PARA 3002 DECISION MAKING IN PARAMEDIC PRACTICE;CLINICAL REASONING – HEURISTICS AND ANALYTICAL REASONING IN HIGH ACUITY CASES.
PARA 3002 DECISION MAKING IN PARAMEDIC PRACTICE;CLINICAL REASONING – HEURISTICS AND ANALYTICAL REASONING IN HIGH ACUITY CASES.
SHORT ANSWER QUESTIONS
PLEASE READ THE FOLLOWING CASE.
CASE: ‘Samuel’
Paramedics have been dispatched to a residential address at 03.47 hours for a 10 year old boy who has woken with extreme shortness of breath.
On arrival
The patient (Samuel) is sitting on his bed. Both parents are with Samuel and have been attempting to slow down his breathing and administer more Ventolin with limited
success.
Background
Samuel has a history of asthma and has been admitted to hospital twice before at the ages of 6 and 9 years old. Both admissions resulted in prolonged management of
chest infections and associated severe asthma. Earlier in the evening he had taken both his preventative corticosteroid medication and his Ventolin inhaler which had
limited effect in relieving the tightness in his chest.
He woke after fitful sleep at approximately 02.00 with increasing shortness of breath and pain down his left side of his chest.
Samuel has been complaining of discomfort down his left side for the last 10-12 hours.
The parents are worried that this may be another chest infection in conjunction with his asthma, but he does not appear to have any fever or productive cough. The
parents state Samuel normally gets a fever and productive cough when he is fighting an infection. Any sign of colds or infection they treat early with the help of
their local GP because of the increasing severity if left.
On Examination
Samuel is leaning forward, appears pale and using accessory muscles to breath. He is breathing in rapid shallow breaths with audible wheeze.
Respiratory Rate 32 / shallow and rapid
Pulse Rate 110 / bounding
SO2 90% on air
Blood Pressure 95 / 65
Auscultation reduce air entry on both left and right lung fields/
Audible respiratory wheeze
Pain score 8 /10 on left side
Skin / integumentary pale, dry, warm
• During WEEK ONE tutorials you will be given details of the experience and knowledge base of the crew attending this case and their provisional diagnosis e.g.
the paramedics may be a combination of a recent graduate who is three months into their internship and a paramedic who has seven years’ experience.
• The following questions will explore your explanation (with links to literature) regarding the decision process behind their diagnosis and treatment
pathways.The explanation should reference the concepts of intuitive (or non-analytical) and analytical reasoning, bias in decision making and the differences regarding
novice to expert practitioner and the effects this has on clinical decision making.
TOTAL: /70 (Worth 15% of your total grade)
QUESTION 1
Describe the reasoning pathway that each of the crew members might have taken to reach their potential diagnosis for this case? Describe how intuitive / pattern
recognition may influence their diagnosis. Describe how analytical (or hypothetico-deductive) reasoning might be used to eliminate other potential diagnosis Support
your discussion using literature. (400 words – provide at least two (2) references to literature on intuitive & analytical reasoning)
Maximum mark
20 /
20
QUESTION 2
What influence would knowledge and experience of the crew members have on what information they considered relevant in this case? Include reference to bias and how
that influences the decision making process. Support your answers using literature and reference to the case. (200 words – provide at least two (2) references to
literature regrading analytical reasoning)
Maximum mark
15 /
15
QUESTION 3
Current literature points to a debate surrounding the reliability of intuitive clinical reasoning in comparison to the analytical, hypothetico-deductive, process of
reasoning. Discuss the benefits and limitations of both forms of reasoning in relation to Samuel’s case. (200 words – provide at least two (2) references to literature
regrading analytical reasoning)
Maximum mark
20 /
20
QUESTION 4
Describe the factors in Samuel’s case which might affect the clinical decisions and diagnosis. Refer to a least two factors from the following areas a) Level of
knowledge and experience of the practitioner b) Patient presentation (clinical signs & symptoms) c) Safety & Harm – Clinical Outcomes d) Psychological / Social e)
Environmental f) Operational / logistical Support why these factors ‘bound’ or constrain the decision making in this case with reference to literature (200 words –
provide at least two (2) references to literature regrading factors that influence clinical reasoning)
Maximum mark
15
CLINICAL REASONING – HEURISTICS AND ANALYTICAL REASONING IN HIGH ACUITY CASES
SHORT ANSWER QUESTIONS
PLEASE READ THE FOLLOWING CASE.
