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Developing Clinical Reasoning in Paramedicine
- 1. CAA500 Assessment Task 2 Video Presentation Nick Callanan
- 2. The need for developing clinical reasoning and decision making in Paramedicine? Development of clinical reasoning and decision making may: Provide benefit to the patient/s Minimise harm to the patient/s Allow for growth in Paramedicine Such as new procedures or drugs Professional Registration It has already allowed for the creation of Intensive Care Paramedics (ICPs) and Extended Care Paramedics (ECPs) With further development other roles may be created.
- 3. Novice vs Average vs Expert Differences in Individual Clinical Decision Makers There is a large number of differences between a novice, average or expert individual clinician. In this presentation I will focus on the following: Cognitive Load The total amount of effort being used in the working memory Learning The individuals want and need to learn Clinical Skills The individuals understanding of learning undertaken Task Ability The individuals ability to undertake tasks Protocols The individuals use of clinical protocols
- 4. Novice Clinician Average Clinician Expert Clinician Cognitive Load • High • Medium • Low Learning • Still trying to learn • No new info • Self educates to maintain job • Motivated • Undertakes in depth research Clinical Understanding • Low • Overwhelmed with information • Medium • Confident in ability • High • Confident in ability • Educates others Clinical Skills • Developing • Understands required skills • Understands reasoning behind their need or use Task ability • Focuses on individual task Poor communication • Multitasks • Increased communication ability • Multitasks Makes advanced clinical decisions Great communication skills Protocols • Follows guidelines with assistance • Individually follows guidelines • Adapts to changing clinical situations
- 5. Novice vs Average vs Expert Levels of Information Processing Novice Generate extensive clinical data High Cognitive load Average Clinician Gathers enough clinical data to make a diagnosis Medium cognitive load Expert Clinician Can often recognise diseases by pattern recognition Low cognitive load
- 6. Illness Scripts Overview Step 0 – Develop ‘Disease Illness script’ Step 1 – Create a Simple Problem List Step 2 – Process Problem List Step 3 – Create ‘Patient Illness Script’ Step 4 – Differential Diagnosis
- 7. ‘Disease Illness Scripts’ Illness scripts contain 4 main sections Epidemiology Who gets the disease/Illness? Time Course How does the disease progress with respect to time? Clinical Presentation Classical Signs and Symptoms Mechanisms What is the biomedical cause of the disease/illness? A clinician will develop these over the span of their career
- 8. Illness Scripts Epidemiology Who gets the illness/disease? Includes: Demographics Age, Gender, Race/ethnicity Risk Factors Other conditions which may impact on the illness Exposures Travel, Occupation, Activities (sexual, hobbies), Pets, Close contacts
- 9. Illness Scripts Time Course How does the disease present with respect to time? Duration of prodrome or symptoms Hyperacute Acute Subacute Chronic Pattern of prodrome or symptoms Constant Stable or worsening Episodic Waxing and waning Biphasic Intermittent
- 10. Illness Scripts Clinical Presentation Classical Signs and Symptoms Key & Differentiating features (Features which allow for distinguishing between diseases which may present with the same syndrome) Must Have (Key) Features Without this feature the disease may not be diagnosed Rejecting Feature Diagnosis may not be made if this feature is present
- 11. Illness Scripts Mechanism What is the biomedical cause of the disease? Known derangements in: Anatomy Physiology Immunology Biochemical Pathways Genetics Known environmental contributors: Microbiology Toxins Pharmacology
- 12. Example Disease Illness Script (Gastroenteritis – Viral & Bacterial) Epidemiology More common in children Common in 3rd world countries Time Course Often acute (mostly viral) Can be chronic (mostly bacterial) Clinical Presentation Both diarrhoea and vomiting Abdominal cramps Melena in stools (bacterial) Dehydration Fever Fatigue Headache General Muscle Pain Mechanisms A pathogenic infection of the small or large bowel.
