Paramedics
           And
        Probability

     Bridging the Gap between
Critical Thinking & Critical knowledge
What is Critical Thinking?
Critical thinking is the intellectually disciplined
process of actively and skillfully conceptu...
What is Critical Thinking?

Critical thinking can be seen as having two
  components:

1) a set of information and belief ...
Science in collaboration with Caring

 Adult Learning      Clinical Trials

 Statistics          Practical’s

 Optimi...
Operational Management
   Staffing Schedules

   Response Staffing

   Response Criteria

  Treatment Priorities

   ...
Operational Management

   Response Staffing
         2 Paramedics
         1 Paramedic & EMT - B

   Response Criteri...
Operational Management

  Treatment Priorities
       IV, O2, EKG, Transport
       Maintaining BP at 120/80
       Fl...
Classroom Management
   Schedules

  Blue Prints of Knowledge

  Exams

   Make-Up Exams
20 Students, 10 Subjects, 53 Make-up exams!

              Time, Effort, and Schedules are all a concern



              ...
How do you schedule Make-up Test for each Subject?


                        1 2 3 4 5 6 7 8 9   10   11   12   13    14  ...
As the Program Director, how do YOU
  resolve the Make-Up Exam issue?

    Methods:
     Create 30 hours Days

        S...
WELL !?!?!

                        1 2 3 4 5 6 7 8 9 10   11   12   13   14   15    16   17   18   19 20
EMS History     ...
As the Program Director, how do YOU
  resolve the Make-Up Exam issue?
           Make the Solution a:
       “COLORING Pro...
1 2 3 4 5 6 7 8 9   10   11   12 13 14   15    16   17   18   19 20
EMS History             1 1 0 0 0 1 1 0 0    0    1   ...
EMS Law 8          Physics        4
            Algebra 5          Ana            3
            Tech Wr 5          Amb Ops...
SO. . .

How many Testing sessions are required ??

                                       Anat
                   Tech Wr...
Let’s Look at Another Example


       G   6   H   5    I

       4       3        7

       D   9   E   4    F

       5 ...
Which is the Fastest Route ??


       G   6   H   5    I

       4       3        7

       D   9   E   4    F

       5 ...
What Method did you use to
    Determine that ??

     G   6   H   5    I

     4       3        7

     D   9   E   4    ...
3 X 3 Block = 20 routes

6 Operations per Block = 120 Operations



    G   6    H   5     I

    4        3        7

   ...
How about Dynamic Programming ?



          11        5

          G    6   H        5    I

          4        3        ...
9 Routes

              For a Total of 32 Operations


     11        5

     G    6    H       5    I

     4         3  ...
1987, England

Commercial Airliner crashes

   126 People onboard

       87 Survived


   HOW ? WHY ?
Injury Severity Scores of Passengers


       Dead            Survivors
       (Scores)          (Scores)


 Min     12   ...
Injury Severity Scores of Passengers

The ISS is also an anatomically based
 ordinal scale, with a range from 1 to
       ...
Injury Severity Scores of Passengers


The ISS is then calculated as the sum
  of the squares of the highest AIS
 scores f...
AIS Score      Injury

   1           Minor

   2         Moderate

   3          Serious

   4          Severe

   5     ...
An example of the ISS calculation is shown below:
      Region             Injury                 AIS        Square
      ...
Injury Severity Scores of Passengers

Highest ISS score obtainable is 75.

ISS below 25 = minimal mortality risk

ISS of 5...
Injury Severity Scores of Passengers


       Dead            Survivors

 Min    12                1

 Mid    66          ...
Does the ISS provide us with the Answers?


                Probably NOT!

   Researchers looked at all the passengers
   ...
pH became one of the greater predictors
             of survival

              Survivors

          Range: 7.45 – 7.58

 ...
What Value Does this information have
             for US ?!?

  Can it provide us with a method to
  determine which Pati...
“Today the triage officer has to play God!”
                                       Noted Paramedic


         Which two ar...
Which two are first to be
               transported?

Victim                                           Respiration   Puls...
Which two are first to be
              transported?

Victim                                           Respiration   Pulse...
Which two are first to be
              transported?

Victim                                           Respiration   Pulse...
Which two are sent first to the ED?