CASE: ‘Samuel’
Paramedics have been dispatched to a residential address at 03.47 hours for a 10 year old boy who has woken with extreme shortness of breath.
On arrival
The patient (Samuel) is sitting on his bed. Both parents are with Samuel and have been attempting to slow down his breathing and administer more Ventolin with limited
success.
Background
Samuel has a history of asthma and has been admitted to hospital twice before at the ages of 6 and 9 years old. Both admissions resulted in prolonged management of
chest infections and associated severe asthma. Earlier in the evening he had taken both his preventative corticosteroid medication and his Ventolin inhaler which had
limited effect in relieving the tightness in his chest.
He woke after fitful sleep at approximately 02.00 with increasing shortness of breath and pain down his left side of his chest.
Samuel has been complaining of discomfort down his left side for the last 10-12 hours.
The parents are worried that this may be another chest infection in conjunction with his asthma, but he does not appear to have any fever or productive cough. The
parents state Samuel normally gets a fever and productive cough when he is fighting an infection. Any sign of colds or infection they treat early with the help of
their local GP because of the increasing severity if left.
On Examination
Samuel is leaning forward, appears pale and using accessory muscles to breath. He is breathing in rapid shallow breaths with audible wheeze.
Respiratory Rate 32 / shallow and rapid
Pulse Rate 110 / bounding
SO2 90% on air
Blood Pressure 95 / 65
Auscultation reduce air entry on both left and right lung fields/
Audible respiratory wheeze
Pain score 8 /10 on left side
Skin / integumentary pale, dry, warm
• You will be given details of the experience and knowledge base of the crew attending this case and their provisional diagnosis e.g. the paramedics may be a
combination of a recent graduate who is three months into their internship and a paramedic who has seven years’ experience.
The following questions will explore your explanation (with links to literature) regarding the decision process behind their diagnosis and treatment pathways.
The explanation should reference the concepts of intuitive (or non-analytical) and analytical reasoning, bias in decision making and the differences regarding novice
to expert practitioner and the effects this has on clinical decision making.
Crews
CREW MEMBER 1
Joshua
? Joshua is a 25 year old graduate with a Bachelor Degree in paramedicine.
? He has been working for the last 3 years as a paramedic within the metropolitan area.
? He has worked as a volunteer firefighter and ambulance officer for 2 years before completing
his degree.
? He is currently living in a house share situation with two other friends while he looks to buy
And finance his own home.
POTENTIAL DIAGNOSIS: SEVERE ASTHMA ATTACK WITH POSSIBLE
MUSCULOSKELTAL INVOLVEMENT
TREATMENT: OXYGEN, NEBULISED SALBUTAMOL, POSTURING2. CREW MEMBER 3
CREW MEMBER 2
Chrystal
? Chrystal (34 years old) has been working as a paramedic for 13 years in both rural and
metropolitan settings.
? She has recently upgraded her certificate IV in emergency care to include the first 18 months
of the paramedic degree.
? She has a husband and 2 children (ages 6 and 8)
POTENTIAL DIAGNOSIS: ASTHMA ATTACK WITH POSSIBLE UNDERLYING
CHEST INFECTION (BACTERIAL)
TREATMENT: OXYGEN, NEBULISED SALBUTAMOL, CONSIDERS IF
PARCETOMOL HAS BEEN GIVEN BY THE PARENTS, POSTURING
Question 1:
Student Description:
Describe the reasoning pathway that each of the crew members might have taken to reach their potential diagnosis for this case?
• Describe how intuitive / pattern recognition may influence their diagnosis.
• Describe how analytical (or hypothetico-deductive) reasoning might be
used to eliminate other potential diagnosis Support your discussion using literature.
(400 words – provide at least two (2) references to literature on intuitive & analytical reasoning) (20 marks)
Question 2:
Student Description:
What influence would knowledge and experience of the crew members have on what information they considered relevant in this case? Include reference to bias and how
that influences the decision making process .
Support your answers using literature and reference to the case.
(200 words – provide at least two (2) references to literature regrading bias in clinical reasoning) (15 marks)
Question 3:
Student Description:
Current literature points to a debate surrounding the reliability of intuitive clinical reasoning in comparison to the analytical (hypothetico-deductive) process of
reasoning. Discuss the benefits and limitations of both forms of reasoning in relation to Samuel’s case .
