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Building Critical Thinking Skills
by Mike Kennamer, EMT-P, M.P.A,
Northeast Alabama Community College
Knowing
why is ultimately important in developing clinical
judgment. Books like Thomson Delmar Learning’s Why-Driven
EMS Enrichment are important to the development of the
skills that set a true pre-hospital care clinician apart from
a trained “algorithm-driven” technician.
I have
claimed for many years that I could teach a reasonably intelligent
person with average motor control all but two of the skills
required of a paramedic in just a few days. The two skills
that require more time are |
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| assessment
and judgment. While I agree that judgment, clinical or otherwise,
cannot be taught, it is, nevertheless, a skill that is vastly
important to pre-hospital practitioners. |
How
then can one acquire clinical judgment? Experience? Yes, to some
extent. However, it is important to differentiate between learning
from experience and just surviving the experience. A fire service
instructor from my past put it this way: There is a difference between
someone with 15 years of experience and someone with one year of
experience repeated 15 times. Experience suggests true growth and
development.
Clinical
judgment results from experiential learning. Experiential learning
begins in the classroom with a strong foundation in anatomy and
physiology followed by frequent opportunities for experiential thinking--
in essence, learning to ask why.
Consider
this example that I have used to teach paramedic students how to
differentiate between right and left heart failure. The scenario
begins: This is my friend Waldo. Unfortunately, Waldo isn’t feeling
well today. See if you can make Waldo feel better.
Waldo
explains, “I . . . am . . . having . . . trouble . . . breathing.”
He goes on to explain (in broken phrases) that he started having
difficulty breathing four nights ago. It seemed to bother him
at first when he was trying to sleep. He would lie down and within
minutes he would start having difficulty breathing (paroxysmal
nocturnal dyspnea, PND). Today he is having marked shortness of
breath, is very apprehensive and easily agitated. He also appears
somewhat cyanotic around his lips and is very diaphoretic. When
we listen to his breath sounds, we hear bilateral rales and rhonchi.
It sounds like there is a little wheezing as well, but Waldo had
no history of asthma or COPD. His blood pressure is high as are
his pulse and respiratory rates. He is coughing up pink frothy
sputum.
What
might be the problem with Waldo? Let’s look at the possibility of
congestive heart failure, particularly left heart failure. Left
heart failure is more likely to occur before right heart failure
and will often cause right heart failure. But what causes left heart
failure?
When
the left ventricle is damaged or ineffective in some way (e.g.,
acute myocardial infarction), oxygenated blood that would normally
be ejected from the left ventricle and sent to all parts of the
body doesn’t move as rapidly as it should. This causes blood to
back up or pool in the pulmonary circulation. What might be the
result of this backup in the pulmonary circulation?
Damage
to the left ventricle results in:
- Decrease
in oxygenated blood going to the body. This decrease causes cyanosis,
apprehension, and decreased level of consciousness.
- Blood
backs up into the pulmonary circulation, which causes pulmonary
edema, rales, rhonchi, and pink frothy sputum.
What
if, like so many people, Waldo doesn’t seek assistance for his left
heart failure until it progresses to right heart failure as well.
You see, as blood backs up into the pulmonary circulation, it then
backs up to the right ventricle. Eventually the backup goes to the
right atria and then to the body.
Your
job is to report what happens, how it happens, why it happens, and
how it affects poor Waldo. Answer these questions about Waldo’s
condition.
- When
blood does not circulate as it should, it backs up or
slows its rate of flow in the body. What signs would you
expect Waldo to exhibit based on blood backing up into
the inferior vena cava?
- What
would you expect to see as a result of the same backup
into the superior vena cava?
- Since
the backup of blood into the systemic circulation will
cause edema, you may want to determine where this edema
would be found. Where are you likely to find this edema
in an ambulatory patient?
- Where
is this edema likely to be found in a patient who is bedridden?
- If
your patient has chronic CHF, what medication might he
take to control this edema?
- What
other medications might the patient take to counteract
the effects of this medication?
- Finally,
how would you treat Waldo in this advanced state of CHF?
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Scenario
or story-based questions make students think about the why and how
of physiology. Instructors may develop these scenarios quickly and
easily to help students develop critical-thinking skills.
Experienced EMTs may use scenarios followed by thoughtful questions
to refresh and sharpen their skills. Partners may also use this
strategy by discussing the physiology behind real calls then relating
various why and what-if scenarios. Regardless how these scenarios
are used, their purpose is to stimulate thinking and cultivate new
questions (and answers). The end result will be a thinking EMT who
learns from each call and experience, thus providing improved patient
care with each call.
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