How does this apply to the education standards? Teaching Critical Thinking. What if you see this? Critical Thinking Defined 12/3/09

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1 Critical Thinking Defined Teaching Critical Thinking Daniel Limmer, EMT-P A smokin hot EMS buzzword A continuous process of inquiry and assessment... Leading to accurate clinical decisions and care What if you see this? Recognize critical patients early in the call How does this apply to the education standards? When do we make important decisions? Education standards are less prescriptive How will exams compensate for the variations that may occur in education and practice? 1

2 Throughout the call... Educators who teach critical thinking... can deal with gray are secure are open-minded critically thinks him/herself and models it in the classroom and in practice What s the point? The ability to think critically is a vital precursor to excellent assessment, care and decision-making We want to prepare street smart students...and we want to survive the new education standards! Do we prepare street ready providers? When is a student street ready? At the end of class? 6 months? 1 year? 2 years? Educators who practice enjoy a benefit Every call is a potential critical thinking exercise (HIPAA sensitive, of course) Migraine call 2

3 Does it have to be clinical? You are driving home through your district after having a few beers when you come across a motor vehicle accident. Do you stop? You are driving home through an adjoining district after having a few beers when you come across a motor vehicle accident. Do you stop? Same crash, different issue You were late getting your certification renewal into the state and your card is expired. You come across a motor vehicle collision. Do you stop? How about this? Or this... You are taking a cardiac patient to the hospital when you come upon a motor vehicle collision. Do you stop? You are called to a shooting. You arrive to find a police officer you frequently work with has been shot in the leg. He is screaming in pain. A perpetrator has been shot in the chest. He is silent but has a pulse. Difficult field decisions... Often aren t what we expect: Identifying criticality Should I call for an ALS intercept? Should I start an IV? Should I apply a cardiac monitor? Transport priority Critical Thinking Complaint vs disease basis for education Which more closely resembles the field? 3

4 Body Systems Approach Central Nervous System (e.g. CVA/ TIA) Endocrine (diabetic) Cardiac/Respiratory Abdominal/GI Shock Neurological Stroke scales Mental status Grip strength? Pupils? Endocrine Blood glucose monitoring History Oral intake Recent illness Cardiac and Respiratory History Complaint (SAMPLE/OPQRST) Risk Factors Vital Signs Dyspnea on exertion Orthopnea Fluid (pedal edema and ascites) Abdominal/GI Shock Chief Complaint (SAMPLE/OPQRST) Intake/Output Physical Examination Vital signs Mental Status MOI/NOI Physical Examination 4

5 Altered Mental Status Case Study You are called to a 56 year old man who woke up with an altered mental status. His wife says he was 100% fine last night. The patient s eyes are open. He responds appropriately but very slowly. Although he doesn t complain of it he seems slightly short of breath. Case #2 (con t) He is found in bed in his pajamas. Denies trauma of any kind Takes medication to help him sleep and for anxiety Has a Hx of prostate cancer and had a radioactive seed placed in his prostate 3 weeks ago. SAMPLE History S - altered mental status. No complaints A - No known allergies M - Xanax, Halcion P - prostate CA, anxiety L - dinner last night E - woke up with an altered mental status Vital Signs Pulse: 88 regular Respirations: 24 BP: 112/64 Pupils: PERRL Skin: warm/dry Oxygen saturation: 96% Think Clinically What are the possibilities? CVA Respiratory/Cardiac Meds Pulmonary embolus Sepsis Diabetes Physical Examination CPSS negative Blood glucose 101 No c/o chest pain, no pedal edema, no Hx of recent immobilization Unable to check medication amounts but patient/family deny accidental or intentional overdose. A 5

6 And the answer is Sepsis Sepsis Altered mental status most common presentation UTI and pneumonia most common causes Don t always present with raging fever and hypotension Do we work as a team? In the field we do But we test individuals in class... Exercises allow group work and group grading Interpersonal issues should be solved by students Early case studies... break decisions down to manageable segments provide a foundation for critical thinking begin to create links to vital information to search out and evaluate You are called to the residence of a 67 year old man who complains of respiratory difficulty. You arrive at a safe scene to find the patient sitting in the tripod position in a living room chair. He is only able to speak 3 4 words without catching his breath. You observe that the patient has pitting pedal edema and hear scattered wheezes throughout the lung and crackles in the bases of both lungs. He stated he has a history of emphysema (60 pack/year smoking history) and has had some heart problems including a little heart attack last year. EKG reveals atrial 110. His medications include albuterol, atrovent, lanoxin, and Nitrolingual (PRN). For the following parts of the medical focused history and physical examination describe, in detail, the relevance and diagnostic value of the following findings if you were to observe them in this patient: (NOTE: Not all findings are found simultaneously in the patient. This exercise asks you to evaluate and comment in detail on each individually and what it might mean to you.) 6

7 Fever Abdominal ascites Productive cough with brown sputum Dull substernal chest pain Chest pain which can be reproduced with a deep inspiration Scattered wheezes Crackles bilaterally lower lobes Lanoxin (medication) Albuterol (medication) Atrovent (medication) Tripod position Increasing to 3 pillow orthopnea over the past week Continuing to smoke Atrial fibrillation Pulse oximetry = 91 2 lpm oxygen at home via nasal cannula Prior intubation with 2 week hospital admission as a result of COPD exacerbation Poor compliance with medication Onset of this incident after considerable exertion Feeling Very, Very Nauseous. Your ambulance is called to a woman feeling nauseous. You arrive to find a 67 year old woman in a housecoat and wearing a bandana over her head. She appears pale and tells you that she is the most nauseous she has ever felt. The woman tells you that she had chemotherapy for lung cancer 5 days ago. She took her medicine for nausea but did not experience significant relief. As you speak to the woman you observe that she is having difficulty breathing although she did not consider it a complaint. When asked about it she tells you that she usually has some distress and that this is a little worse than usual. You observe that she is quite nervous. The temperature in the house is approaching 95 degrees and the humidity is high. Identify at least 2 or 3 people in your world that have a history of respiratory problems of any kind. These can be asthma, emphysema, bronchitis or congestive heart failure (CHF). You might have to dig pretty hard to find someone with the more serious problems but you shouldn t have any difficulty finding someone with asthma or bronchitis. Once you do, conduct an interview where your objective is to find out as much about their problem as possible. The following are some suggestions for questions you might ask: When did you first find out you had? How did you know something was wrong? What does it feel like when it gets bad? What makes the problem come on? Is there anything you can t do due to your problem? What medications, if any, do you take? What do the medications do for the problem? Case-based Errors Poorly designed case studies Too easy Impossible to solve Fringe topics Improper balance between lecture and cases 7

8 Scavenger Hunt A photocopy of the article entitled Airflow Attack Pediatric Asthma from JEMS magazine A photocopy of a page from an internal medicine textbook having to do with asthma A photocopy of a peer-reviewed journal article having to do with chest pain or myocardial infarction An item used in the assessment of the chest but not a stethoscope Scavenger Hunt The class, route(s) and dosing strategies for the following medications: a. Atenolol b. Furosemide c. Atrovent d. Vanceril e. Sildenafil The shoe size of Captain??????? A purple M&M Choose items that the students must find in a limited time period. Items relate to classroom topics Good for introduction to a course or individual topics Can build teamwork Scene Choreography Thank You! Dan Limmer, EMT-P danlimmer@mac.com 8