(200 words – provide at least two (2) references to literature regarding the benefits and limitations of both forms of reasoning) (20 marks)
Question 4:
Student Description:
Describe the factors in Samuel’s case which might affect the clinical decisions and diagnosis. Refer to a least two factors from the following areas ;
??Level of knowledge and experience of the practitioner ??Patient presentation (clinical signs & symptoms)
??Safety & Harm – Clinical Outcomes
??Psychological / Social
??Environmental
??Operational / logistical
Support why these factors ‘bound’ or constrain the decision making in this case with reference to literature
(200 words – provide at least two (2) references to literature regrading factors that influence clinical reasoning) (15 marks)
Readings
BOOK CHAPTER:
Mason, J., & Nixon, V. (2013). Clinical Decision Making. In V. Nixon (Eds.), Professional Practice in Paramedic, Emergency and Urgent Care (pp. 50-76). Wiley-
Blackwell. (eReadings)
ARTICLES:
• Rajkomar A and Dhaliwal G (2011). “Improving diagnostic reasoning to improve patient safety.” Perm J 15(3): 68-73.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200103/
• Pelaccia, T., Tardif, J., Triby, E., & Charlin, B. (2011). “An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process
theory”. Medical education online, 16. http://med-ed-online.net/index.php/meo/article/view/5890
• Ferreira, A. P. R. B., Ferreira, R. F., Rajgor, D., Shah, J., Menezes, A., & Pietrobon, R. (2010). “Clinical reasoning in the real world is mediated by bounded
rationality: implications for diagnostic clinical practice guidelines”. PloS one, 5(4), e10265. http://www.plosone.org/article/info%3Adoi
%2F10.1371%2Fjournal.pone.0010265
• Jensen, J. L., Croskerry, P., & Travers, A. H. (2009). “Consensus on Paramedic clinical decision making during high-acuity emergency calls: results of a
Canadian Delphi study”. BMC emergency medicine, 9(1), 17.http://search.proquest.com/docview/920099138/fulltextPDF?accountid=10910
• Van Beuzekom, M., Boer, F., Akerboom, S. & Hudson, P. (2010) Patient safety: latent risk factors. British Journal of Anaesthesia, 105, 52-59.
http://bja.oxfordjournals.org/content/105/1/52.full.pdf+html
• Walker, I. A., Reshamwalla, S. & Wilson, I. H. (2012) Surgical safety checklists: do they improve outcomes? British Journal of Anaesthesia.
http://bja.oxfordjournals.org/content/109/1/47.full.pdf+html
Anazodo, A., Murthi, S., Frank, K., Hua, P., Hartsky, L., Imle, C., Stephens, C., Menaker, J., Miller, C., Dinardo, T., Pasley, J., & Mackensie, C. (2014) Assessing
trauma care provider judgement in the prediction of need for life-saving interventions. Injury http://dx.doi.org/10.1016/j.injury.2014.10.063
PARA3002 Clinical Reasoning Short Answer Marking Guide
Question 1:
Student Description:
Describe the reasoning pathway that each of the crew members might have taken to reach their potential diagnosis for this case?
• Describe how intuitive / pattern recognition may influence their diagnosis.
• Describe how analytical (or hypothetico-deductive) reasoning might be used to eliminate other potential diagnosis
Support your discussion using literature.
(400 words – provide at least two (2) references to literature on intuitive & analytical reasoning) (20 marks)
Grade
Key points
F
• not answered
• no outline of the potential clinical reasoning pathway for the given diagnosis or reference to the case,
• unclear explanation of intuitive and analytical reasoning,
• poor evidence to support the discussion regarding clinical reasoning and the use of mental short cuts,
• rationales and explanation of analytical reasoning is not clear or absent
P
• clinical reasoning pathways mentioned but not outlined or discussed,
• definition of intuitive and analytical reasoning given but with no development of the discussion or links to the case,
• rationales and explanation given but not discussed,
• reference quality marginal
CR
• clinical reasoning pathways are well explained with some analysis & synthesis,
• intuitive and analytical reasoning well defined and explained,
• the use of analytical reasoning well supported,
• good references
DN
• excellent explanation of the clinical reasoning pathways with in-depth discussion and links to the case,
• intuitive and analytical reasoning defined, explained and discussed with clear reference to the case/clinician knowledge and experience,
• thoughtful rationales which support discussions and use of analytical reasoning,
• excellent references
HD
• as DN above, but with outstanding synthesis and exploration of concepts
Question 2:
Student Description:
What influence would knowledge and experience of the crew members have on what information they considered relevant in this case? Include reference to bias and how
that influences the decision making process.
