I recently had an opportunity to submit proposals to my state's annual symposium. It gave me an opportunity to present the concept of "Naked EMT Teaching." The idea was inspired by The Naked Presenter: Delivering Powerful Presentations With or Without Slides1 by Garr Reynolds.
I wanted to convey the idea that we are too wedded to powerpoints and/or rigid curriculum, which keeps us from doing the best job we can in teaching students our trade. To improve our abilities, we need to develop and embed new concepts in our teaching practice.
Medical critical thinking
The physician model for critical thinking is a three part activity:
- Medical inquiry – history, physical exam and diagnostic testing
- Clinical decision-making – a cognitive process that evaluates information to diagnose or manage a patient's condition
- Clinical reasoning – combining medical inquiry with clinical decision making and physician knowledge2
Dan Limmer, Tim Miscovitch and William Krost wrote about critical thinking for EMTs in a two-part article published in EMS Magazine.3,4 Phrases such as "differential diagnosis," "active, inquisitive, aggressive assessment" and "develop strategic and dynamic care plans" are found in the article. These concepts were not part of the 1994 EMT-Basic National Standard Curriculum (NSC).
The take-home concept is that EMTs should function as clinicians not technicians. "An EMT who is a thinking clinician is able to identify patients who are stable or unstable and require prompt transport. The EMT clinician also makes decisions such as when to call for advanced life support or air-medical evacuation, when to perform rapid extrication and when to immobilize the patient before removing him from the vehicle."3
Effective clinical learning
Critical thinking is evaluating patient assessment results against past patient encounters and the caregiver's knowledge of the disease process. Application of pathophysiology is a new element in the Educational Standards. Teaching pathophysiology and using it as part of a critical thinking process are new learning outcomes.
These learning outcomes change the role of instructors from vocational trainers to clinical educators. How can dedicated, experienced vocational trainers become clinical educators? It requires a combination of knowledge and teaching techniques beyond an updated PowerPoint presentation.
There are two EMT transition textbooks5,6 that provide essential anatomy, physiology and pathophysiology of the knowledge areas covered in an Education Standard program. Publishers have textbooks to support community college paramedic anatomy, physiology and pathophysiology courses7,8,9.
It would be great if EMT instructors could attend a course providing ems-focused anatomy, physiology and pathophysiology that would include teaching techniques and examples. Lacking that, here are two concepts that may help experienced EMT instructors.
Two summers ago I taught our first Educational Standard course with a brand-new edition of a popular EMT textbook. I provided this feedback to the editor:
"A frustration is the vagueness of some numbers. For example on page xxx, Table xx-x 'Vital Signs'. Need to read through two paragraphs to parse out what would qualify as a blood pressure reading that would be hypertensive or hypotensive."
I was channeling my vocational instructor need to have the "right" number to define a "normal" blood pressure. In medicine there is no absolutely correct number for blood pressure determination.
Clinicians appreciate that no patient presents like a textbook case. The goal is to determine what assessment and clinical findings are important to develop a patient care plan and determine transport priority. This requires a willingness on the instructor's part to teach more of the "grey" and less of the "black and white." Yes, it will take longer, and may be more frustrating to students. But the result will be a student who is more willing to look at the big picture, rather than just a number.
Case-based learning through concept mapping
Richard Beebe uses this technique in his paramedic textbook to get the students to visualize the patient's problem: "Concept Maps offer a way for instructors to help students conceptualize ideas in the classroom and help them develop the critical-thinking skills necessary for determining a field diagnosis. Each Concept Map, utilizing a typical emergency scenario, walks students through the critical thinking steps used during an EMS response."10
Start with boxes, each representing a component of the patient's condition. Each box will have a sign, symptom, pertinent negative, general EMT impression of patient or other data. You will have six to twenty boxes.11
Consider how the boxes are related to each other, and make connections between each box. Use descriptions, such as FEELING LIGHTHEADED "may be due to" BLOOD PRESSURE 86/52. This process facilitates differential diagnosis and can guide inquisitive assessment, identifying areas for focused assessment. Once all of the boxes are connected, the student has a better understanding of what is happening to the patient and can develop a strategic and dynamic care plan.
1. Reynolds, G. (2010) The Naked Presenter: Delivering Powerful Presentations With or Without Slides. New Riders. ISBN 978-0-321-70445-0.
