Critical Thinking in EMS
June 2010 CE
Condell Medical Center EMS System
Site Code # 107200-E-1210
Prepared by: Lt. William Hoover, Wauconda FD
Reviewed by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
Upon successful completion of this module, the
EMS provider will be able to:
• Identify the need for critical thinking in
Emergency Medicine
• Identify patient care influenced by biased
decision making
• Identify documentation influenced by biased
decision making
• Identify critical thinking skills and their
application to EMS
2
Objectives cont’d
• Identify communication issues that can lead to
patient care errors
• Identify different levels of patient acuity
• Identify transportation options a patient
may/may not have
• Identify use of differential diagnosis to provide
improved patient care
3
Objectives cont’d
• Discuss, as a member of a group, factors
involving lawsuit Schulman v. County of Los
Angeles
• Discuss, as a member of a group, factors
involving lawsuit Hackman v. American
Medical Response
• Discuss, as a member of a group, factors
involving lawsuit Wright v. City of Los Angeles
4
Critical Thinking in EMS
• There is a need for field based EMS personnel
to think “outside the box”.
A number of lawsuits initiated due to inaccurate
care of a patient.
Determine best way to provide quality care.
SOP’s cannot cover every scenario we may face in
the field
• Decision making is expected of us!
5
Critical Thinking in EMS
• We must obtain medical information for each
individual patient.
 Then we have to decide what we think is going
wrong with our patient.
 After that we come up with a plan for
treatment.
 Then we evaluate the treatment; make
modifications as needed.
• Simple, right???
6
SOP’s
• They are only one tool in our toolbox
• Each patient is different & needs to have their
own treatment plan.
• SOP’s should not be our first option, rather
they should be our safety net.
• We should use our paramedic training to
figure out what is wrong with our patient &
how we are going to fix it as our first option.
7
SOP’s
• What if our plan is not covered under the
SOP’s?
Medical control!
Medical Control should be our second
option for making the decision.
8
Example…
• Patient info:
– 45 year old male, difficulty breathing
– 124/78, P-90, R-28, SPO2-96%, Temp- 1010 F
– Productive cough
• Diagnosis?
– Probably pneumonia?
• What if patient breathing gets worse?
– Would you give him oxygen? Would you want to
put him on CPAP? Nebulizer treatment?
9
Making the right choice• Oxygen is a given for any breathing issues, so
there is no issue placing them on a NRB mask
• Have we ever been taught to use CPAP on a
pneumonia patient…not really
• So, we contact Medical Control, give report and
ask if we can use CPAP with this patient.
• If Medical Control gives permission, then we are
good to go
• If we can’t reach Medical Control, we revert to
our SOP’s
– There is no SOP for Pneumonia, so we would not be
allowed to use CPAP without an order
10
BREAK OUT SESSION
• Break up into groups and review case #1
– Details in handout
• Have one member take notes and be prepared
to present your answers to the following:
– What is wrong with the patient?
– What treatment plan would you have?
– How would you give report to hospital?
– Which SOP would cover this patient?
11
Case #1 -Schulman v. County of Los Angeles
• 22 y/o female student had 1 alcoholic beverage with
dinner and returned home 2100
• 2210 out again (Karaoke bar) and had 1 beer
• 2230 sang a song and soon after had symptoms:
–
–
–
–
–
–
–
–
Excruciatingly sharp pain near left ear
Dizziness getting worse
Began to stumble
Became acutely disoriented
Holding head in pain
Began vomiting
Speech now unintelligible
Patient collapsed
12
Case #1 - Biased Decision Making
• The patient in case review #1 suffered from a
cerebral hemorrhage.
• A three hour delay in diagnosis in the ED due
to the biased decision making by the
paramedics
• Schulman v. County of Los Angeles Fire
Department (February 7, 2006).
• Note: Full details of case in handout
13
Biased Decision Making
• It is important to evaluate each patient based
on the individual call, not prior calls.
• Has anyone had a “chronic caller”?
– After awhile, did the care provided decrease in
quality?
– This is the call where we cringe when the tones go
out. We all recognize the address.
– This is also the call that we get into trouble with
when the patient has a legitimate problem and we
miss it due to sloppy medicine & biased thoughts.
14
Biased documentation
• Think about what you write!
• Imagine sitting on the witness stand
explaining to the court what PITA stands for!
• If you are called for a patient with chest pain
and don’t treat the patient’s chest pain, have
you really done your job?
