Ch14 Critical Thinking and Clinical Decision Making.docx

Chapter 14 Critical Thinking and Clinical Decision Making Unit Summary Upon completion of this chapter and related course assignments, students will understand the importance of the development of critical-thinking skills for the paramedic by incorporating the stages of critical thinking for those patients with critical life threats. Students will be able to recognize the significant role critical thinking has in clinical decision making. Students will be able to discuss how to identify problems, incorporate data gathered through assessment and evaluation of the patient, and synthesize this information to develop a treatment plan that supports a positive patient outcome. Students will also be able to compare and contrast patient protocols or standing orders with patient care algorithms, while understanding that neither of these is intended to replace critical thinking in the prehospital environment. National EMS Education Standard Competencies Assessment Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan. Knowledge Objectives List and explain the four cornerstones of effective paramedic practice: (1) gathering, evaluating, and synthesizing; (2) developing and implementing a patient care plan; (3) using judgment and independent decision making; and (4) thinking and working under pressure. (pp 695-698) 2. Explain the benefits and drawbacks of patient protocols or standing orders and patient care algorithms in the EMS system in which you work. (p 696) 3. Explain how to distinguish patients with critical life threats from those in serious condition and those with minimal non-life-threatening injuries. (p 698) 4. Describe the stages of critical thinking and thought processes in the prehospital setting: concept formation, data interpretation, application of principle, reflection in action, and reflection on action. (pp 698–701) 5. List and explain the six Rs of critical thinking: (1) Read the scene; (2) Read the patient; (3) React; (4) Reevaluate; (5) Revise the plan; and (6) Review your performance. (pp 702-704) Skills Objectives There are no skills objectives for this chapter. Readings and Preparation • Review all instructional materials including Chapter 14 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials. • Consider reading these articles ahead of time and summarizing them for students or using them for further discussion of the issues surrounding critical thinking. “Critical Thinking: A New Approach to Patient Care” by D. L. Sullivan & C. Chumbley: http://www.ncbi.nlm.nih.gov/pubmed/20399376 “Critical Thinking Framework for Any Discipline” by R. Duron, B. Limbach, & W. Waugh: http://www.isetl.org/ijtlhe/pdf/IJTLHE55.pdf “Active Learning Strategies to Promote Critical Thinking” by S. E. Walker: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC233182/pdf/attr_38_03_0263.pdf “Paramedic Clinical Decision Making” by J. L. Jensen (Thesis): http://dalspace.library.dal.ca/dspace/bitstream/handle/10222/12738/2010%2004%2014%20JENSEN%20thesis%20PDF%20A%20format.pdf?sequence=1 Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation • To use live scenarios in the classroom to generate group discussion on application of critical-thinking skills in the clinical decision making process, consult EMS Scenarios: Case Studies for the EMS Provider, available at www.jblearning.com, ISBN: 9780763755553. Enhancements • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities. • Consider developing case studies representative of various critical patient scenarios that would allow the opportunity for students to begin applying the stages of critical thinking even if they are not prepared to treat the patient to the paramedic level of care. • Check with local EMS organizations to determine if there are any protocols or treatment algorithms used for paramedic decision-making pathways. If some are available, ask for a copy to share with students. • Consider purchasing a book of logic puzzles. Familiarize yourself with the activities. These make terrific exercises for applying deductive reasoning to solve problems. Identify one or two that will challenge students, and consider allowing them time to work on it and then share how they arrived at the solution. • Content connections: Remind students that all patients have the potential to present with critical issues regardless of age, nature of illness, mechanism of injury, or location. These are foundational skills that they will need to apply throughout their career. Students should also be reminded that the new graduate is not expected to be as adept with application of experience and intuition as that of a seasoned practitioner. Caution should be used when making conclusions about patient condition, and treatment should always be initiated based on presentation and condition, not beliefs. Students should be aware that baseline knowledge gained about normal body systems, lab values, and clinical findings are important to gauge against abnormal findings during assessments. The remainder of the course