Transcript Chapter 14: Critical Thinking and Critical Decision Making

Chapter 14
Critical Thinking and
Clinical Decision Making
National 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.
Introduction
• Paramedics must be able to:
− Identify problems.
− Set patient care priorities.
− Develop a care plan.
− Execute the plan.
Introduction
• Cookbook medicine can lead to ineffective
care.
− Patients may present atypically.
− The scene may be unstable.
© Mark C. Ide
• You are expected to provide quality patient
care.
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
• 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 decisionmaking process.
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
• 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
• 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
• 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
• You must
immediately
recognize and treat
life threats.
− Circumstances
determine the
treatment plan.
− Use criticalthinking and
decision-making
skills.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
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
• 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.
© Peter Willott, The St. Augustine Record/AP Photos
Range of Patient Conditions
Range of Patient Conditions
• Critical patients
• Serious patients
• Mortally wounded or
dead
• “Walking wounded”
or minimally injured
• Critical life threats
include:
− Major multisystem
trauma
− Devastating singlesystem trauma
− End-stage disease
presentations
− Acute presentations of
chronic conditions
Range 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 Formation
• First stage in
prehospital care
• Gather information
from your senses
and diagnostic
tools.
© Craig Jackson/InTheDarkPhotography.com
• Begins as the
paramedic arrives
at the scene
Concept 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 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 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 Action
• Fourth step
• Treat patients
while monitoring
intervention
effects.
− Avoid tunnel vision.
© Craig Jackson/InTheDarkPhotography.com
Reflection 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 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
• 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 Rs
• Read the scene.
− Overall safety
− Environmental
conditions
− Immediate
surroundings
− Access and egress
− Mechanism of
injury
© Jones & Bartlett Learning. Courtesy of MIEMSS.
The 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 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 Rs
• Revise the plan.
− Be open to changing working diagnosis.
• Review the performance.
− Continuous quality improvement (CQI) meeting
− Informal discussions with partners
Summary
• 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).
Summary
• 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.
Summary
• 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.
Summary
• 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.
Summary
• 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.
Summary
• Paramedics should maintain an attitude that
is open to learning in order to constantly
improve their practice and maintain
excellence in prehospital care.
Credits
• 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.