• Can you treat a patient following two different
protocols?
15
Minimizing Bias in Assessment
• Most errors in EMS are caused by slipshod
assessments.
– Short cuts on vitals
– Incomplete assessment
– Not obtaining all of the medical history
– Incomplete medication review (what are
the meds for?)
– Not fully exposing patient
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Minimizing Bias in Assessment
• Remove biased feelings and treat all patients
the same.
– After 9/11 did Muslim patients receive the
same quality of care?
– Does a minority on welfare get treated the
same as the local elected official?
• Simply be nice to everyone!
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It’s not all your fault!!!
• EMS has focused on SOP training,
memorization of algorithms and refresher
education.
• What good is a mnemonic if everyone
remembers the letters, but not what they
stand for?
• It is your responsibility to learn a few new
EMS items on your own.
18
Learning Critical Thinking Skills
• Think independently
– Police arrive at MVC with a “drunk”
– But, this patient looks pale.
Most “drunks” you’ve seen have a flushed face.
– Patient glucose, when checked, was 19.
• Be open-minded! Not everything is as it seems.
• Be courageous
– Be an advocate for your patient
– Stand up for what is right
19
Learning Critical Thinking Skills
• Study mistakes of others
• Review good calls of others
• Critique your calls, documentation and
performance
– Did you provide the best treatment to your
patient?
– Could you have improved your performance on
the call?
– What could you do different?
20
Communication Issues
Tenerife airport disaster
The collision took place on March 27, 1977, at 17:06:56 local
time. The aircraft were operating as Pan Am Flight and KLM
Flight 4805. Taking off in heavy fog on the airport's only
runway, the KLM flight crashed into the top of the Pan Am
aircraft back taxiing in the opposite direction. The Pan Am had
followed the back taxiing of the KLM aircraft, under the
direction of Air Traffic Control, and the KLM's flight crew had
been aware of Pan Am back taxiing behind them on the same
runway. Despite lack of visual confirmation (because of the
fog) the KLM captain thought that Pan Am had cleared the
runway and so attempted to take off without further
clearance to do so.
21
Communications Issues
• Immediately after lining up, the KLM captain advanced the
throttles (a standard procedure known as "spin-up", to verify
that the engines are operating properly for takeoff) and the
co-pilot , surprised by the maneuver, quickly advised the
captain that clearance had not yet been given. The Captain
responded, "I know that. Go ahead, ask.“ . The co-pilot then
radioed the tower that they were "ready for takeoff" and
"waiting for our clearance". The KLM crew then received a
clearance which specified the route that the aircraft was to
follow after takeoff. The instructions used the word "takeoff",
but did not include an explicit statement that they were
cleared for takeoff.
22
Communications Issues
• The co-pilot read the flight clearance back to the controller,
completing the read back with the statement "we're now at
takeoff" or "we're now, uh, taking off" (the exact wording of
his statement was not clear, indicating to the controller that
they were beginning their takeoff roll). The Captain
interrupted the co-pilot's read back with the comment "We're
going”
23
Communications Issues
• The Spanish controller, who could not see the runway due to
the fog, initially responded with "OK" (terminology which is
nonstandard), which reinforced the KLM captain's
misinterpretation that they had takeoff clearance. The
controller's response of "OK" to the co-pilot's nonstandard
statement that they were "now at takeoff" was likely due to
his misinterpretation that they were in takeoff position and
ready to begin the roll when takeoff clearance was received,
but not actually in the process of taking off. The controller
then immediately added "Stand by for takeoff, I will call you",
indicating that he had not intended the clearance to be
interpreted as a takeoff clearance. He probably had not heard
the captain's announcement that they were "going", since the
captain had said this to his fellow crew members and not
transmitted it on the radio himself.
24
Communications Issues
• However, a simultaneous radio call from the Pan Am
crew caused mutual interference on the radio
frequency, which was audible in the KLM cockpit as a
whistling sound. This made the crucial latter portion of
the tower's response audible only with difficulty by the
KLM crew. The Pan Am crew's transmission, which was
also critical, was reporting that "We're still taxiing
down the runway!" This message was also blocked by
the interference and inaudible to the KLM crew. Either
message, if heard in the KLM cockpit, would have given
the KLM crew time to abort its second takeoff attempt.
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Miscommunication in EMS?
• Communication between ECRN & Paramedics
– Did we paint a good picture of what we have?
