ADVANCED ASSESSMENT Critical Thinking Skills “The eyes only see what the brain knows” ONTARIO BASE HOSPITAL GROUP Mike Muir AEMCA, ACP, BHSc Kevin McNab AEMCA, ACP Narrated by: Rob Theriault Instructor Notes by: Rob Theriault EMCA, RCT(Adv.), CCP(F) • Welcome to the slide presentation on Critical Thinking Skills • This is the first in a series of slides in Module 1of the Rural Remote concept Program • I say “concept” because the Rural Remote ACP Program is in it’s conceptual stage. The concept is one of providing the didactic portion of an ACP program through a distance education format to facilitate the training of Paramedics in rural and remote communities. The hope is that community colleges will adopt this concept to facilitate the ACP education of Paramedics where traditional face to face teaching is not practical. • A prerequisite to this series of slides is the OBHG Education Subcommittee’s ALS Pre- course manual, Second Edition (Copyright 2005, Ministry of Health and Long Term Care).
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ADVANCED ASSESSMENTCritical Thinking Skills“The eyes only see what the brain knows”
• Welcome to the slide presentation on Critical Thinking Skills• This is the first in a series of slides in Module 1of the Rural Remote concept Program• I say “concept” because the Rural Remote ACP Program is in it’s conceptual stage. The
concept is one of providing the didactic portion of an ACP program through a distanceeducation format to facilitate the training of Paramedics in rural and remote communities.The hope is that community colleges will adopt this concept to facilitate the ACPeducation of Paramedics where traditional face to face teaching is not practical.
• A prerequisite to this series of slides is the OBHG Education Subcommittee’s ALS Pre-course manual, Second Edition ( Copyright 2005, Ministry of Health and Long TermCare).
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AUTHORSMike Muir AEMCA, ACP, BHScParamedic Program ManagerGrey-Bruce-Huron Paramedic Base HospitalGrey Bruce Health Services, Owen Sound
Kevin McNab AEMCA, ACPQuality Assurance ManagerHuron County EMS
Copyright 2005, 2003 Ontario Base Hospital Group
ADVANCED ASSESSMENTCritical Thinking Skills
REVIEWERS/CONTRIBUTORSRob Theriault EMCA, RCT(Adv.), CCP(F)Peel Region Base Hospital
Not all slides have soundNot all slides have sound
Paramedic profession has changed21st century healthcare has changed.
technology of the day has changed our status.we are professionals, not technicians.
to fulfill this role you must develop new ways ofhandling situations.develop critical thinking skills.
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Instructor Notes:
• Educated care providers – i.e. those who understand the rationale behind the protocolsare more likely to comply with protocols and standing orders as they are better equippedto appreciate the risk/benefit ratio of any intervention. If you look at the U.S. system ofEMS education, they have completely overhauled & improved (and extended) theeducational requirements to reach the EMT-P level (see U.S. National StandardCurriculum). They have done so because EMS educators, Medical Directors and EMSindustry leaders realized that basic training and instruction on following algorithmswasn’t sufficient – that “technicians” are more likely to breech protocol because theyunable to fully grasp the risk/benefit ratio of any given procedure and therefore can’tappreciate the consequences of protocol deviation or non-compliance.
• Paramedicine is a very dynamic field. Practices change frequently based on the newerand more sound research
• Technologies also change and improve, and this requires a more educated and criticalthinking Paramedic. e.g. the introduction in recent years of pulse oximetry to prehospitalcare.
• We are professional health care providers - not technicians.• To fulfil the role of health care professional we need a thorough knowledge of medicine
and technology to handle every day emergencies in new and betters ways
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every patient is unique.very few, if any, patients have read the textbook.patients seldom look like the book says they aresupposed to…e.g. have “pressure-like” chestdiscomfort when having a heart attack.don’t rely on so-called “classic” presentationsemploy a systematic, yet focused approach to everypatient and don’t rely on “pattern” recognition
Why Is Critical Thinking Important?