allows students to synthesize this data with the processes of critical thinking and clinical decision making. • Cultural considerations: Discuss various religious and cultural attitudes about decision making and patient care. For example in some religions, male paramedics may not examine female patients, and husbands make all treatment decisions for their wives. These limitations may inhibit the paramedic from obtaining all necessary data from assessments that would typically be performed and formulating an appropriate treatment plan. The paramedic must be able to work within cultural and religious boundaries while still providing care for the patient. Teaching Tips Be careful not to assume that students possess an adequate knowledge base to move beyond application of the general stages of critical thinking. This is an early chapter in the course, and students are less likely to apply paramedic-level approaches to patient assessment and treatment. This should not hinder your ability to apply the information and modify the approach to the appropriate level of care. Focus on refreshing the basic assessment skills of the student as well. Do not assume that students are proficient with performing all aspects of patient assessment. Consider running through a general case scenario at the start of the course as a short pretest to identify whether any students are struggling with these components and if so, which ones. Unit Activities Writing activities: Assign each student one of the six stages of critical thinking. Have them research and prepare a paper outlining the significance of that stage, as well as how it integrates with the process as a whole. Have them incorporate an example of a patient encounter where this stage is applied. Student presentations: Provide students with a medical protocol and field diagnosis. Ask them to research the condition and identify specific areas of data collection and assessment that are essential to formulate a patient care plan.They should then create a presentation for their findings. Group activities: Using groups of three to four students, have them develop and role-play a critical patient case scenario based on assigned types of critical patients. Ask that they apply the stages of critical thinking to the assessment, treatment, and transport decisions for the patient. Alternate: If you purchased the logic puzzle book, consider providing each group with a puzzle to solve and then share the solution after the group has discussed how they completed the exercise. Visual thinking: Select photos that display various stages of a patient encounter that will allow students to identify and discuss the six Rs of the critical-thinking process. Divide the class into small groups and have them discuss their findings at the end of the exercise. Pre-Lecture You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Medic” scenario found throughout Chapter 14. • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. On a daily basis, paramedics must be able to: 1. Identify problems. 2. Set patient care priorities. 3. Develop a care plan. 4. Execute that plan. B. Cookbook medicine—blindly following steps without fitting them to the specific circumstances involved—can lead to ineffective care for the patient. 1. Many patients present atypically. 2. The prehospital environment is dynamic. 3. The scene may be unstable. 4. Emergency settings may be chaotic. C. Paramedics are expected to provide quality patient care. II. The Cornerstones of Effective Paramedic Practice A. Gathering, evaluating, and synthesizing 1. The first cornerstone of your practice involves gathering, evaluating, and synthesizing information. 2. You must be able to communicate and obtain information from many types of patients. a. Different age groups b. Different educational backgrounds c. Different abilities to communicate d. Patients who have consumed drugs or alcohol 3. Assess and evaluate gathered information to develop a treatment plan, by: a. Checking the validity of the information using your judgment and communication skills i. Example: A patient with a sprained ankle may request morphine. The patient may be an illicit drug user, or may be knowledgeable about medications and have a low tolerance for pain. You will need to explain to the patient why morphine cannot be administered in this situation. b. Be as objective as possible in the decision-making process. 4. Evaluate the information you obtain from: a. The scene b. The patient c. A bystander 5. Determine which information is valid and invalid. 6. Process, or synthesize, the information. 