• If the ECRN is asking a lot of questions,
probably not.
– ECRN unfamiliar with field conditions?
• EMS unable to obtain IV, ET, etc.
• Directions that you don’t feel are right?
What should you do? Should you just
follow orders anyway?
26
Miscommunication With Dispatch
• Dispatched to a “Full Code” at local nursing
home
• Ambulance rolls with engine as back up for
additional personnel for the “Full Arrest”
• “Full Code” to the nursing home was an
internal terminology meaning the patient had
no DNR
27
Blah, blah, blah…
• You are dispatched to a call for a 53 year-old
female with abdominal pain
• Your focus would naturally be thinking of a
problem in the abdomen, but as we know it
could be a cardiac event
• Keep an open mind!
28
Patient Acuity Levels
• Life threatening
– Critical; red; arrested; imminently arresting;
needs immediate intervention
• Potentially life threatening
– Relatively stable but could worsen; yellow;
need careful monitoring for changes
• Non-life threatening
– Stable; green; care at BLS level
29
Life Threatening
• These are the calls where we need to use our
brains. THINK!
• What can you do to stabilize the patient?
• Accelerated transport means thinking fast and
moving fast
• Presents challenges with ALS skills while
moving
• Is there something you could do outside of
SOP’s that you can/need to request Medical
Control?
30
Potential Life Threatening
• These are the patients we are relieved they
still have a pulse when we arrive at ED
• We need to recognize this patient and be
proactive in our treatment
• Stay one step ahead of the problem
– Assess, assess, assess
– And reassess often to note deterioration
• Did we say reassess?
31
Non-life Threatening
• Obviously a slower pace and the ability to ask
more questions
• Generally we have the time to be more of a
detective at the home
• Where does patient get their meds from?
– Patient given steroids by one doctor for breathing
issues. Prescription filled at pharmacy “A”.
– Patient given steroids by second doctor for shoulder
injury. Prescription filled at pharmacy “B”.
– Patient did not feel well. Wonder why???
32
BREAK OUT SESSION
• Get back with your groups and review Case #2
• Have one member take notes and be prepared
to present your answers to the following:
– How would your group handle a call like this?
– Does the bystander statements give us cause to be
concerned about the patient?
– Would this case be different if the paramedics had
done a full work up on the patient?
33
Case #2 – Hackman v.
American Medical Response
• A female struck a parked car in a residential area
• Air bag deployed
• Bystanders report patient was “dazed”, “confused”,
“unstable”, “speech slurred”, “wobbled”, and
“swayed like she was drunk”
• Ems found patient standing next to vehicle talking
with police
• Ems conducted a visual and interactive assessment
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Case #2 cont’d
• EMS assessed:
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Breathing
Verbal responsiveness
Eyes
Ability to move extremities
Skin color
Asked questions regarding alcohol consumption
• EMS concluded patient not injured
• Patient stated she was “fine” and refused transport
• 20 minutes after EMS left, patient collapsed
– Bystanders report speech slower, slurred, walking around
“dumbfounded”
• EMS returned and transported patient
35
Case #2 cont’d
• EMS contends that if they felt patient needed
treatment, then they would have filled out a
form for patient to sign AMA and strongly
encouraged treatment & transport
• Hackman v. American Medical Response; April
16, 2004
• Patient alleges negligence by leaving her at
the scene after 1st visit
• Judgment reverse: Plaintiff entitled to costs
• Note: Full details of case in handout
36
Transportation Options
• Trauma patient
– Transport to a Level 1: if transport inside of 25
minutes
• Condell Medical Center, Libertyville
• Lutheran General, Park Ridge
• Helicopter vs. ground transport
– Level 2 facility: Closest hospital
• Criteria is different regarding surgical interventions
37
Transportation Options
• Medical patient
– We don’t have the options of bypassing one
hospital to go to another (per IDPH rules & regs)
Stroke Centers
Cardiac cath labs
Pediatric ED
• Use some common sense
– If hospital CT is out of service, request transport to
next closest appropriate hospital for a patient
experiencing a possible stroke
38
Transportation Options
• A patient can go to a hospital that is not the
closest in life threatening, potential life
threatening or non-life threatening situations
– Patient must be awake & oriented
• They must sign the call sheet/release stating
their wish to go to a hospital further away
• Make sure they sign the paper before
transporting. If they die during the transport,
it’s tough to get their signature then!
