Critical Thinking and Clinical Decision Making Chapter 14 Critical Thinking and Clinical Decision Making

Part 1 During the past two weeks, the cold and flu season has hit, and it has affected many members of the community, including some of your coworkers. As you sip your morning coffee and listen to the shift captain relay the plan for the day’s events, you hear dispatch tones. You are dispatched to 1611 Lynne Lane for a 65-year-old woman complaining of weakness, fatigue, and dizziness. A family member requested no lights or siren.

Part 1 (cont’d) As you arrive on the scene, you are met by the patient’s daughter, who called 9-1-1 after speaking to her mother on the phone. She explains that her mom believes “she just has a cold.” Her daughter is concerned it might be something more.

Part 1 (cont’d) Primary Assessment Recording Time: 0 minutes Appearance Eyes open, flat affect Level of consciousness A (Alert to person, place, and day) Airway Patent Breathing Rapid with adequate tidal volume Circulation Radial pulses are present and rapid bilaterally

Part 1 (cont’d) When do you begin patient assessment? What are the benefits and the risks of diagnosing based on dispatch?

Part 2 The patient tells you that she’s sorry her daughter has bothered you. She tells you that she asked her daughter to bring over some food and cold medicine, not for her to call an ambulance. She says it’s true that she hasn’t been feeling well since early this morning, but she doesn’t think it’s anything major. She apologizes to you again and says, “I’m sure you have better things to do.”

Part 2 (cont’d) Vital Signs Recording Time: 10 minutes Skin Slightly moist, slightly pale, and warm Pulse 110 beats/min, regular Blood Pressure 130/82 mm Hg Respirations 36 breaths/min SaO2 95% on room air

Part 2 (cont’d) What are pertinent negatives? What information is missing from the above assessment?

Part 3 The patient denies having a recent history of productive cough, fever, chills, body aches, nausea, or vomiting, but does admit she’s felt quite tired and a bit short of breath since she woke around 6 AM. Your partner asks her if she wishes to be transported to the hospital, and she asks, “Do I really need to go?” You tell her since her daughter was concerned enough to call 9-1-1 coupled with her feeling of shortness of breath, these are both good reasons to be transported to the hospital for further evaluation.

Part 3 (cont’d) After hearing this explanation, she agrees to treatment and to transport. You place her on oxygen, start an 18-gauge IV of normal saline in her right hand to keep the vein open, and place her on the cardiac monitor.

Part 3 (cont’d) Reassessment Recording Time: 15 minutes Skin Slightly moist, pale, and warm Pulse 102 beats/min, regular Blood Pressure 130/74 mm Hg Respirations 30 breaths/min SaO2 98% on 4 L/min via nasal cannula Temperature 98.6°F (37°C) ECG Sinus rhythm

Part 3 (cont’d) How can a patient’s opinion affect treatment and transport decisions? Can men and women have different symptoms of acute illness?

Part 4 You are writing your patient care report when you hear the emergency department physician say, “Mrs. Jones, it appears that you are having a heart attack.” Your heart drops as you realize you’ve made a big mistake. As the doctor passes by, he tells you the news and lets you know your call will be brought up in your department’s monthly quality assurance/quality improvement review.

Part 4 (cont’d) Reassessment Recording Time: 20 minutes Skin Slightly moist, pink, and warm Pulse 94 beats/min, regular Blood Pressure 130/80 mm Hg Respirations 30 breaths/min Temperature 98.6°F (37°C) ECG Sinus rhythm

Part 4 (cont’d) Do good paramedics make mistakes like this one? What was done right in this call? How can a paramedic’s attitude affect patient care? How could this mistake have been avoided?