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Instructor Notes:
• “Every patient is unique”. That sounds like an obvious statement, but the reality is thatdespite a number of so-called “classic” presentations, there are a number of patientswho present with atypical signs and symptoms and there are those who may haveclassic symptoms, but the Paramedic has to go the extra mile to extract the information.This may occur for a variety of reasons including language barrier, patient’s level ofdistress, denial, etc
• Standing orders and algorithms are written and designed to ensure the maximumnumber of patients will benefit from a standing order and a minimum number will beplaced at risk. Having said this, the critical thinker will assume that every patient isunique and at risk until proven otherwise. Patient’s don’t read the textbooks and so weshouldn’t expect that every patient’s clinical presentation is going to have at least one ormore classic clinical features – case in point, the number of AMIs who present withatypical signs and symptoms.
- Memorizing information results in short term recall. Understanding leads to long termmemory
- “pattern” recognition refers to looking at a patient’s presentation superficially andinferring a provisional diagnosis based on a perception that this patient looks just likeanother you’ve seen and therefore their diagnosis must be………………. Patternrecognition with patient presentation leads to misdiagnosis. A sequential and focusedassessment, keeping an open mind and using open ended questions and aninvestigative curiosity will yield greater accuracy
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Goal For Every Paramedic
develop Differential Diagnosis.narrow it to a Field Diagnosis.develop and Implement a treatment strategy.reassess & re-evaluatedo it well!!
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Instructor Notes:
- A “Differential diagnosis” is the formal way for describing what Paramedics do on everycall. It’s the process of narrowing the diagnosis down to a list of 2-5 possibilities byperforming a focused assessment and taking a thorough history. The key however is toactually go through a mental process of coming up with a list of 2-5 possibilities.
- Differential diagnosis is an important term because it’s the correct terminology for whatwe do.
- The differential diagnosis is the platform from which to choose the most appropriatetreatment(s). It’s also the point at which it may be more appropriate to withhold atreatment – e.g. withholding ASA in a suspected thoracic aortic dissection, or choosing totransport quickly and differ the performance of procedures until en route to the hospitalas these interventions are unlikely to be of any benefit and may be harmful if they delaytransport.
- Frequent re-evaluation of the patient and treatment strategy, especially in the criticalpatient, is imperative.
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Components of Critical Thinking
sound knowledge: “the eyes only see what the brain knows”formulating a differential diagnosis
Looking at signs & symptoms in terms of their sensitivity &specificity
determine a treatment plan while weighing therisk/benefit ratio for all interventionsre-evaluating
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Instructor Notes:
• “the eyes only see what the brain knows”. A differential diagnosis is not possible withouta sound knowledge.
• e.g. a difference in blood pressure between the right and left arm, combined with tearing-like chest pain may signify a dissecting thoracic aneurysm (blood dissects between theintimal layer and the tunica media into one of the subclavian arteries, lowering the BP inone arm). If you didn’t know this, you wouldn’t think to perform this assessment and youwould be lacking a piece of valuable information to help narrow the differential diagnosis.
• Every treatment intervention requires that you carefully weight the risks against thebenefits. e.g. nitroglycerin may improve coronary circulation and reduce the heart’sworkload through venodilation and preload reduction, but it also lowers blood pressure.i.e. the balance of the risk:benefit ratio can swing in either direction depending on thepatient’s current presentation and how she/he responds to initial treatment(s).
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Sound Knowledge
a thorough knowledge of body systems and medicalconditions is essential for processing informationobtained through patient assessment and historygatheringwithout a sound knowledge, you would not knowwhat information is relevant and what information ismissing to help you make decisions about treatment
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Instructor Notes:• A thorough knowledge of body systems and medical conditions is essential• For example...abdominal pain can be vague. A sound knowledge of the organs and
vessels in the abdomen and the signs and symptoms associated with an acute event isessential for the paramedic to be able to distinguish the benign from the life threatening.
• When there is a language barrier or when the patient simply doesn’t know their medicalhistory, a good knowledge of prescription drugs may provide invaluable information.
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Scenario # 1
Your patient is a 58 year old male. His chiefcomplaint is shortness of breath. He tells you hischest is “uncomfortable”. The patient appears to bein moderate to severe distress with 1-2 word dyspnea.Auscultation of the chest reveals crackles.At this point, what is the differential diagnosis?