Victim                                       Transport Order / Treatment Order
1. el...
Summary
 Many tools available to increase the
  quality of care we provide to OUR
                patients
Numerous proces...
Summary


Provide a scientific basis from which the



     “Hands of Medicine”

           “Cares”
Bob Waddell II

bobwaddell@bresnan.net

    (307) 920 2020
Critical Thinking
Critical Thinking
Critical Thinking
Critical Thinking
Critical Thinking
Critical Thinking
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Critical Thinking- Shore EMS Conference 2010

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Critical Thinking

  1. 1. Paramedics And Probability Bridging the Gap between Critical Thinking & Critical knowledge
  2. 2. What is Critical Thinking? Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness.
  3. 3. What is Critical Thinking? Critical thinking can be seen as having two components: 1) a set of information and belief generating and processing skills, and 2) the habit, based on intellectual commitment, of using those skills to guide behavior.
  4. 4. Science in collaboration with Caring  Adult Learning  Clinical Trials  Statistics  Practical’s  Optimization  Probability  Modeling  Simulation
  5. 5. Operational Management  Staffing Schedules  Response Staffing  Response Criteria Treatment Priorities  Vehicle Staging
  6. 6. Operational Management  Response Staffing  2 Paramedics  1 Paramedic & EMT - B  Response Criteria  9 minutes response times
  7. 7. Operational Management Treatment Priorities  IV, O2, EKG, Transport  Maintaining BP at 120/80  Fluid Bolus  Vehicle Staging  System Status Management
  8. 8. Classroom Management  Schedules Blue Prints of Knowledge Exams  Make-Up Exams
  9. 9. 20 Students, 10 Subjects, 53 Make-up exams! Time, Effort, and Schedules are all a concern 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0 Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0 Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0 Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0 Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 Anatomy 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 Pharmacology 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0 Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
  10. 10. How do you schedule Make-up Test for each Subject? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0 Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0 Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0 Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0 Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 Anatomy 0 0 0 0 1 0 0 00 1 0 0 0 0 1 0 0 0 0 1 Pharmacology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0 EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0 Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 Students 2, 7, 12, and 17 have conflicts if Technical Writing and Algebra are schedule at the same time. Students 1, 3, 6, 8, 11, 13, 16, and 18 have conflicts if Chemistry and Pharmacology are scheduled at the same time.
  11. 11. As the Program Director, how do YOU resolve the Make-Up Exam issue? Methods:  Create 30 hours Days  Specific Make-Up Test Times  Trial and Error  Other ??
  12. 12. WELL !?!?! 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0 Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0 Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0 Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0 Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 Anatomy 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 Pharmacology 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0 Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
  13. 13. As the Program Director, how do YOU resolve the Make-Up Exam issue? Make the Solution a: “COLORING Problem” A Welch – Powell or Chromatic Number Algorithm
  14. 14. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0 Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0 Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0 Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0 Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 Anatomy 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 Pharmacology 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0 Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 Anat Tech Wr EMS Hx Amb Ops Algebra Chem Bio EMS Law Phys Pharm
  15. 15. EMS Law 8 Physics 4 Algebra 5 Ana 3 Tech Wr 5 Amb Ops 3 EMS Hx 4 Bio 2 Chem 4 Pharm 2 Anat Tech Wr EMS Hx Amb Ops Algebra Chem Bio EMS Law Phys Pharm
  16. 16. SO. . . How many Testing sessions are required ?? Anat Tech Wr EMS Hx Amb Ops Algebra Chem Bio EMS Law Phys Pharm FOUR !!
  17. 17. Let’s Look at Another Example G 6 H 5 I 4 3 7 D 9 E 4 F 5 9 8 A 6 B 10 C
  18. 18. Which is the Fastest Route ?? G 6 H 5 I 4 3 7 D 9 E 4 F 5 9 8 A 6 B 10 C
  19. 19. What Method did you use to Determine that ?? G 6 H 5 I 4 3 7 D 9 E 4 F 5 9 8 A 6 B 10 C
  20. 20. 3 X 3 Block = 20 routes 6 Operations per Block = 120 Operations G 6 H 5 I 4 3 7 D 9 E 4 F 5 9 8 A 6 B 10 C
  21. 21. How about Dynamic Programming ? 11 5 G 6 H 5 I 4 3 7 8 15 D 9 E 4 F 7 5 9 8 20 A 6 B 10 C 15 17
  22. 22. 9 Routes For a Total of 32 Operations 11 5 G 6 H 5 I 4 3 7 8 15 D 9 E 4 F 7 5 9 8 20 A 6 B 10 C 15 17
  23. 23. 1987, England Commercial Airliner crashes 126 People onboard 87 Survived HOW ? WHY ?
