Advance Preparation Invite your medical director in to discuss critical thinking. Invite experienced EMS providers to class to share the lessons of experience. Research and prepare non-EMS-related clinical thinking/decision-making resources.
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Planning Your Time: Plan 40 minutes for this chapter. EMT Diagnosis and Critical Thinking (10 minutes) How a Clinician Reaches a Diagnosis (15 minutes) How an EMT Can Learn to Think Like an Experienced Physician (15 minutes) Note: The total teaching time recommended is only a guideline.
Teaching Time: 10 minutes Teaching Tips: Break old assumptions. EMTs do diagnose. Critical thinking is an essential tool for the EMS provider. Make judgment and critical thinking an ongoing part of your course. When practicing scenarios (in any lesson), add elements of critical thinking and decision making.
Points to Emphasize: A diagnosis is the conclusion that the EMT reaches, after assessing a patient, about the nature of the patient’s condition. Critical thinking is an analytical process that can help to solve problems in an organized and efficient manner. EMTs must use critical thinking to arrive at a diagnosis. Talking Points: Diagnosis for the EMT is called “presumptive diagnosis,” “field diagnosis,” or “working diagnosis.” It can be difficult to differentiate between all the information received; therefore the EMT must simultaneously use critical thinking to determine what information is pertinent. Discussion Topics: Define diagnosis. Discuss what is meant by critical thinking. Describe its role in EMS. Class Activity: Hand out a patient scenario that includes signs and symptoms and assessment findings. Have students develop a diagnosis and defend their conclusions. Knowledge Application: Have a class discussion on critical thinking. Brainstorm important elements of critical thinking and discuss how they relate to making a diagnosis. Critical Thinking: Some say EMTs cannot diagnose. Discuss why their arguments might or might not be true.
Video Clip Obstacles to Problem Solving In what ways can we solve problems? What obstacles do people encounter when solving problems? Why it is important for an EMT to be able to solve problems?
Teaching Time: 15 minutes Teaching Tips: Consider inviting your medical director or other physicians to discuss their approach to making a diagnosis. Use real-world examples to demonstrate the issues involved in making a diagnosis in the world of emergency medicine. Spend time discussing the traits of experienced clinicians. Use specific examples and build a strategy out of the individual components. Present the good and bad habits of experienced providers. Teach the limitations of diagnostic shortcuts.
Talking Points: The first steps are to gather information, consider possibilities, and reach a conclusion. How these steps are implemented varies significantly among traditional clinicians, emergency medicine clinicians, and EMS clinicians.
Point to Emphasize: The availability of resources is what often guides the approach to making a diagnosis. Talking Points: Further evaluation involves diagnostic tests such as laboratory values or x-rays and may sometimes lengthen the differential diagnosis or (“differential” for short). Discussion Topic: Contrast the traditional diagnostic method with the techniques of emergency providers. How do they differ, and why?
Point to Emphasize: Emergency physicians and EMS providers must account for immediate life threats in their diagnostic procedures. Talking Points: Information gathered from the history and physical can guide the ED physician toward a differential and the ordering of specific tests. However, the ED physician does not have as many testing modalities available as the traditional clinician. This may require only the most serious of differentials to be resolved leaving the less significant for follow-up. Discussion Topic: Discuss how experienced providers approach making a diagnosis. What specific traits do they use in their technique? Class Activity: Discuss problem solving with your medical director. What insights might this person have?
Talking Points: The EMT has a great deal in common with the emergency physician. Both have limited resources, must act quickly and efficiently, and have limited treatment options. The EMT, however, is not burdened with multiple types of patients at the same time which adds its own limitations. EMTs face adverse conditions and have very limited options at their disposal. EMT education is focused on certain conditions with high morbidity and mortality. Knowledge Applications: Have students work in small groups to examine particular diagnostic methods (traditional, emergency physician, and EMT). Have groups present and discuss their findings. Have students interview experienced providers about how they reach a diagnosis. Discuss students’ findings.
Talking Points: The list of diagnoses may often be short or general. Through re-evaluation and reassessment the EMT may gather additional information leading to a restatement of the chief complaint. Discussion Topic: Contrast the traditional diagnostic method with the techniques of emergency providers. How do they differ, and why? Class Activity: Challenge students with exceptionally difficult scenarios. The point is not necessarily to reach the correct diagnosis, but rather to develop a working strategy. Discuss. Critical Thinking: What are the bad diagnostic habits of the experienced provider? How might you avoid these habits as you develop in your career?
Talking Points: You must continually look for information that will rule in/rule out your conclusions. Patients may have more than one thing wrong with them, so you can’t stop looking.