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Take a minute now, before you move to the next slide, andwrite down a list of at least 4-5 conditions which may result in
the presentation described above
Take a minute now, before you move to the next slide, andwrite down a list of at least 4-5 conditions which may result in
the presentation described above
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Instructor Notes:• Ask yourself: what are the causes chest discomfort? What causes 1-2 word dyspnea?
What causes crackles? What causes all three? Can you list more than one condition thatmight result in this presentation?
• Do you have sufficient information to form a management plan at this point?• There is a long list of conditions that make the chest feel “uncomfortable”• There are also many conditions that result in pulmonary crackles - are they
unilateral or bilateral crackles - this may make the difference between a cardiacetiology and some other cause
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Differential Diagnosis
AMI or anginaacute pulmonary edema 2o to CHFcardiogenic shockpulmonary toxinpneumoniaCOPD exacerbationpulmonary embolusother?
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Instructor Notes:• although many of the conditions listed on this slide may typically have unique clinical
features or historical information, all of these conditions can also present as per theprevious slide – this is why it’s critical to come up with a mental list (differential diagnosis)and then narrow the list with further assessments and history gathering
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The Patient Is Getting Worse!!
as you are taking a history, the patient is becomingless responsive.you quickly assess the pulse and find it weak anddifficult to count.the wife tells you he has a history of heart trouble andthat he described the chest pain as “heavy” in nature.his medications include an ACE inhibitor, a nitrate, adiuretic and an antigout drugnow what do you think the problem may be?
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Instructor Notes:
• can you begin to cross off some of the conditions from the list?• Don’t abandon all conditions but one yet, but at this point, and for the purpose of the
exercise, you can scratch off the ones that are now less plausible
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Differential Diagnosis
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AMI or anginaacute pulmonary edema 2o to CHFcardiogenic shockpulmonary toxinpneumoniaCOPD exacerbation or anaphylaxispulmonary embolusother?
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Instructor Notes:• now that we have some additional information about the patient, we can begin to narrow
the differential diagnosis.• Example: there is no mention that the patient is febrile, no recent Hx of infection, no
cough, etc - so we can eliminate pneumonia (this doesn’t mean we can necessarily rule itout entirely, but from a prehospital treatment strategy perspective we can take it off thelist)
• nothing in the history at this point suggest an exposure to an aerosolized irritant -so we can eliminate a pulmonary toxin
• there is no history of COPD or exposure to an allergen, so we can eliminate“exacerbation of COPD” and “anaphylaxis”
• The pain is “heavy” in nature and there is no history of DVT, peripheral vasculardisease or blood clotting disorder, so we can take pulmonary embolus off the listas well.
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Sensitivity & SpecificityRemember the scenario: 58 year old male with SOBand he tells you his chest is uncomfortable. 1-2 worddyspnea and coarse crackles.
Sensitivity: the frequency with which a sign or symptomoccurs in a given illness – e.g. shortness of breathoccurs frequent in the setting of AMI (high sensitivity)
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Specificity: describes the uniqueness of a sign orsymptom for a given medical condition – e.g. “heavychest discomfort” occurs in few conditions other than AMI,therefore it is a symptom that has a high specificity forAMI
Instructor Notes:• Given the initial information in the scenario, there is limited information upon which to
base some treatment decisions
• the frequency with which a sign or symptom occurs in a given illness describes thesensitivity of that sign or symptom for that condition – e.g. shortness of breath occursfrequent in the setting of AMI (high sensitivity)
• Specificity describes the uniqueness of a sign or symptom for a given medical condition– e.g. “heavy chest discomfort” occurs in few conditions other than AMI, therefore it is asymptom that has a high specificity for AMI
• Conversely, using the same example, although SOB has a high sensitivity in AMI, it hasa very low specificity – i.e. SOB may occur frequent in AMI, but there are also a greatmany other causes of SOB other than AMI.
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Why do you have to take vital signs?
as you prepare equipment, your partner has beentaking vital signs. He reports the following:
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BP is 60/40pulse is 60respirations are 32 and shallowwhat other diagnostic tools will you use?what other information do you wish to have?