7. Example: 64-year-old man reporting chest pains; type 1 diabetes since childhood; started smoking in high-school; has had COPD since his 50s. a. Synthesis requires that you consider how each element interacts with the others, and ultimately how they affect your patient’s current condition. i. Diabetes is related to circulatory complications and often leads to vascular disease. (a) With shock, a high blood glucose level can make progressively thickening blood stickier. (b) Low blood glucose may kill someone or result in quick brain damage (c) Chronic high blood glucose takes a toll on every organ or body system (such as vision problems or amputated fingers/toes). ii. COPD often results in hypoxia and hypercarbia. iii. With new onset chest pain, it is likely that coronary artery disease has caused one or more arties to become blocked, resulting in the death of part of the heart. b. Synthesis in this case: “I have a patient with diseases of both circulation and gas exchange. There is a possibility that part of the patient’s heart is dying because vessels are unable to deliver oxygenated blood to a portion of the heart muscle.” i. You must treat the combined effect of your patient’s disease process to prevent the unperfused section of the patient’s heart from dying. c. This is synthesis—taking individual conditions and mentally gluing them together to determine their potential for having a life-threatening impact. i. In this scenario, assume the patient has ACS. B. Developing and implementing a patient care plan 1. The second cornerstone of your practice is the development and implementation of a patient care plan. 2. Once the working diagnosis has been established and the chief complaint has been identified, the treatment plan is guided by patient care protocols or standing orders from the EMS system where you work. 3. Protocols or standing orders define the essential standard of care for patients with certain illnesses, injuries, or behavior conditions. a. They will specify: i. Performance parameters (what you can and cannot do without direct medical control) ii. When you need to contact medical control before providing care 4. Protocols promote both a standard approach and standard of quality care as defined by regional, state, or national standards. a. Protocols, standing orders, and patient care algorithms do not generally address: i. Vague patient complaints that do not fit into a neat clinical description ii. Multiple disease etiologies b. Patients with atypical presentations will require multiple treatment modalities. C. Using judgment and independent decision making 1. The third cornerstone is using judgment and independent decision making. 2. Example: You are called to a factory. A machinist was injured on the job and has a serious gash to the upper part of his leg. A significant amount of blood is gushing from his femoral artery. a. In this situation, it is best to delay contact with medical control until the bleeding is resolved and you are en route. b. Even under the best circumstances, the patient may have died before you completed a call with medical control. c. To save the patient, you must immediately recognize the life threat and treat it (in this case, with continuous direct pressure and, ideally, a tourniquet). 3. Circumstances should determine a paramedic’s treatment plan. 4. Necessary treatment changes will only happen if you are using your critical-thinking and decision-making skills to the best of your abilities. D. Thinking and working under pressure 1. The final cornerstone of your practice is the ability to think and work under pressure. a. Example: You ring the doorbell of the address to which you have been dispatched, and a hysterical mother opens the door and hands you a cyanotic, apneic 18-month-old who has been submerged in a bathtub. b. Only a combination of knowledge coupled with excellent psychomotor clinical skills will allow you to avert a patient care disaster. 2. You must be able to: a. Work under extreme pressure. b. Think and perform quickly and effectively. III. The Range of Patient Conditions A. You must be able to determine if the patient is sick or not sick. 1. For patients who are sick, you must be able to quantify how sick they are. a. This allows you to make the best choices as to the care you must provide: i. At the scene ii. In the ambulance while en route B. Clear thinking in an emergency starts with a triage process. 1. Critical patients need immediate care to survive. 2. Serious patients need care within the next few minutes to half hour to have a positive outcome. a. Otherwise, they become critical patients. 3. Two groups remain: a. Mortally wounded or dead b. “Walking wounded” (non-life threats) or minimally injured 4. Patients with critical life threats include those with: a. Major multisystem trauma b. Devastating single-system trauma c. End-stage disease presentations d. Acute presentations of chronic conditions 5. Patients in serious condition include those with: a. Serious multisystem trauma b. Acute presentations of “first-time” medical events c. Multiple disease etiologies 6. Patients with minimal, non-life-threatening injuries include: a. Simple abrasions b. Partial-thickness burns of an extremity, with less than 5% body surface area c. Small lacerations with only capillary bleeding IV. Critical Thinking and Clinical Decision Making A. Concept formation 1. The first stage of the thought process in prehospital care. 2. Gather information from your five senses and from your diagnostic tools. a. This evaluation process should begin as the paramedic arrives at the scene. i. What is the mechanism of injury or the nature of the present illness? ii. Does the patient present as uncomfortable or very ill? iii. What is the patient’s emotional state? iv. What is the patient’s level of consciousness (LOC)? (a) To determine if the patient can give you reliable information (b) To determine baselines for medical condition 3. The process continues with the performance of a primary assessment to identify medical condition and serious threats. 