Point to Emphasize: Experienced clinicians develop key traits in the diagnostic approach. Talking Points: Shortcuts in critical thinking are called heuristics. The more time a clinician spends providing care and experiencing different patients, the more information becomes available to them for critical thinking and diagnosis. They begin to see patterns and similarities that can help steer them in a particular direction. These patterns can also lead to biases that can affect judgment. Biases include representativeness, anchoring and adjustment, overconfidence, confirmation bias, illusory correlation, and search satisfying. Discussion Topics: Describe the pitfalls of diagnostic shortcuts. How might they actually limit an EMTs ability to make an accurate diagnosis? Discuss how experienced providers approach making a diagnosis. What specific traits do they use in their technique? Knowledge Application: Work in small groups. Assign each group a particular diagnostic trait of an experienced provider. Ask them to discuss that trait and present their findings to the class. Findings must include advantages, disadvantages, and applicability to EMS.
Video Clip Decision-Making Information Why is it important to cast away underlying assumptions when making a decision? What is the difference between decision making and problem solving? Why is it important to define a problem? Discuss the steps in solving a problem. What is group think?
Teaching Time: 15 minutes Teaching Tips: Since students like things to be clear cut, instructors often make the mistake of trying to make everything completely objective. Imprint early on that medicine is, in many ways, a subjective science. Demonstrate that good providers are flexible. Medicine constantly changes. Invite experienced providers to class. Have them discuss the lessons that they have learned and validate the traits discussed in this section.
Points to Emphasize: There are critical thinking traits that EMTs can learn from experienced providers. Adopting these attitudes can improve their capability to solve problems and work through difficult issues. Ambiguity and uncertainty will always be present in medicine. This is true in the back of an ambulance as well. Talking Points: Understand the limits of your knowledge and realize you won’t always have the answer you seek. When you get a vital sign or a value that doesn’t seem right, don’t assume it’s wrong. Investigate it. Discussion Topics: Describe the role of ambiguity in the diagnostic process. How do the limitations of technology impact an EMT’s diagnostic technique?
Points to Emphasize: Many of the attitudes and understandings of experienced clinicians focus upon flexibility. This is an extremely important trait for a new EMT to develop. Talking Points: Medicine is an ever-changing field. As a clinician, you must stay up-to-date with information and continually strive to learn. One of the requirements of licensure is continuing education. Utilize continuing education to remain ahead of the new information concerning treatment, research in EMS, and updates on protocols. No matter your experience, seek methods from other providers and listen to suggestions from all experience levels.
Discussion Topics: How do both a strong foundation of learning and continued education improve an EMT’s ability to diagnose? Define and discuss the term elaborated knowledge. Class Activity: Discuss problem solving with an experienced EMS provider. What lessons has this person learned from experience? Knowledge Application: Have students work in small groups. Assign each group an attitude or understanding of an experienced clinician. Have the groups present ways in which those traits improve diagnostic technique. Critical Thinking: This section presents “learning from others” as a positive trait used to improve diagnostic technique. What actual steps might you use on the job to realize this strategy?
Talking Points: Reaching a diagnosis is a process that can be learned. Critical thinking comes from study, practice, and reflection. It is a skill that takes time. Know the boundaries of your knowledge. Don’t let a diagnosis attempt delay your patient care.
Video Clip Leadership What are the desired outcomes of effective leadership? Why is it important for an EMT to be an effective leader? List qualities of an outstanding leader. When providing emergency care, why must an EMT balance the needs of others? Discuss some roles associated with different levels of management.
Video Clip Delegating Authority What is delegation? Who is accountable when a task has been delegated to another person? What can delegation accomplish? Why should an EMT be able to delegate tasks to others effectively? What factors might negatively impact effective delegation? Why is praise from a leader essential?
Talking Points: A differential is based on history, physical exam, and vital signs and includes both physical and intellectual activity. The first priority in emergency medicine is finding and alleviating all life threats. Heuristics allow an experienced provider to utilize shortcuts to reach a diagnosis, saving time and ultimately benefiting the patient. By embracing ambiguity, understanding limitations, utilizing different methods, forming a strong foundation of knowledge, being organized, and being a lifelong student as well as reflecting on what we have learned, we can think like experts.
Talking Points: The complaint of chest pain should encourage you to ask additional questions. “Stress” should not be the diagnosis and the complaint of chest pain should be taken seriously. Consider immediate life threats, then additional resources. The next step is to assess the patient and begin to draw some conclusions. What might some of those conclusions be?
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