- 13. Illness Scripts Overview Step 0 – Develop ‘Disease Illness script’ Step 1 – Create a Simple Problem List Step 2 – Process Problem List Step 3 – Create ‘Patient Illness Script’ Step 4 – Differential Diagnosis
- 14. Simple problem lists Information is gathered from the patient This should be information which is thought to be relevant to the current presentation Often an extensive list with some information being irrelevant or non-specific to their current disease/illness
- 15. Example Problem List 15yo Male Fever Vomit x5 Watery Denies Blood Diorrhea since this AM Runny Denies Blood Dark urine Abdominal Pain Headache (2/10 Pain) Feeling fatigued Warm, Pink, Clammy skin Poor oral water tolerance Tachycardic Hypotensive
- 16. Illness Scripts Overview Step 0 – Develop ‘Disease Illness script’ Step 1 – Create a Simple Problem List Step 2 – Process Problem List Step 3 – Create ‘Patient Illness Script’ Step 4 – Differential Diagnosis
- 17. Processed Problem List This step is designed to process information into medical terms which may assist with recall Often many signs and symptoms are joined together to form a syndrome or disease to further aid in diagnosis Fewer items on this list may aid in narrowing the diagnostic possibilities
- 18. Processed Problem List Example 15yo Male Fever Vomit x5 Watery Denies Blood Diorrhea since this AM Runny Denies Blood Dark urine Abdominal Pain Headache (2/10 Pain) Feeling fatigued Warm, Pink, Clammy skin Poor oral water tolerance Tachycardic Hypotensive 15yo Male Vomiting and Diorrhea since AM Dehydration Headache Fatigue Abdo Pain Clammy Skin
- 19. Illness Scripts Overview Step 0 – Develop ‘Disease Illness script’ Step 1 – Create a Simple Problem List Step 2 – Process Problem List Step 3 – Create ‘Patient Illness Script’ Step 4 – Differential Diagnosis
- 20. Patient Illness Script The elements of a patient Illness script are similar to a disease illness script to aid with a differential diagnosis and to aid with pattern recognition. Elements include: Epidemiology Exposures & Past History (ONLY as a risk or predisposing factor) Time Course Duration, Persistence & Intensity Syndrome Statement Elements of processed problem list which aren’t listed above Important Past Medical History If not mentioned elsewhere
- 21. Example Patient Illness Script Epidemiology 15yo Male Time Course Acute Syndrome Statement Vomiting Diorrhea Dehydration Headache Fatigue Abdo Pain Clammy Skin Other PMHx N/A 15yo Male Vomiting and Diorrhea since AM Dehydrated Headache Fatigue Abdo Pain Clammy Skin
- 22. Illness Scripts Overview Step 0 – Develop ‘Disease Illness script’ Step 1 – Create a Simple Problem List Step 2 – Process Problem List Step 3 – Create ‘Patient Illness Script’ Step 4 – Differential Diagnosis
- 23. Differential Diagnosis This process sorts through various hypotheses of conditions in an attempt to diagnose the patients current condition. This process is often done using tiers This sorts the hypotheses into most to least likely and assigns emergency acuity If more than 1 disease remains a Venn diagram may be used This compares and contrasts diseases in an attempt to diagnose the patient
- 24. Illness Scripts Teirs Tier I – Clinically High Likelihood Disease explains all of patients major findings Patient has all major manifestations of the disease They have no rejecting features & may have a key feature Tier IE - Emergency (Regardless of likelihood) Used to treat lower likelihood diseases because there may be severe consequences if missed Do not overuse this category Tier II – Clinically Moderate Likelihood Disease exposes most of the patient’s findings Patient lacks some of the usual manifestations of the disease The patient has no rejecting features Tier III – Clinically Low Likelihood Patient has single or few features of disease Patient has a rejecting feature of the disease
- 25. Example Tiers Tier I – Clinically High Likelihood Gastroenteritis (Viral) Tier IE - Emergency (Regardless of likelihood) Appendicitis Tier II – Clinically Moderate Likelihood Gastroenteritis (Bacterial) Food poisoning Tier III – Clinically Low Likelihood Bowel Cancer
- 27. Still Unknown Gather more information Gathering large amounts is acceptable in this situation Complete more clinical tests