Chapter 1 3 Clinical Decision Making -...

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Chapter 13Chapter 13Clinical Decision MakingClinical Decision Making

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ObjectivesObjectivesList the key elements of paramedic practiceList the key elements of paramedic practice

Discuss limitations of protocols, standing Discuss limitations of protocols, standing orders, algorithmsorders, algorithms

Outline key components of the criticalOutline key components of the critical--thinking process for paramedicsthinking process for paramedics


ObjectivesObjectivesIdentify elements necessary for an effective Identify elements necessary for an effective criticalcritical--thinking processthinking process

Describe situations that may necessitate the Describe situations that may necessitate the use of critical thinking while giving prehospital use of critical thinking while giving prehospital patient carepatient care

Describe six elements needed for effective Describe six elements needed for effective critical decision making in the fieldcritical decision making in the field


Mosby, Inc. items and derived items © 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition PowerPoint Lecture Notes

Chapter 13: Clinical Decision Making

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ScenarioScenarioYou respond to a private home for a person You respond to a private home for a person who has fallen down the steps. Your elderly who has fallen down the steps. Your elderly patient is awake, slightly confused, and patient is awake, slightly confused, and moves all extremities. He has a normal heart moves all extremities. He has a normal heart rate, but his blood pressure is low and his rate, but his blood pressure is low and his skin is pale and cool. His wife hands you a skin is pale and cool. His wife hands you a bag with his bag with his ““heartheart”” medicine.medicine.


DiscussionDiscussionDoes this patient face an obvious life threat?Does this patient face an obvious life threat?

What part of his initial presentation doesnWhat part of his initial presentation doesn’’t fit?t fit?

How might his home medicines affect his clinical How might his home medicines affect his clinical presentation?presentation?

What treatment should be considered?What treatment should be considered?


Cornerstones ofCornerstones ofEffective Paramedic PracticeEffective Paramedic Practice

Gather, evaluate, synthesize informationGather, evaluate, synthesize information

Develop and implement patient management Develop and implement patient management plansplans

Apply judgment and exercise independent Apply judgment and exercise independent decision makingdecision making

Think and work effectively under pressureThink and work effectively under pressure



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Spectrum of Prehospital CareSpectrum of Prehospital Care

Obvious, critical life threatsObvious, critical life threatsMajor multisystem traumaMajor multisystem traumaDevastating singleDevastating single--system system traumatraumaEndEnd--stage disease stage disease presentationspresentationsAcute presentations of Acute presentations of chronic conditionschronic conditions

Potential life threatsPotential life threatsSerious multisystem Serious multisystem traumatraumaMultiple disease etiologiesMultiple disease etiologies

NonNon--lifelife--threatening threatening presentationspresentations

Minor illness or injuryMinor illness or injuryEMS system misuse EMS system misuse


Protocols, Standing Orders, Protocols, Standing Orders, Patient Care AlgorithmsPatient Care Algorithms

BenefitsBenefitsStandardized approachStandardized approachDefine, outline performanceDefine, outline performance

LimitationsLimitationsDonDon’’t fit nonspecific complaintst fit nonspecific complaintsDonDon’’t address multiple etiologiest address multiple etiologiesPromote linear thinkingPromote linear thinking


Components, Stages, and SequencesComponents, Stages, and Sequences



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Concept FormationConcept Formation

Information gathered Information gathered to form general to form general impression of patientimpression of patient

The "what" of patient The "what" of patient storystory


Concept FormationConcept FormationElementsElements

Scene assessment Scene assessment Chief complaintChief complaintHistoryHistoryAffect Affect Initial assessment Initial assessment Physical examPhysical examDiagnostic testsDiagnostic tests


Data InterpretationData InterpretationData gatheredData gathered

Paramedic knowledgeParamedic knowledgeAnatomy and physiologyAnatomy and physiologyPathophysiologyPathophysiology

Paramedic attitudeParamedic attitude

Experience of Experience of paramedicparamedic



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Application of PrincipleApplication of Principle

Field impression/working Field impression/working diagnosisdiagnosis

Protocols/standing ordersProtocols/standing orders

Treatment/interventionTreatment/intervention


EvaluationEvaluationPatient reassessmentPatient reassessment

Reflection in actionReflection in action

Revision of impressionRevision of impression

Protocol/standing Protocol/standing ordersorders

Revision of Revision of treatment/interventiontreatment/intervention


Reflection on ActionReflection on ActionRun critiqueRun critique

Addition to/modification Addition to/modification of paramedic of paramedic experience baseexperience base



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Fundamental Elements of Fundamental Elements of Critical Thinking for ParamedicsCritical Thinking for Paramedics

Adequate fund of knowledgeAdequate fund of knowledge

Ability to:Ability to:Focus on specific and multiple data elementsFocus on specific and multiple data elementsGather and organize data and form conceptsGather and organize data and form conceptsIdentify and deal with medical ambiguityIdentify and deal with medical ambiguity


Fundamental Elements of Fundamental Elements of Critical Thinking for ParamedicsCritical Thinking for Paramedics