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Instructor Notes:• Does this information change your treatment plan? Why?• Think of treatments in risk/benefit terms and ask why drugs which might have otherwise
been indicated for this patient are no not in his best interest?• What would be the value of the SpO2 and a 12 Lead ECG?
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Field Diagnosis
at this point you should be narrowing it down to acardiac event.what is the management plan?
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Instructor Notes:
• You should be able to narrow the differential diagnosis at this point to a cardiac event• Next, you need to think of a management plan• Before moving on to the next slide, write down the treatment options for a patient with
this condition. Write down even those you think might be risky• Then list the benefits of each treatment down one column and the risks down another
Instructor Notes:• The patient’s acuity is generally defined by the severity or acuteness of their condition• generally speaking, a depression or alteration of the following system(s), will help you
judge the patient’s acuity:• CNS• Respiratory• cardiovascular (hemodynamics)
• an altered mental status or depressed level of awareness suggest hypoxia, cerebralischemia, brain injury, a lesion, a metabolic disturbance, drug overdose, substratedepravation (e.g. hypoglycemia), or other serious condition
• respiratory distress or respiratory insufficiency is a potentially life threatening emergency• hemodynamic instability can result from pump failure, tachy or bradydysrhythmias,
volume depletion, distributive shock (e.g. anaphylaxis, neurogenic shock), or othercauses. All of these can be life threatening.
• there are also conditions in which the CNS, respiratory or cardiovascular systems maynot be compromised but may be in imminent danger - e.g. the so-called “ticking time-bomb” of a dissecting abdominal aortic aneurysm
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Patient AcuityCritical Life Threatening
major Multi-system traumadevastating single system traumaend stage diseaseacute medical conditionacute exacerbation of chronic conditioncompounding co-morbiditiescritical thinking must be swift
skills are performed by instinctdrawing on your trainingpatient fits standard algorithms
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Instructor Notes:• The Paramedic must be able to determine within the first couple of minutes whether a
patient has a life-threatening condition that warrants immediate intervention and earlytransport - this requires a solid knowledge base, excellent clinical skills and goodinstincts.
• Understanding the potential complicating influence of co-morbidities is essential wheninjuries or illness alone may not appear to be serious
• “co-morbidity” example: an elderly patient with non life-threatening trauma from an MVCis intubated and had two IVs running wide open. She was cyanosed, hypotensive and herHR was 128 with frequent multiform PVCs. She appears to be in a pre-arrest state.Upon re-assessment, there is no A/E in her left lung.
• The ETT is pulled back, A/E is re-established in both lungs. Her HR then comes down,her BP comes up and her colour improves dramatically.
• Any young and otherwise healthy person with a right mainstem intubation would tolerateit reasonably well. However, her age and Hx of COPD (co-morbidity) made her unable tocope with that kind of hypoventilation and hypoxia.
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Patient Acuity
Non-Life ThreateningMajority of EMS CallsMinor illness or injuryRequires very little critical thinking
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Instructor Notes:• These calls deserve our full attention like any other call. Paramedics who
are quick to dismiss a call as “minor” are at risk of jeopardizing patientcare and their career - an experienced Paramedic gives the benefit of thedoubt and approaches all calls with eyes wide open and, more importantly,with an open mind.
• An open mind will help to keep you from missing something critical - e.g.febrile seizures in children are usually benign and may be downplayed bysome Paramedics – a good clinician will appreciate that there are manycauses of seizures in children – some are benign, some are life-threatening and it is impossible to distinguish one from the other in thefield. We do not have the ability to send blood work off to the lab, analyzea sputum sample or do a urinalysis or CT the head. Understanding theprocess of a differential diagnosis is critical
• e.g. syncopal episodes are often the result of a simple vasovagal incident.However, some re due to hypovolemia and orthostatic hypotension, sinuspauses, Torsade de Pointes and the list of other life threatening causesgoes on. Never be to quick to dismiss.
• Also, remember that the so-called “frequent flyers” also have medicalemergencies. A Paramedic who is non-judgmental and treats all callsseriously until proven otherwise, will be less likely to miss a seriousillness/injury when it happens.