4. A secondary assessment follows, to determine a. A pertinent medical history b. Any medications the patient is taking c. The patient’s affect (emotional state reflected in physical behavior) 5. Vital signs are then taken. B. Data interpretation 1. Second stage of the critical-thinking process 2. Evaluate all gathered information. a. A paramedic should understand how the body works, and have a background in anatomy, physiology, and pathophysiology. b. A good attitude is paramount in good paramedic care, and includes: i. Showing compassion and interest for each patient ii. Providing best care for each patient C. Application of principle 1. Third stage of critical-thinking process 2. Initial field impression becomes a working diagnosis a. What you believe to be the problem and focus of your treatment 3. The treatment plan for the working diagnosis is determined by patient care protocols, or standing orders. a. Protocols represent the standard of care and defines: i. What you can do without contacting medical control ii. What you cannot do without contacting medical control D. Reflection in action 1. The fourth step is actively treating the patients while monitoring the intervention effects. a. Periodically check your interventions in order to revise your impression. b. Avoid tunnel vision. i. Keep your mind open to all possible causes of your patient’s condition. ii. Patients may have a condition that presents in a way that differs from the typical signs and symptoms. E. Reflection on action 1. The last stage in the critical-thinking process occurs after the call is over. 2. Reflect on and learn from the decisions and actions taken on each call. a. A review should be considered an opportunity to evaluate what went right and what went wrong on the call. b. An open attitude of learning from each call will help a paramedic improve his or her skills. 3. Provides the opportunity to improve your thinking, decision making, and patient care a. Growth will only happen if you can admit mistakes and are willing to continue to learn. 4. Fundamental elements that contribute to critical thinking and clinical decision making include: a. Adequate knowledge in medical sciences, including anatomy and physiology b. Ability to gather and organize data to form concepts c. Ability to focus on specific and multiple data d. Ability to identify medical ambiguity e. Ability to understand what is and what is not relevant data f. Ability to analyze and compare similar and contrary situations g. Ability to explain reasoning and defend positions V. From Theory to Practical Application A. Each call has unique circumstances that require appropriate care. 1. Changes in call variables will determine a paramedic’s ability to manage the call. a. Each call must be handled in a professional manner, with the best possible care provided. 2. Paramedics must learn to deal with their own reactions when dealing with extreme emergency scenes by: a. Improving their mental conditioning b. Improving their skill performance 3. The following checklist may support better thinking under pressure: a. Scan the situation. b. Stop and think. c. Move forward, make decisions, and act on behalf of the patient. d. Stay calm, maintaining clear mental control. e. Continue to reevaluate the patient. VI. Taking It to the Streets A. Remembering the six Rs can help a paramedic in the critical-thinking process. 1. Read the scene. a. An emergency scene can give the paramedic important information, some of which can only be found at the site. i. Overall safety of the scene ii. Environmental conditions iii. Immediate surroundings iv. Access and egress issues v. In cases of trauma, the mechanism of injury b. Other issues to consider when interpreting the scene include: i. Was it hot, cold, or wet? ii. Were there eyewitnesses to provide additional information? 2. Read the patient. a. Offer the patient your hand to shake when introducing yourself. i. If the patient takes your hand and answers appropriately, you can determine there Glasgow Coma Scale score. b. Observe the patient. i. LOC ii. Level of comfort or discomfort iii. Skin color iv. Position v. Work of breathing vi. Deformity or asymmetry c. Talk to the patient. i. Determine the chief complaint. ii. Obtain a medical history and history of the current problem. d. Touch the patient. i. Assess skin temperature and moisture level. ii. Assess pulse rate, regularity, and strength. e. Auscultate lung sounds. f. Identify life threats such as airway, breathing, and circulation problems. g. Get complete and accurate vital signs to determine a baseline. i. For patients with serious conditions, do two sets of vital signs for comparative data. ii. For critical patients, do three or more sets of vital signs to assess trends and to check if the patient is stabilizing. 