Ability to:Ability to:Differentiate relevant and irrelevant dataDifferentiate relevant and irrelevant dataAnalyze and compare similar situationsAnalyze and compare similar situationsRecall situations where diagnosis was incorrectRecall situations where diagnosis was incorrectExplain decisionExplain decision--making reasoning and construct making reasoning and construct argumentsarguments


Field Application ofField Application ofAssessmentAssessment--Based Patient ManagementBased Patient Management

Systematic means of:Systematic means of:Analyzing patientAnalyzing patient’’s problemss problemsDetermining how to solve themDetermining how to solve themCarrying out action planCarrying out action planEvaluating effectivenessEvaluating effectiveness

Integration of: Integration of: Interpersonal skillsInterpersonal skillsScientific knowledgeScientific knowledgeSkillsSkills



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Patient Acuity SpectrumPatient Acuity SpectrumEMS activated for many reasonsEMS activated for many reasons

Few prehospital calls true life threatsFew prehospital calls true life threats

Minor medical and traumatic events require Minor medical and traumatic events require little critical thinkinglittle critical thinking

Usually relatively easy decision makingUsually relatively easy decision making


Patient Acuity SpectrumPatient Acuity SpectrumObvious life threats may pose limited criticalObvious life threats may pose limited critical--thinking challengesthinking challenges

May fit "model" for standardized treatment (e.g., May fit "model" for standardized treatment (e.g., cardiac arrest)cardiac arrest)

Patients between minor and lifePatients between minor and life--threatening threatening events can pose greatest criticalevents can pose greatest critical--thinking thinking challengechallenge


Thinking Under PressureThinking Under PressureHormonal "fight or flight" responseHormonal "fight or flight" response

Positive Positive •• Enhanced visual and auditory acuityEnhanced visual and auditory acuity•• Improved reflexes and muscle strengthImproved reflexes and muscle strength

Negative Negative •• Impaired criticalImpaired critical--thinking skillsthinking skills•• Diminished concentration and assessment abilityDiminished concentration and assessment ability



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Mental ConditioningMental ConditioningKey to effective performance under pressureKey to effective performance under pressure

Skills learned at pseudoinstinctive performance Skills learned at pseudoinstinctive performance levellevelAutomatic response for technical treatment Automatic response for technical treatment requirementsrequirements


Mental ChecklistMental ChecklistStop and thinkStop and think

Scan the situation Scan the situation

Decide and actDecide and act

Maintain clear and concise controlMaintain clear and concise control

Regularly and continually reevaluate patient Regularly and continually reevaluate patient


Facilitating BehaviorsFacilitating BehaviorsStay calm; do not panicStay calm; do not panic

Assume and plan for worst; err on side of Assume and plan for worst; err on side of patientpatient

Maintain systematic assessment patternMaintain systematic assessment pattern

Balance analysis, data processing, and Balance analysis, data processing, and decisiondecision--making stylesmaking styles



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DecisionDecision--Making StylesMaking StylesSituational analysis Situational analysis

Reflective versus impulsiveReflective versus impulsive

Data processing Data processing Divergent versus convergentDivergent versus convergent

Decision making Decision making Anticipatory versus reactiveAnticipatory versus reactive


Read the PatientRead the Patient

ObserveObserveLevel of responsivenessLevel of responsivenessSkin colorSkin colorPosition and location Position and location

TalkTalkFind chief complaintFind chief complaintNew problem or worsening New problem or worsening preexisting condition?preexisting condition?

TouchTouchSkin temperature and Skin temperature and moisturemoisturePulse rate, strength, and Pulse rate, strength, and regularityregularity

AuscultateAuscultateLower airwayLower airwayUpper airwayUpper airway


Read the PatientRead the Patient

Identify life threatsIdentify life threats

Vital signsVital signsTriage tool to estimate severityTriage tool to estimate severityAssists in identifying life threats Assists in identifying life threats Influenced by age, physical and medical conditions, Influenced by age, physical and medical conditions, and current medicationsand current medications



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Read the SceneRead the Scene

Environmental conditionsEnvironmental conditions

Evaluate immediate surroundingsEvaluate immediate surroundings

Mechanism of injuryMechanism of injury


ReactReact

Address life threats in the order foundAddress life threats in the order found

Determine most common and probable cause that fits Determine most common and probable cause that fits patientpatient’’s presentations presentation

Consider most serious condition that fits patientConsider most serious condition that fits patient’’s initial s initial presentationpresentation

If clear medical problem is elusive, presenting signs and If clear medical problem is elusive, presenting signs and symptomssymptoms


ReevaluateReevaluate

Focused and detailed assessmentFocused and detailed assessment

Response to initial management/interventionsResponse to initial management/interventions

Discovery of less obvious problemsDiscovery of less obvious problems



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Revise Management PlanRevise Management Plan


Review PerformanceReview Performance

Run critiqueRun critiqueIdentification of areas that can be improved on Identification of areas that can be improved on similar calls in the futuresimilar calls in the future


ConclusionConclusion

The paramedic must be able to gather, evaluate, The paramedic must be able to gather, evaluate, and synthesize information; develop and implement and synthesize information; develop and implement

appropriate management plans; apply judgment appropriate management plans; apply judgment and exercise independent decision making; and and exercise independent decision making; and

think and work effectively under pressure.think and work effectively under pressure.



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Questions?Questions?



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