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Protocols, Standing Orders andAlgorithms
Protocols, standing orders and algorithms helppromote a standardized approach to the “classicpatient”.Clearly defines and outlines performance boundaries.However:
What about the patient that doesn’t fit the model?The patient with multiple, serious problems?Promotes “cookbook” medicine.
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Instructor Notes:• standing orders are designed to allow Paramedics to treat life-threatening conditions and
garden variety medical emergencies without having to contact a physician.• standing orders are designed to provide the maximum amount of benefit to the maximum
number of patients with the minimum amount of risk.• Complying with standing orders and protocols is for the patient’s safety.• Deviating from standing orders not only places the patient at risk but also breeches the
trust between Medical Director and Paramedic and places the Paramedic at risk ofdisciplinary action.
• A “cookbook” approach is not a bad thing, but it’s important to be a thinking cook.• The harsh reality is that Standing orders are not perfect and some patients who may
benefit from from a standing order are deprived. However, a good standing order willreduce that number to an acceptable minimum. e.g. if one of the requirements foradministration of Glucagon is that the patient have a history of diabetes, it’s because if apatient who is hypoglycemia is not diabetic, it begs the question whether they have acondition such as pheochomocytoma or insulinoma, both of which are conditions thatmay be exacerbated by the administration of Glucagon. Conversely, since we knowthese two conditions are very uncommon, if the Paramedic encounters an unconsciouspatient who is hypoglycemic and it’s impossible to elicit a past medical history, thechances are very high that this is a diabetic hypoglycemic and the risk-benefit scale tipsin favour of Glucagon administration.
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For an effective critical thinking process, severalelements must be present:
know anatomy, physiology and pathophysiologyfocus on large amounts of data simultaneouslyorganize the datadifferentiate between relevant and irrelevant dataanalyze and compare similar situationsbe able to defend the decision
Critical Thinking Skills
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Instructor Notes:• The cornerstone of critical thinking is a sound knowledge base.• A strong knowledge base and the discipline to assimilate large amounts of data and
decipher relevant information quickly is what distinguishes the critical thinking clinicianfrom the skills-focused technician
• Critical thinking requires a search for relevant information and the ability to put asideirrelevant information- then rapidly analyzing it and formulate a decision based on a soundprovisional diagnosis (or Field Diagnosis).
• The next step is a critical evaluation of all treatment options, weighing the risk-benefit ratioand ensuring viable options are in compliance with standing orders
• Finally, the patient and treatment have to be reevaluated and new or continued treatmentplans adjusted accordingly - and you have to be able to defend your decisions - i.e. it’s notenough to explain that you were simply following standing orders
• A weak knowledge base leads to indecisiveness, weak critical thinking and the inability todefend or explain the rationale for the care you provided or withheld.
• Lastly…a Paramedic has to be invested in his/her life-long education and be accountablefor his/her actions.
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SUMMARY
Critical thinking is the ability to think under pressureand make clear, precise and accurate decisionsweighing all the factors and risks & benefits oftreatments.Your patient depends on your critical thinking ability.
This ability is developed over time and requires aninvestment in your career and professional development!!
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Instructor Notes:
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Paramedic Practice
3 things to do in a short time.gather information.evaluate the information.process the information.
turn that information into the field diagnosis.develop and implement a management plan.
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Instructor Notes:
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Narrow the Field
first part of the history taking will give you thedifferential diagnosis.this is a broad group of problems – difficult to developa plan.must be able to narrow the problems to a fielddiagnosis.from the field diagnosis comes the plan.
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Instructor Notes:• REMINDER…when the history is limited or difficult to obtain, that the patient’s
medication may paint a clearer picture of the underlying medical conditions – e.g. thepatient in pulmonary edema who is unable to communicate a medical history can presenta bag of drugs containing digoxin, furosemide and other drugs that speak for him.
