Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Care:

Principles & Practice

Volume 2

Patient Assessment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 4

Clinical Decision Making

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Topics

Introduction to Critical Thinking

Paramedic Practice

Critical Thinking Skills

Thinking Under Pressure

The Critical Decision Process

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Critical Thinking

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Critical Thinking

As a paramedic, you inevitably will face your

moment of truth.

– A critical decision can mean the difference

between life and death.

Twenty-first-century paramedics are

prehospital practitioners of emergency

medicine—not field technicians.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Making critical decisions

requires clinical judgment—

the use of knowledge and

experience to diagnose patients

and plan their treatment.

Introduction to Critical Thinking

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Practice

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Practice

As a paramedic, you must gather, evaluate, and synthesize much information in very little time.

Requires the use of all senses.

The differential diagnosis is a preliminary list of possible causes for your patient’s problem.

By conducting a history and physical exam the paramedic will arrive at a field diagnosis.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Practice

The paramedic will apply clinical experience

and exercise independent decision-making

in order to develop and implement a

management plan.

Paramedics perform procedures in various

uncontrolled and unpredictable

environments.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Acuity

The severity or acuteness of your patient’s

condition.

The spectrum of care in the pre-hospital

setting includes three general classes of

patient acuity.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Classes of Acuity

Those with obvious life-threats

Those with potential life-threats

Those with non-life-threatening

presentations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Obvious Life-Threats

Major multi-system trauma

Devastating single-system trauma

End-stage disease (i.e., renal failure)

Acute presentations of chronic diseases

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Potential Life-Threats

Serious multi-system trauma

Multiple disease etiology

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Non-Life-Threats

Isolated minor illnesses and injuries

Majority of calls are non-life threats

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Protocols, standing orders,

and patient care algorithms provide

a standardized approach to

emergency patient care.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Protocol

A standard that includes general and

specific principles for managing certain

patient conditions.

Protocols are also for special situations such

as physician on-scene, radio failure, and

termination of resuscitation.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Standing Orders

Treatments you can perform before

contacting the medical direction physician

for permission

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Algorithm

Schematic flow

chart that outlines

appropriate care for

specific signs and

symptoms

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

While algorithms, standing

orders, and protocols provide

paramedics with guidance…

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

…do not allow the linear thinking or

“cookbook medicine” that protocols promote

restrain you from consulting with your

medical direction physician.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Critical Thinking Skills

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Critical Thinking Skills

Knowing anatomy, physiology, and

pathophysiology

Focusing on large amounts of data

Organizing information

Identifying and dealing with medical

ambiguity

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Critical Thinking Skills

Differentiating between relevant

and irrelevant data

Analyzing and comparing similar

situations

Explaining decisions and constructing

logical arguments

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Useful Thinking Styles

A paramedic must stay calm and not panic.

– The key is focusing on the task and blocking out

the distractions.

Assume and plan for the worst.

Establish and maintain a systematic

assessment pattern.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Be like the duck— cool and calm on the water’s

surface, while paddling feverishly underneath!

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thinking Under Pressure

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thinking Under Pressure

With experience, you will learn to

manage nervousness and maintain a

steadfast, controlled demeanor.

Except for safety concerns, never allow

anything to distract you from your most

important job—assessing and caring for

your patient.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Useful Management Styles

Situation analysis

– Reflective vs impulsive

Data processing

– Convergent vs divergent

Decision making

– Anticipatory vs reactive

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thinking Under Pressure

Physical influences

– Autonomic response

Sympathetic response is useful

– Increases visual, auditory, reflexes, and

muscular strength

Sympathetic response may be detrimental

– Diminish ability to concentrate

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Mental Checklist

Developing a routine mental checklist as a

good way to stay focused and systematic.

Develop acronyms and mnemonics to

remember critical elements during stressful

incidents.

– SAMPLE, OPQRST-ASPN, AVPU, etc.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Mental Checklist

Scan the situation

Stop and think

Decide and act

Maintain control

Re-evaluate

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The Critical Decision Process

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The Critical Decision Process

Form a concept

Interpret the data

Apply the principles

Evaluate

Reflect

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Form a Concept

Observe patient’s mental status, skin color, positioning, and note any deformities or asymmetry.

Conduct an initial assessment.

Ascertain your patient’s history.

Conduct a focused physical exam of the appropriate areas.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Interpret the Data

Interpret all of your data in light of your

knowledge and experience.

Your attitude toward managing patients with

these symptoms also becomes a factor.

Determine the most common and

statistically probable conditions that fit your

patient’s initial presentation.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Apply the Principles

Devise a management plan that covers all

contingencies.

Use written protocols, standing orders, and

all the interventions at your disposal to

manage your patient’s particular problem.

Consult medical direction for atypical

presentations.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Evaluate

Reassess your patient’s condition and the

effects of interventions.

Initial impressions may be altered.

A detailed exam may be conducted to find

less obvious conditions.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Reflect

Discuss events with the physician.

Conduct a run critique with the crew.

Increase your experience base.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Putting It All Together

The Six Rs

Read the scene

Read the patient

React

Re-evaluate

Revise the management plan

Review your performance

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Summary

Introduction to Critical Thinking

Paramedic Practice

Critical Thinking Skills

Thinking Under Pressure

The Critical Decision Process