Introduction to Paramedic Practice (Week 9: Clinical reasoning and decision making)

Question 1

Clinical reasoning: What does the ‘dual process theory’ describe?

Answer 1

• This theory describes two ways that humans make decisions, and is something that has been used to study and describe the clinical reasoning process

Question 2

Clinical reasoning: What is ‘system 1 thinking’?

Answer 2

• Describes fast, automatic and intuitive thinking. More ‘autopilot’ thinking.

Question 3

Clinical reasoning: What is ‘system 2 thinking’?

Answer 3

• Describes ‘manual mode’, more analytical, systematic and deliberate thinking

Question 4

What are some benefits of both system 1 and system 2 thinking?

Answer 4

SYSTEM 1:
- can be used to take action without complete information (find it, fix it)
- If we recognise enough of the pattern, we can rapidly diagnose and treat
- Can treat immediate threats to life without diagnosing the underlying causes

SYSTEM 2:
- Less prone to bias and emotional compromise
- Decisions are likely to be more reliable, less errors
- Good for complex situations
- Can be good when there is no typical pattern (atypical presentations)

Question 5

What are some cons of system 1 and 2 thinking?

Answer 5

SYSTEM 1:
- Can be influenced by emotions, beliefs and behaviour
- Can be less accurate than system 2 thinking
- Can be prone to bias
- Relies on previous experience

SYSTEM 2:
- Slower
- High cognitive load - difficult to multitask
- Over analysis can lead to decision paralysis
- Fatiguing

Question 6

What are some factors that affect the reasoning process?

Answer 6

• Anchoring (tram lining, first impression, jumping to conclusions)
• Confirmation bias (belief bias, following hunches, pseudodiagnosticity, positive testing, effort after meaning, relevance bias
• Overconfidence bias/self-serving attribution bias (usually think you know more than you do without sufficient info gathered)
• Fundamental attribution (judgemental attribution, negative stereotyping)
• Affective bias/Affective dispositions to respond/ADR (theory that your emotional state can influence the clinical reasoning process)
• Human factors (lack of NTS)
• Cognitive load

Question 7

Strategies and tools:

What are some strategies for clinical reasoning?

Answer 7

• Understanding that everyone can have flawed reasoning
• Develop metacognitive practice - think about how you think
• Recognise CDR/ADR

Question 8

Strategies and tools:

What are some tools

Answer 8

• CPG’s
• System 2 thinking
• Assess, confirm, treat, evaluate

Question 9

What do NSA, RSA and PSA stand for in vital sign acquisition?

Answer 9

• Neurological status assessment (NSA)
• Repsiratory status assessment (RSA)
• Perfusion status assessment (PSA)

Question 10

What is included in an NSA assessment?

Answer 10

• GCS scoring
• Pupil assessment (PEARL acryonym for pupils equal and reactive to light)
• ## FAST assessment in some cases for some types of strokes

Question 11

Causes of altered mental status: what is the AEIOU -tips mneumonic standing for?

Answer 11

A - Alchohol
E - Epillepsy
I - Insulin
O - Overdose
U - Uremia (kidney failure/organs)

T - Toxins/temperature
I - Infection
P - Psychogenic, poisoning
S - Stroke, shock, seizure, syncope, space occurring lesion (e.g brain tumour)

Question 12

What is included in an RSA assessment? (respiratory status assessment)?

If the patient’s BREATHING in DR-ABC of the primary survey is abnormal, then you should be prioritising an RSA.

Answer 12

• General appearance: calm, anxious, distressed, fighting to breathe, exhausted, agitated, responding to pain, unresponsive
• Conscious state: Alert, withdrawn, not focused or responding appropriately, responding to pain, unresponsive
• Words per breath
• SPO2 rate (modify for COPD)
• Resp rate per minute
• Effort/work of breathing
• Breath sounds and chest auscultation
• Ausc over trachea

Question 13

EXTRA: RSA (lung sounds!)

• What do crackles, wheezes and stridor sound like?

Question 14

What is included in a PSA assessment?

If patient’s circulation in DRC-ABC is abnormal, you should be prioritising a PSA assessment

Answer 14

• Level of consciousness: alert and orientated, agitated, restless etc
• Skin: is it pale, cool, clammy etc?
• HR in BPM
• Pulse strenght
• Pulse pressure
• CRT
• SPo2 on room air (modify for COPD)
• RR (breath/min)