We no longer gather data for MD to evaluate, we make our own decisions about how to treat a pt. And that decision one day could mean the difference between life and death for your pt. We practiced this last week when we tried some scenarios Any examples from real life? We have to be an advocate (agent or delegate) for our patients. We must look out for their best interests and their wishes. They can’t do it for themselves.
Pt seldom present with classic S/S. You can’t just use the cookbook protocol approach It’s just not that easy.
Gather info Analyze data Form Field Diagnosis Devise Plan, and evaluate effectiveness All under pressure and time constraints In the out of hospital environment with factors that do not exist in Hospital Examples?
One of the biggest skills you will develop is when a situation is serious, grave, dire. Choose your own adjective (shit hits the fan) However, most of our calls are mundane.
Patients with obvious life-threats pose limited critical thinking challenges
Patients who fall on the acuity spectrum between minor and life-threatening pose the greatest critical thinking challenge For example Ped resp distress to failure Use your knowledge, skills and clinical judgement to decide when to intervene
Minor medical and traumatic events require little critical thinking and are relatively easy decisions
These only address classic patient presentations – how about non specific complaints or atypical patients Do not address multiple disease etiologies So how do we start to assess and treat these patients
Take the time to think rather than taking impulsive action and anticipate the worst. Have a plan B ready ie be ready to intubate
Ability to think under pressure cannot be taught You will be the team leader, develop clinical judgement with a routine mental checklist Above all – Stay Calm.
Stop and think – beware of tunnel vision, anticipate harmful effects of medications
A. Concept formation 1. MOI/ scene assessment 2. Initial assessment and physical examination 3. Chief complaint 4. Patient history 5. Patient affect (mood attitude) 6. Technical tools a. Pulse oximetry b. Glucose monitoring c. Et cetera B. Data interpretation 1. Data gathered 2. EMT-Critical Care Technician knowledge of anatomy and physiology and pathophysiology (education) 3. EMT-Critical Care Technician attitude 4. Previous experience base of the EMT-Critical Care Technician (clinical experience) 5. Find Differential Diagnosis – preliminary list of possible causes ie audible wheezes, COPD, Asthma etc C. Application of principle 1. Field impression/ working diagnosis (field diagnosis) 2. Protocols/ standing orders 3. Treatment/ intervention D. Evaluation 1. Reassessment of patient 2. Reflection in action 3. Revision of impression 4. Protocol/ standing orders 5. Revision of treatment/ intervention E. Reflection on action 1. Run critique 2. Addition to/ modification of experience base of the EMT-Critical Care Technician
1. Read the patient a. Observe the patient (1) Level of responsiveness/ consciousness (2) Skin color (3) Position and location of patient - obvious deformity or asymmetry b. Talk to the patient (1) Determine the chief complaint (2) New problem or worsening of preexisting condition c. Touch the patient (1) Skin temperature and moisture (2) Pulse rate, strength, and regularity d. Auscultate the patient (1) Identify problems with the lower airway (2) Identify problems with the upper airway e. Status of ABC’s - identifying life-threats f. Complete and accurate set of vital signs (1) Use as triage tool to estimate severity (2) Can assist in identifying the majority of life-threatening conditions (3) Influenced by patient age, underlying physical and medical conditions, and current medications 2. Read the scene a. General environmental conditions b. Evaluate immediate surroundings c. Mechanism of injury 3. React a. Address life-threats in the order they are found b. Determine the most common and statistically probable cause that fits the patient’s initial presentation c. Consider the most serious condition that fits the patient’s initial presentation d. If a clear medical problem is elusive, treat based on presenting signs and symptoms 4. Reevaluate a. Focused and detailed assessment b. Response to initial management/ interventions c. Discovery of less obvious problems 5. Revise management plan 6. Review performance at run critique
Pt assess clinical decision making
Clinical Decision Making
Topics Paramedics as Practitioners Life-Threatening Conditions Protocols, Standing Orders, Algorithms Critical Thinking Process “Six R’s” of Putting It All Together
Introduction 21st Century Paramedics are prehospital practitioners of emergency medicine— not field technicians. As a paramedic, you inevitably will face your moment of truth— a critical decision that can mean the difference between life and death.
Making critical decisions requires critical judgment— the use of knowledge andexperience to diagnose patients and plan their treatment.
A Paramedic …must gather, evaluate, and synthesize much information in very little time. …can then develop a field diagnosis—a prehospital evaluation of the patient’s condition and its causes.
Acuity The severity or acuteness of your patient’s condition.
The spectrum of care in theprehospital setting includes threegeneral classes of patient acuity.
Classes of Acuity Those with obvious life-threats Those with potential life-threats Those with non-life-threatening presentations
Non-life-threats include… Isolated minor illnesses and injuries
Protocols, standing orders,and patient care algorithms provide a standardized approach to emergency patient care.
Protocol A standard that includes general and specific principles for managing certain patient conditions.
Standing Orders Treatments you can perform before contacting the medical control physician for permission.
Algorithm Schematic flow chart that outlines appropriate care for specific signs and symptoms.
To use an algorithm, follow the arrows to yourpatient’s symptoms and provide care as indicated.
While algorithms,standing orders, and protocols provide paramedics with guidance…
Do not allow the linear thinking, or “Cookbook Medicine” that protocolspromote to restrain you fromconsulting with your medical direction physician.
Paramedic’s Critical Thinking Skills (1 of 2) Knowing anatomy, physiology, and pathophysiology Focusing on large amounts of data Organizing information Identifying and dealing with medical ambiguity
Paramedic’s Critical Thinking Skills (2 of 2) Differentiating between relevant and irrelevant data Analyzing and comparing similar situations Explaining decisions and constructing logical arguments
Be like the duck—cool and calm on the water’s surface,while paddling feverishly underneath!
Except for safety concerns, never allow anything to distract you from your most important job— assessing and caring for your patient.
Use reflective,anticipatory thinking when assessing and treating patients.
Thinking Under Pressure With experience, you will learn to manage nervousness and maintain a steadfast, controlled demeanor. Develop a routine mental checklist to stay focused and systematic.
Mental Checklist Scan the situation Stop and think Decide and act Maintain control Re-evaluate
The Critical Decision Process Form a concept Interpret the data Apply the principles Evaluate Reflect
Putting It All Together The Six R’s Read the scene Read the patient React Re-evaluate Revise the management plan Review your performance
Summary Paramedics as Practitioners Life-Threatening Conditions Protocols, Standing Orders, Algorithms Critical Thinking Process “Six R’s” of Putting It All Together