3. React. a. The first priority is to treat any life-threatening problems. b. Then consider possible causes of symptoms to develop a working diagnosis. c. If you cannot come up with a working diagnosis, provide care based on presenting signs and symptoms. 4. Reevaluate. a. Follow up on any interventions to make sure they are improving the patient’s condition. i. Reassess to make sure nothing has been overlooked. b. While reassessing the patient, add information from the secondary assessment to the primary assessment. 5. Revise the plan. a. Be open to changing the working diagnosis and treatment plan if other factors or circumstances become apparent. 6. Review the performance. a. Once a call is completed, a review will create an opportunity to reexamine, learn from any mistakes, and improve skills. b. Reviews can be: i. A formal continuous quality improvement (CQI) meeting. ii. Informal discussions with partners. VII. Summary A. A paramedic’s first cornerstone of practice is the ability to gather, evaluate, and synthesize information. B. Once the information is gathered, a paramedic needs to assess and evaluate its validity and effect on the patient care plan. C. After the paramedic evaluates the information obtained from the scene, patient, and bystanders, the information must be processed (synthesized). D. A paramedic’s second cornerstone of practice is the development and implementation of a patient care plan. E. The patient care plan should be defined by patient care protocols and standing orders of the paramedic’s EMS system. F. A paramedic’s third cornerstone of practice is judgment and making independent decisions. G. A paramedic’s fourth cornerstone of practice is the ability to think and work under pressure. H. The first stage in prehospital care critical thinking is gathering initial information through the five senses, applying diagnostic skills, and using the process of concept formation. I. Data interpretation, the second stage of the critical-thinking process, occurs when the paramedic evaluates the gathered information. J. The third stage of the critical-thinking process occurs with the run review or run critique after the call is completed and the paramedic reflects on the total call, how the gathered information was processed, and how each decision was reached. K. Paramedics can use the six Rs to determine the steps to a call: 1. Read the scene. 2. Read the patient. 3. React. 4. Reevaluate. 5. Revise the plan. 6. Review performance. L. Paramedics should maintain an attitude that is open to learning in order to constantly improve their practice and maintain excellence in prehospital care. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and the application of paramedic knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 14. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: C. Evaluating the location of the ambulance. Rationale: Answers A, B, and D are critical elements to reading a scene. Evaluating the location of the ambulance is not. Looking for danger and situations that may create an unsafe scene for yourself or your crew is paramount to ensuring a safe scene to provide effective patient care. 2. Answer: D. reading the patient. Rationale: The six Rs help you remember how to provide patient care and transport. Once you read the scene, you need to read the patient and gather information about the problem. 3. Answer: A. Correct life threats. Rationale: The most important duty paramedics have other than keeping themselves safe is to do no harm and save lives. Therefore, life threats to airway, breathing, and circulation need to be corrected first. 4. Answer: B. Reevaluate Rationale: One of the best ways to find out whether your critical thinking is going in the right direction is to reevaluate the patient. The patient is the best resource to ascertain whether your treatment is improving the patient’s condition. 5. Answer: A. data interpretation. Rationale: Data interpretation is a key measure in every patient contact. The better you are at interpreting everything on the scene, the more likely the patient will receive the correct treatment and be transported to the appropriate facility. 6. Answer: B. review your performance. Rationale: You can never learn everything, and the great part about being a paramedic is that you will always have different patients experiencing different problems. There will be occasions where you miss something or are incorrect in your assessment, but by reviewing your performance, either by talking to a mentor or with your peers, using the QI process, you can learn the areas in which you can improve and become a better provider. 