• A barrel chested patient with a life-long history of smoking may provide you all theinformation you need to conclude the patient is likely an emphysemic despite his denialof any past or present respiratory illness
• A 12 Lead ECG may reveal an old MI in a patient who denies any cardiac history
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Facilitating Behaviors
stay calmanticipate problemswork systematicallyremain flexiblereassessre-evaluatedon’t be afraid to discuss situation with your partnerand/or with medical control
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Instructor Notes:• The following is a list of facilitating behaviours• An experienced Paramedic should be calm on all calls unless his or her life is in danger.• Another important element of critical thinking is to anticipate problems and plan for them.
This doesn’t mean anticipating “seizure-coma-death” in all patients. It means anticipatingrealistic problems – e.g. you should get an emesis basin/bag ready when a patient isnauseous; you may wish to prepare the suction unit as well if the patient has an altered ordiminished mental status; you should be prepared to hook up the defribrillator pads andrun an arrest when a patient presents with crushing chest pain and hemodynamicinstability;
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Thought for the Day
to be an excellent paramedic, you must be like aduck:
cool and calm on the surfacepaddle feverishly underneath
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Instructor Notes:• An expression I like is: “It’s ok to have butterflies - as long as they fly in formation”.• If anxiety is interfering with your ability to stay focused, imagine what the patient is
experiencing!• Calm comes from confidence – confidence comes from knowledge, experience,
reflective practice, accountability, a patient-focused approach and a commitment to life-long learning.
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Useful Thinking Styles
do not allow distractions, unless situation says-”getout” for personal safetyreflective vs. impulsivedivergent vs. convergentanticipatory vs. reactive
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Instructor Notes:• Staying focused is particularly important when performing a controlled act.
•There are times when you need to step back and take in the big picture and thereare times when you need to be singularly focused – e.g. while starting an IV, this isnot the time to think about what questions to ask the patient next. Zoom in on theskill, make it your sole focus, accomplish the task, then step back and get the “big”picture again. There is of course room for adjustment to this approach onceproficiency at a skill is achieved.
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Reflective Vs. Impulsive
ReflectiveTaking your time to figure out what is wrongActing thoughtfully, deliberately, analyticallyGood in the non-life threatening situations
ImpulsiveActing instinctivelyNo time to thinkProtocols, algorithm knowledgeGood in the obvious or potential life threateningsituations
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Instructor Notes:• With respect to reflective practice – the mere act of verbalizing your assessment
findings to your partner is in a sense, a reflective approach because yourverbalizing your thoughts/assessment findings for the purpose of validation andto seek input. A reflective approach is arguably more practical in non-lifethreatening situations but I would argue that it can be done on critical calls aswell…particularly when life-saving interventions have been initiated and nowyou’re re-assessing the patient.
• Impulse reactions – though the term sounds like rash reactions, in fact what itmeans is reacting swiftly based in sound clinical knowledge and experience
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Divergent VS. Convergent
DivergentTakes into account all aspects of a complexsituationThe patient down a 30 foot embankment withmultiple injuries.
ConvergentFocuses on the most important aspectsThe patient that is apneic, with a pulse
Experience teaches when to use which style
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Instructor Notes:
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Anticipatory Vs. Reactive
AnticipatoryAnticipate and preventSeen in the confident, experienced paramedics
ReactiveLet’s see what happens firstSeen in the less confident, less knowledgeable ofless experienced paramedicsCan be costly to the patient
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Instructor Notes:
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Summary
maintain a working knowledge of anatomy,physiology and pathophysiologyknow the principles of emergency medicinegather informationdevelop a working field diagnosisform a management planevaluate the interventionscompare your findings
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Instructor Notes:
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What About Our Patient?
the patient is “circling the drain”.now what?
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Instructor Notes:
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What About Our Patient?
Remember? Bilateral course crackles, B/P 60/40always remember your basics.every advanced call has a basic component.don’t be afraid to revert to basics and know why.
defend your plan
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Instructor Notes:• Sometimes the best course of action is simply supportive care and transport.• This is clearly a hemodynamically unstable patient who may benefit from an inotropic
(increases the force of contractility) drug such as dopamine, but more importantly, needsto be transported quickly to the hospital where he can managed in the ER and/or theintensive care unit.
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ONTARIOBASE HOSPITAL GROUP
Ontario Base Hospital GroupSelf-directed Education Program
