and multiple data

− Ability to identify medical ambiguity

− Ability to understand relevant/irrelevant data

− Ability to analyze and compare situations

− Ability to explain reasoning

From Theory to Practical Application

From Theory to Practical Application

• Each call has unique circumstances.

• Checklist to support thinking under pressure:− Scan situation.

− Stop and think.

− Move forward, make decisions.

− Stay calm.

− Continue reevaluation.

The Six RsThe Six Rs

• Read the scene.− Overall safety

− Environmental conditions

− Immediate surroundings

− Access and egress

− Mechanism of injury

© Jones & Bartlett Learning. Courtesy of MIEMSS.

The Six RsThe Six Rs

• Read the patient.− Observe the

patient.

− Talk to the patient.

− Touch the patient.

− Auscultate lung sounds.

− Identify life threats.

− Obtain vital signs.

© Mark C. Ide

The Six RsThe Six Rs

• React.− Treat any life-threatening problems.

− Develop a working diagnosis or provide care based on presenting signs and symptoms.

• Reevaluate.− Follow up on interventions.

The Six RsThe Six Rs

• Revise the plan.− Be open to changing working diagnosis.

• Review the performance.− Continuous quality improvement (CQI) meeting

− Informal discussions with partners

SummarySummary

• The first cornerstone of the paramedic’s practice is the ability to gather, evaluate, and synthesize information.

• A paramedic needs to assess and evaluate the validity of information and its impact on the patient care plan.

• After evaluation, the information must be processed (synthesized).

SummarySummary

• The second cornerstone of paramedic practice is the development and implementation of a patient care plan.

• The patient care plan is defined by protocols and standing orders of the paramedic’s EMS system.

• The third cornerstone is judgment and making independent decisions.

SummarySummary

• The fourth cornerstone of practices is the ability to think and work under pressure.

• The first stage in prehospital care critical thinking is gathering initial information through the five senses and diagnostic tools, using the process of concept formation.

SummarySummary

• Data interpretation is the second stage of the critical-thinking process and occurs when the paramedic evaluates the gathered information.

• The third stage of the critical-thinking process is the review after the call is completed.

SummarySummary

• The six Rs will help the paramedic determine the steps to a call:− Read the scene.

− Read the patient.

− React.

− Reevaluate.

− Revise the plan.

− Review the performance.

SummarySummary

• Paramedics should maintain an attitude that is open to learning in order to constantly improve their practice and maintain excellence in prehospital care.

CreditsCredits

• Chapter opener: © Jones & Bartlett Learning. Courtesy of MIEMSS.

• Backgrounds: Purple—Courtesy of Rhonda Beck; Green—Courtesy of Rhonda Beck; Gold—Jones & Bartlett Learning. Courtesy of MIEMSS.

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.