Support your answers using literature and reference to the case.
(200 words – provide at least two (2) references to literature regrading bias in clinical reasoning) (15 marks)
Grade
Key points
F
• not answered,
• the difference between novice to experienced / expert practitioner not clearly defined or discussed,
• knowledge base and experience of practitioner in relation to clinical reasoning not discussed,
• no reference to bias and the relationship to clinical reasoning
P
• the difference between novice and experienced / practitioner defined but not discussed,
• knowledge base and experience of practitioner in relation to clinical reasoning mentioned but not discussed,
• reference to bias but not to how it effects clinical reasoning,
• reference quality marginal
CR
• the difference between novice and experienced / practitioner defined and discussed in relation to the case and the practitioners,
• knowledge base and experience of practitioner in relation to clinical reasoning discussed and beginning links to the case and practice made,
• reference to bias and links made to the effects on clinical reasoning,
• Good references
DN
• excellent explanation of the difference between novice and experienced / practitioner and discussed in relation to the case and the practitioners,
• thoughtful discussion of the relationship between knowledge base and experience of the practitioner and clinical reasoning with links to the case and practice made,
• Links and discussion of bias and the effects on clinical reasoning,
• excellent references
HD
• as DN above, but with outstanding synthesis and exploration of concepts
Question 3:
Student Description:
Current literature points to a debate surrounding the reliability of intuitive clinical reasoning in comparison to the analytical (hypothetico-deductive) process of
reasoning. Discuss the benefits and limitations of both forms of reasoning in relation to Samuel’s case.
(200 words – provide at least two (2) references to literature regarding the benefits and limitations of both forms of reasoning) (20 marks)
Grade
Key points
F
• not answered
• no reference to literature that discusses the reliability of intuitive vs analytical reasoning,
• benefits and limitations not identified (intuitive reasoning),
• benefits and limitations not identified (analytical reasoning),
• no links made to the case
P
• literature that discusses the reliability of intuitive vs analytical reasoning is introduced but not discussed,
• benefits and limitations identified (intuitive reasoning),
• benefits and limitations identified (analytical reasoning) ,
• links made to the case,
• reference quality marginal
CR
• literature that discusses the reliability of intuitive vs analytical reasoning is introduced and discussed,
• benefits and limitations identified (intuitive reasoning) and discussed,
• benefits and limitations identified (analytical reasoning) and discussed,
• links made to the case and the relationship between benefits and limitations,
• good references
DN
• excellent explanation of the literature that discusses the reliability of intuitive vs analytical reasoning and critically discussed,
• benefits and limitations of both analytical and intuitive reasoning are critically discussed,
• Clear and thoughtful links are made between benefits and limitations and the case and the effect on reasoning,
• excellent references
HD
• as DN above, but with outstanding synthesis and exploration of concepts
Question 4:
Student Description:
Describe the factors in Samuel’s case which might affect the clinical decisions and diagnosis. Refer to a least two factors from the following areas;
? Level of knowledge and experience of the practitioner
? Patient presentation (clinical signs & symptoms)
? Safety & Harm – Clinical Outcomes
? Psychological / Social
? Environmental
? Operational / logistical
Support why these factors ‘bound’ or constrain the decision making in this case with reference to literature
(200 words – provide at least two (2) references to literature regrading factors that influence clinical reasoning) (15 marks)
Grade
Key points
F
• not answered,
• none or only one factor identified,
• no discussion of the effect on clinical decision making
P
• two factors are identified but not clearly related to the case and practitioner diagnosis,
• the factors are defined but not discussed or linked to how they affect the decision making,
• reference quality marginal
CR
• two factors are identified and discussed in relation to the case & practitioner diagnosis,
• the factors are defined and linked to how they affect the decision making,
• Good references
DN
• excellent explanation of the two factors and in-depth discussion in relation to the case & practitioner diagnosis,
• thoughtful and in-depth discussion of the relationship between the factors and their effect on the case and practitioner diagnosis,
• excellent references
HD
• as DN above, but with outstanding synthesis and exploration of concepts
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