Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition
PowerPoint Lecture Notes
Chapter 13: Clinical Decision Making
Chapter 13
Clinical Decision Making
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Objectives
z
List the key elements of paramedic practice
z
Discuss limitations of protocols, standing
orders, algorithms
z
Outline key components of the criticalcriticalthinking process for paramedics
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Objectives
z
Identify elements necessary for an effective
criticalcritical-thinking process
z
Describe situations that may necessitate the
use of critical thinking while giving prehospital
patient care
z
Describe six elements needed for effective
critical decision making in the field
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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Scenario
You respond to a private home for a person
who has fallen down the steps. Your elderly
patient is awake, slightly confused, and
moves all extremities. He has a normal heart
rate, but his blood pressure is low and his
skin is pale and cool. His wife hands you a
bag with his “heart”
heart” medicine.
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Discussion
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Does this patient face an obvious life threat?
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What part of his initial presentation doesn’
doesn’t fit?
z
How might his home medicines affect his clinical
presentation?
z
What treatment should be considered?
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Cornerstones of
Effective Paramedic Practice
z
Gather, evaluate, synthesize information
z
Develop and implement patient management
plans
z
Apply judgment and exercise independent
decision making
z
Think and work effectively under pressure
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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2
Spectrum of Prehospital Care
z
Obvious, critical life threats
¾
¾
¾
¾
Major multisystem trauma
Devastating singlesingle-system
trauma
EndEnd-stage disease
presentations
Acute presentations of
chronic conditions
z
Potential life threats
¾
¾
z
Serious multisystem
trauma
Multiple disease etiologies
NonNon-lifelife-threatening
presentations
¾
¾
Minor illness or injury
EMS system misuse
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Protocols, Standing Orders,
Patient Care Algorithms
z
Benefits
¾
¾
z
Standardized approach
Define, outline performance
Limitations
Don’
Don’t fit nonspecific complaints
Don’
Don’t address multiple etiologies
¾ Promote linear thinking
¾
¾
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Components, Stages, and Sequences
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3
Concept Formation
z
Information gathered
to form general
impression of patient
¾
The "what" of patient
story
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Concept Formation
z
Elements
Scene assessment
Chief complaint
¾ History
¾ Affect
¾ Initial assessment
¾ Physical exam
¾ Diagnostic tests
¾
¾
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Data Interpretation
z
Data gathered
z
Paramedic knowledge
¾
¾
Anatomy and physiology
Pathophysiology
z
Paramedic attitude
z
Experience of
paramedic
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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4
Application of Principle
z
Field impression/working
diagnosis
z
Protocols/standing orders
z
Treatment/intervention
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Evaluation
z
Patient reassessment
z
Reflection in action
z
Revision of impression
z
Protocol/standing
orders
z
Revision of
treatment/intervention
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Reflection on Action
z
Run critique
z
Addition to/modification
of paramedic
experience base
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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5
Fundamental Elements of
Critical Thinking for Paramedics
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Adequate fund of knowledge
z
Ability to:
Focus on specific and multiple data elements
Gather and organize data and form concepts
¾ Identify and deal with medical ambiguity
¾
¾
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Fundamental Elements of
Critical Thinking for Paramedics
z
Ability to:
Differentiate relevant and irrelevant data
Analyze and compare similar situations
¾ Recall situations where diagnosis was incorrect
¾ Explain decisiondecision-making reasoning and construct
arguments
¾
¾
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Field Application of
AssessmentAssessment-Based Patient Management
z
Systematic means of:
Analyzing patient’
patient’s problems
Determining how to solve them
¾ Carrying out action plan
¾ Evaluating effectiveness
¾
¾
z
Integration of:
Interpersonal skills
Scientific knowledge
¾ Skills
¾
¾
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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6
Patient Acuity Spectrum
z
EMS activated for many reasons
z
Few prehospital calls true life threats
z
Minor medical and traumatic events require
little critical thinking
¾
Usually relatively easy decision making
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Patient Acuity Spectrum
z
Obvious life threats may pose limited criticalcriticalthinking challenges
¾
z
May fit "model" for standardized treatment (e.g.,
cardiac arrest)
Patients between minor and lifelife-threatening
events can pose greatest criticalcritical-thinking
challenge
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Thinking Under Pressure
z
Hormonal "fight or flight" response
Positive
• Enhanced visual and auditory acuity
• Improved reflexes and muscle strength
¾ Negative
• Impaired criticalcritical-thinking skills
• Diminished concentration and assessment ability
¾
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7
Mental Conditioning
z
Key to effective performance under pressure
Skills learned at pseudoinstinctive performance
level
¾ Automatic response for technical treatment
requirements
¾
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Mental Checklist
z
Stop and think
z
Scan the situation
z
Decide and act
z
Maintain clear and concise control
z
Regularly and continually reevaluate patient
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Facilitating Behaviors
z
Stay calm; do not panic
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Assume and plan for worst; err on side of
patient
z
Maintain systematic assessment pattern
z
Balance analysis, data processing, and
decisiondecision-making styles
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DecisionDecision-Making Styles
z
Situational analysis
¾ Reflective
z
Data processing
¾
z
versus impulsive
Divergent versus convergent
Decision making
¾
Anticipatory versus reactive
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Read the Patient
z
¾
¾
¾
z
z
Observe
Talk
¾
¾
Find chief complaint
New problem or worsening
preexisting condition?
Touch
¾
Level of responsiveness
Skin color
Position and location
¾
z
Skin temperature and
moisture
Pulse rate, strength, and
regularity
Auscultate
¾
¾
Lower airway
Upper airway
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Read the Patient
z
Identify life threats
z
Vital signs
Triage tool to estimate severity
Assists in identifying life threats
¾ Influenced by age, physical and medical conditions,
and current medications
¾
¾
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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9
Read the Scene
z
Environmental conditions
z
Evaluate immediate surroundings
z
Mechanism of injury
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React
z
Address life threats in the order found
z
Determine most common and probable cause that fits
patient’
patient’s presentation
z
Consider most serious condition that fits patient’
patient’s initial
presentation
z
If clear medical problem is elusive, presenting signs and
symptoms
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Reevaluate
z
Focused and detailed assessment
z
Response to initial management/interventions
z
Discovery of less obvious problems
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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10
Revise Management Plan
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Review Performance
z
Run critique
¾
Identification of areas that can be improved on
similar calls in the future
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Conclusion
The paramedic must be able to gather, evaluate,
and synthesize information; develop and implement
appropriate management plans; apply judgment
and exercise independent decision making; and
think and work effectively under pressure.
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Mosby, Inc. items and derived items © 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
11
Questions?
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Mosby, Inc. items and derived items © 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
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