Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. ©...

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Care:Principles & Practice

Volume 2 Patient Assessment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 4 Clinical Decision Making

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Topics

Introduction to Critical Thinking

Paramedic Practice

Critical Thinking Skills

Thinking Under Pressure

The Critical Decision Process

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Critical Thinking

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Critical Thinking

As a paramedic, you inevitably will face your moment of truth.– A critical decision can mean the difference

between life and death.

Twenty-first-century paramedics are prehospital practitioners of emergency medicine—not field technicians.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Making critical decisions requires clinical judgment—the use of knowledge and

experience to diagnose patients and plan their treatment.

Introduction to Critical Thinking

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Practice

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Practice

As a paramedic, you must gather, evaluate, and synthesize much information in very little time. Requires the use of all senses.The differential diagnosis is a preliminary list of possible causes for your patient’s problem. By conducting a history and physical exam the paramedic will arrive at a field diagnosis.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Practice

The paramedic will apply clinical experience and exercise independent decision-making in order to develop and implement a management plan.

Paramedics perform procedures in various uncontrolled and unpredictable environments.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Acuity

The severity or acuteness of your patient’s condition.

The spectrum of care in the pre-hospital setting includes three general classes of patient acuity.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Classes of Acuity

Those with obvious life-threats

Those with potential life-threats

Those with non-life-threatening presentations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Obvious Life-Threats

Major multi-system trauma

Devastating single-system trauma

End-stage disease (i.e., renal failure)

Acute presentations of chronic diseases

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Potential Life-Threats

Serious multi-system trauma

Multiple disease etiology

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Non-Life-Threats

Isolated minor illnesses and injuries

Majority of calls are non-life threats

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Protocols, standing orders, and patient care algorithms provide

a standardized approach to emergency patient care.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Protocol

A standard that includes general and specific principles for managing certain patient conditions.

Protocols are also for special situations such as physician on-scene, radio failure, and termination of resuscitation.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Standing Orders

Treatments you can perform before contacting the medical direction physician for permission

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Algorithm

Schematic flow chart that outlines appropriate care for specific signs and symptoms

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

While algorithms, standing orders, and protocols provide paramedics with guidance…

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

…do not allow the linear thinking or “cookbook medicine” that protocols promote

restrain you from consulting with your medical direction physician.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Critical Thinking Skills

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Critical Thinking Skills

Knowing anatomy, physiology, andpathophysiology

Focusing on large amounts of data

Organizing information

Identifying and dealing with medicalambiguity

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Critical Thinking Skills

Differentiating between relevant and irrelevant data

Analyzing and comparing similar situations

Explaining decisions and constructing logical arguments

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Useful Thinking Styles

A paramedic must stay calm and not panic.– The key is focusing on the task and blocking out

the distractions.

Assume and plan for the worst.

Establish and maintain a systematic assessment pattern.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Be like the duck—cool and calm on the water’s

surface, while paddling feverishly underneath!

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thinking Under Pressure

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thinking Under Pressure

With experience, you will learn tomanage nervousness and maintain a steadfast, controlled demeanor.

Except for safety concerns, never allow anything to distract you from your most important job—assessing and caring for your patient.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Useful Management Styles

Situation analysis– Reflective vs impulsive

Data processing– Convergent vs divergent

Decision making– Anticipatory vs reactive

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thinking Under Pressure

Physical influences– Autonomic response

Sympathetic response is useful– Increases visual, auditory, reflexes, and

muscular strength

Sympathetic response may be detrimental– Diminish ability to concentrate

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Mental Checklist

Developing a routine mental checklist as a good way to stay focused and systematic.

Develop acronyms and mnemonics to remember critical elements during stressful incidents. – SAMPLE, OPQRST-ASPN, AVPU, etc.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Mental Checklist

Scan the situation

Stop and think

Decide and act

Maintain control

Re-evaluate

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The Critical Decision Process

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The Critical Decision Process

Form a concept

Interpret the data

Apply the principles

Evaluate

Reflect

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Form a Concept

Observe patient’s mental status, skin color, positioning, and note any deformities or asymmetry. Conduct an initial assessment. Ascertain your patient’s history.Conduct a focused physical exam of the appropriate areas.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Interpret the Data

Interpret all of your data in light of your knowledge and experience.

Your attitude toward managing patients with these symptoms also becomes a factor.

Determine the most common and statistically probable conditions that fit your patient’s initial presentation.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Apply the Principles

Devise a management plan that covers all contingencies.

Use written protocols, standing orders, and all the interventions at your disposal to manage your patient’s particular problem.

Consult medical direction for atypical presentations.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Evaluate

Reassess your patient’s condition and the effects of interventions.

Initial impressions may be altered.

A detailed exam may be conducted to find less obvious conditions.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Reflect

Discuss events with the physician.

Conduct a run critique with the crew.

Increase your experience base.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Putting It All Together

The Six RsRead the scene

Read the patient

React

Re-evaluate

Revise the management plan

Review your performance

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Summary

Introduction to Critical Thinking

Paramedic Practice

Critical Thinking Skills

Thinking Under Pressure

The Critical Decision Process