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
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
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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.
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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?
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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
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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
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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
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Concept FormationConcept FormationElementsElements
Scene assessment Scene assessment Chief complaintChief complaintHistoryHistoryAffect Affect Initial assessment Initial assessment Physical examPhysical examDiagnostic testsDiagnostic tests
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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.