  24. 24. Injury Severity Scores of Passengers Dead Survivors (Scores) (Scores) Min 12 1 Mid 66 12 Max 75 50
  25. 25. Injury Severity Scores of Passengers The ISS is also an anatomically based ordinal scale, with a range from 1 to 75. To compute the ISS the nine AIS body regions are grouped into six: head or neck, face, chest, abdominal or pelvic contents, extremities or pelvic girdle, and external.
  26. 26. Injury Severity Scores of Passengers The ISS is then calculated as the sum of the squares of the highest AIS scores for the three most severely injured body regions.
  27. 27. AIS Score Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Unsurvivable
  28. 28. An example of the ISS calculation is shown below: Region Injury AIS Square Description Top Three Head & Neck Cerebral 3 9 Contusion Face No Injury 0 Chest Flail Chest 4 16 Abdomen Minor Contusion 2 of Liver 5 25 Complex Rupture Spleen Extremity Fractured femur 3 External No Injury 0 Injury Severity Score: 50
  29. 29. Injury Severity Scores of Passengers Highest ISS score obtainable is 75. ISS below 25 = minimal mortality risk ISS of 50 = mortality of 50% ISS is 70 = it is close to 100%
  30. 30. Injury Severity Scores of Passengers Dead Survivors Min 12 1 Mid 66 12 Max 75 50
  31. 31. Does the ISS provide us with the Answers? Probably NOT! Researchers looked at all the passengers Vital Signs including: Pulse pH Respirations Mental Status PO2 Blood Pressure
  32. 32. pH became one of the greater predictors of survival Survivors Range: 7.45 – 7.58 Only one of the Dead had a pH within this range
  33. 33. What Value Does this information have for US ?!? Can it provide us with a method to determine which Patient to care for first? Which Patient has the greatest potential for survival? Something else?
  34. 34. “Today the triage officer has to play God!” Noted Paramedic Which two are first to be transported? Victim Respiration Pulse Mental Status 1. elderly lady seems unconscious... <30 Yes Obeys Commands 2. unconscious man pulled from train... <30 Yes Localizes 3. middle age woman awakes confused... <30 Yes Obeys Commands 4. unconscious patient .. pulse is slow... >30 Yes Withdraws pain 5. unconscious woman… breathing slow... <30 Yes Extends from pain 6. woman on stretcher .. breathing rapidly… >30 Yes Pushes away pain 7. Amtrak porter found .. breathing rapidly… <30 Yes Pushes away pain 8. unconscious victim ... trouble breathing... <30 Yes Extends from pain Based on START criteria
  35. 35. Which two are first to be transported? Victim Respiration Pulse Mental Status 1. elderly lady seems unconscious... <30 Yes Obeys Commands 2. unconscious man pulled from train... <30 Yes Localizes 3. middle age woman awakes confused... <30 Yes Obeys Commands 4. unconscious patient .. pulse is slow... >30 Yes Withdraws pain 5. unconscious woman… breathing slow... <30 Yes Extends from pain 6. woman on stretcher .. breathing rapidly… >30 Yes Pushes away pain 7. Amtrak porter found .. breathing rapidly… <30 Yes Pushes away pain 8. unconscious victim ... trouble breathing... <30 Yes Extends from pain Based on START criteria
  36. 36. Which two are first to be transported? Victim Respiration Pulse Mental Status 1. elderly lady seems unconscious... 28 56 Obeys Commands 2. unconscious man pulled from train... 20 130 Localizes Pain 3. middle age woman awakes confused... 8 40 Obeys Commands 4. unconscious patient .. pulse is slow... 44 36 Withdraws pain 5. unconscious woman… breathing slow... 6 20 Extends from pain 6. woman on stretcher .. breathing rapidly… 36 130 Pushes away pain 7. Amtrak porter found .. breathing rapidly… 40 44 Pushes away pain 8. unconscious victim ... trouble breathing... 8 38 Extends from pain Based on START criteria
  37. 37. Which two are first to be transported? Victim Respiration Pulse Mental Status 1. elderly lady seems unconscious... 28 56 Obeys Commands 2. unconscious man pulled from train... 20 130 Localizes Pain 3. middle age woman awakes confused... 8 40 Obeys Commands 4. unconscious patient .. pulse is slow... 44 36 Withdraws pain 5. unconscious woman… breathing slow... 6 20 Extends from pain 6. woman on stretcher .. breathing rapidly… 36 130 Pushes away pain 7. Amtrak porter found .. breathing rapidly… 40 44 Pushes away pain 8. unconscious victim ... trouble breathing... 8 38 Extends from pain
  38. 38. Which two are sent first to the ED? Victim Transport Order / Treatment Order 1. elderly lady seems unconscious... Fifth 2. unconscious man pulled from train… Sixth 3. middle age woman awakes confused... Third 4. unconscious patient .. pulse is slow... First 5. unconscious woman… breathing slow... Eighth 6. woman on stretcher .. breathing rapidly… Fourth 7. Amtrak porter found .. breathing rapidly… Second 8. unconscious victim pinned.. trouble breathing... Seventh
  39. 39. Summary Many tools available to increase the quality of care we provide to OUR patients Numerous processes that can be taught in the classroom and clinical settings which promote better utilization of resources = HIGHER QUALITY OF CARE Allows EMS providers to become an active participant in the Practice of Emergency Care
  40. 40. Summary Provide a scientific basis from which the “Hands of Medicine” “Cares”
  41. 41. Bob Waddell II bobwaddell@bresnan.net (307) 920 2020

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