2. Marx, J (ed), et al. (2009) Rosen's Emergency Medicine – Concepts and Clinical Practice, 7th edition. Mosby. ISBN 978-0323054720
3. Limmer, D. D., et al. (2008) Beyond the basics, the art of critical thinking, Part 1. EMS Magazine 37(4) p. 87.
4. Limmer, D. D., et al. (2008) Beyond the basics, the art of critical thinking, Part 2. EMS Magazine 37(5) p. 76.
5. American Academy of Orthopaedic Surgeons (AAOS). (2013) Emergency Medical Technician Transition Manual: Bridging the Gap to the National EMS Standards. Jones and Bartlett, ISBN 978-1-4496-0915-3.
6. Limmer, D. D. and J. J. Miscovitch (2011) Transition Series: Topics for the EMT. Pearson Education/Brady, ISBN 978-0-13-511351-6.
7. Bledsoe, B. E., et al. (2007) Anatomy & Physiology for Emergency Care, 2nd edition. Prentice Hall. ISBN 978-0132342988
8. Elling, B., el al. (2006) Paramedic: Pathophysiology. American Academy of Orthopaedic Surgeons/Jones and Bartlett, ISBN 978-0763737658.
9. Elling, B., el al. (2005) Anatomy & Physiology Paramedic. American Academy of Orthopaedic Surgeons/Jones and Bartlett, ISBN 978-076373925.
10. Beebe, R. and J. Myers. (2011) Professional Paramedic, Volume III: Trauma Care & EMS Operations. Cengage Learning. ISBN 978-1428323483.
11. Cañas, A. J. and J. D. Novak (2009) Constructing your First Concept Map. Institute for Human and Machine Cognition. Accesses May 14, 2013 from: http://cmap.ihmc.us/docs/ConstructingAConceptMap.html
Paramedics do not diagnose diseases in the same manner that physicians do. Paramedics assess signs and symptoms and formulate treatment plans based upon their findings. The approach paramedics utilize is called "assessment-based management."
Paramedics need to understand the subtle differences in patient presentation between a patient who is "not sick," "sick," and "not yet sick." Sometimes the patients at each end of the spectrum are easier to identify than those in the middle. Maintaining a high level of alertness with every patient contact is one way of catching changes in the patient’s condition as it occurs. Knowing when enough information is gathered to form an assessment of the problem needs to be balanced with the need to manage the patient. This is particularly true when managing life-threatening and potentially life-threatening problems.
There is a difference in how problems are solved by both novice and expert paramedics. Novices can learn from the strategies experts use to build their own skills, but experience is the only real way to become an expert. Critical thinking skills can be developed, and there are some heuristic tools commonly used by physicians that may be useful in EMS. Bias thought processes result in difficulties in problem solving. Being aware of possible biases and consciously filtering for them can minimize the impact they have on critical thinking.
A compulsive, organized approach to every patient encountered is the rule. If you obtain a chief complaint, a focused history around this complaint, and a complete set of accurately taken vital signs and critically interpret them in light of the patient’s presenting complaint, an accurate assessment of the underlying problem may be formulated. Appropriate resuscitative measures should be undertaken, and an appropriate disposition should be made on all patients.
Chapter OutlineWhat is Critical Thinking?
- Elements of the EMS Critical Thinking Process
- Why Doesn’t a Diagnosis Matter in the Prehospital Setting?
- Sick, Not Sick, and Not Yet Sick
Paramedic Clinical Reasoning
Strategies for Critical Thinking
- Pattern Recognition
- Other Heuristics
- Controlling Bias in the Decision-Making Process
Need to Know
- Paramedics do not diagnose diseases in the same manner as physicians. Paramedics assess signs and symptoms and formulate treatment plans based upon their findings without the benefit of the many diagnostic studies available in the hospital. The approach paramedics utilize is called "assessment-based management."
- Paramedics need to understand the subtle differences in patient presentation between a patient who is "not sick," "sick," and "not yet sick."
- There is a difference in how problems are solved by both novice (new) and expert (appropriately experienced) paramedics. Novices can learn from the strategies experts use and build upon their own skills, but experience is the only real way to become an expert.
- Knowing when enough information is gathered to form an assessment of the problem needs to be balanced with the need, and timing of when, to manage the patient—particularly when the problem is life-threatening.
- Critical thinking skills can be developed, and there are some methods commonly used by physicians that may be useful in EMS.
- Biased thought processes result in difficulties in problem solving. Being aware of possible biases and consciously filtering for them can minimize the impact they have on critical thinking.