39
Signed Releases
• We cannot play Bonnie & Clyde and kidnap
people. If they don’t want to go, it’s their right.
• This is an area where we get into trouble
(remember Hackman v. AMR with no
documentation?)
• Documentation is our best option to protect
ourselves. Take the time to write down what the
patient said!
• Fill out all boxes, signatures, etc. or Sharon will
hunt you down! (Sharon reviews all releases)
40
Documentation of Releases
• Of all times to have detailed, careful documentation,
these are the times
• May only have the documentation to rely on for
recall of details
• Absolutely need a full set of vitals
– Even better are vitals at the time you leave the patient to
demonstrate patient condition/stability
– Can always get respiratory rate, effort, skin conditions on
patients that refuse vitals
– How do you get “refuses vitals” on a minor when waiting
for parent arrival? Why weren’t vitals already done?
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Documenting Releases cont’d
• If there is a spot, fill it out!!!
– What is the patient refusing?
• Initial assessment (ie: vitals)? Further assessment?
• Treatment? Transportation?
– All three signatures present?
• Patient?
– Check whose signature is obtained
• Ambulance personnel?
• Witness?
– Date documented?
• Did you document instructions to the patient?
42
Trick Bag of Releases
• Did you need involvement of Medical Control?
– Did you document who you talked to?
• If patient is hypoglycemic, is the last documented
blood sugar greater than 60?
• If you talked to the parents via phone for a minor, did
you document the permission was via phone and get
the parent’s name?
– Must use authorized person to sign the release
• If the patient unable to sign, did you document
verbal permission obtained from patient
– Not okay to have spouse, police, others sign for patient
43
Differential Diagnosis
• Requires close attention to all aspects of the
assessment, signs & symptoms, complaints and
diagnostic information.
• When dispatched, we should start forming a
broad list of possible diagnosis of patient.
– Trouble breathing: Think COPD, Asthma, Pneumonia,
etc
• Once we get on scene we should start eliminating
possibilities
44
Differential Diagnosis
• For every chief complaint, form your list of
possible causes
– 70 year-old calls 911 for difficulty breathing
• Has no past hx of asthma & takes no asthma meds
• Combine the most critical and most common
causes for the complaint
• Use your diagnostic tools to either prove or
disprove a cause.
• Move on to the next cause
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List of “R” ‘s
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•
•
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React to life threats
Read the scene and patient
Respond to your findings
Re-evaluate your treatment
Revise as necessary
Review your performance
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Case Study
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•
•
•
72 year-old with shortness of breath
B/P: 134/62, P: 96, R: 30, SPO2: 94% room air
Pale, cool, moist skin
Hx of emphysema after 50 years of 2 pack a day
smoking
• What are some possible causes of the breathing
issues?
• What would you need to prove or disprove your
theory?
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Differential diagnosis
• When working through the possible causes,
eliminate the most critical or life threatening first.
• Consider underlying causes that may be hidden
– Elderly patient who fell and broke leg
• Was it a cardiac event that caused the fall?
– Doesn’t look good with a leg well splinted but patient
suffers critical damage to the heart due to lack of
diagnosis
48
Patient History
• A valuable tool in figuring out what is
happening now, but not the end all
• Bar owner with history of abdominal problems
and alcohol abuse calls for stomach pains
– No 12 lead was done because of the hx.
– Patient was having an MI and was eventually
taken to cath lab with 100% occlusion noted in
some arteries
• Don’t fall into the history trap!
49
Zepeda v. City of Los Angeles
• Parents of shooting victim sued city for
wrongful death alleging that a paramedic crew
refused to render medical attention or
otherwise assist victim until police arrived at
the scene.
• Court found that the paramedics were not
obligated to render assistance when scene
was not secure.
50
Zepeda v. City of Los Angeles
• Paramedics could not be found negligent
when they did not start rendering care until
the scene was secured.
• Do we stage too often or not often enough?
– 16 year-old female patient with an overdose
• Should we stage for police?
– 78 year-old male at nursing home who is “out of
control”
• Should we stage?
51
References
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Advanced Medical Life Support, 3rd ed.
Wikipedia.com
Thelegalguardian.com
www.ncrel.org “Critical Thinking Skills”
Jems, April 2010 “Critical Thinking: A new
approach to patient care”
• Jems, November 2008 “How to minimize the
influence of bias in Patient Assessment”
52