7. Answer: D. Leave the scene until police arrive and secure it. Rationale: As stated many times in EMS training, you and your partner are the most important people on a call, and you need to ensure your own safety. Do not put yourself or your crew in harm’s way. Leave the scene until the police have control of it, then return and provide patient care. Play it safe, and you will go home after every shift. Additional Questions 8. Rationale: This patient brings up an interesting treatment thought process. Normally, 16-year-olds do not suffer from cardiac problems; however, it is possible. This has to be well thought out, and questions need to be posed to the patient to find out what is really occurring. Ruling out a muscle pull or trauma should be a priority, and you should quickly obtain a 12-lead ECG, and take a thorough history, including family history. The ultimate treatment should come from your experience, critical-thinking skills, and also medical control, if you feel it necessary to call. If no other cause for chest pain can be found, the patient should be treated for acute coronary syndrome. Assignments A. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by instructor). B. Read Chapter 15, Airway Management and Ventilation, for the next class session. Unit Assessment Keyed for Instructors 1. Describe what is meant by “cookbook medicine,” and list four reasons why it can lead to ineffective patient care. Answer: Cookbook medicine” refers to blindly following steps without applying them to the specific circumstances or considering the effectiveness or appropriateness of these actions. It can lead to ineffective pateint care because many patients present atypically, the prehospital environment is dynamic, the scene may be or become unstable, and the scene may be chaotic. p 695 2. Discuss the three components of the first cornerstone of paramedic practice. Answer: Gathering data includes obtaining information from various types of patients, including those with comunication barriers due to age, education, alcohol/drug impairments, or ability to communicate. Evaluating data includes checking validity and being objective. Synthesizing the data requires that the paramedic consider how each element interacts with others and how they affect the patient’s current condition. pp 695-696 3. Discuss the importance of patient care protocols or standing orders in developing and implementing a patient care plan. Answer: After determining a working diagnosis, the treatment plan is guided by existing patient care protocols or standing orders from your EMS system. These define the essential standard of care for patients and specify performance parameters, including when medical control should be contacted before continuing treatment. p 696 4. Explain why use of judgment and independent decision making is a cornerstone of paramedic practice. Answer: Some clinical presentations are such that delays can significantly affect patient outcome. Paramedics must be able to make effective decisions on when to act in the patient’s best interest. Using critical thinking and decision-making skills will allow the paramedic to make necessary treatment changes. p 697 5. Describe how use of the triage process can enable the paramedic to think clearly in an emergency. Answer: The paramedic must be able to identify those patients who are sick in order to quantify how sick and what treatment decisions must be acted upon quickly. Critical patients must have immediate care to be able to survive. Those who are serious will need care quickly or they are at risk for deterioration to become critical patients. Identification of those patients who are mortally wounded or deceased must be determined to avoid those who are critical from being delayed in receiving treatment. Those with non-life-threatening or minimal injuries can often wait until additional resources are available. p 698 6. Describe concept formation as the first stage of the critical-thinking process in prehospital care. Answer: Concept formation is the gathering of information that begins as the paramedic arrives at the scene. It includes determination of the mechanism of injury/nature of illness. The paramedic should then form a general impression that includes the emotional state of the patient and level of consciousness. The primary assessment and identification of serious life threats, as well as the secondary assessment including vital signs, are also part of this stage. pp 698-699 7. Discuss the significance of data interpretation in the critical-thinking process. Answer: Data interpretation requires the paramedic to have a good understanding and background in anatomy and physiology, as well as pathophysiology. All information gathered must be evaluated based on the paramedic’s understanding of how the body works. Experience provides an important platform to build upon. The paramedic’s ability to think and formulate a working diagnosis may be influenced both by the patient’s attitude as well as the paramedic’s. The treatment plan is based upon the working diagnosis, which is supported by how the data has been interpreted. p 699 8. Explain the concept of tunnel vision and how it can negatively affect the success of the treatment plan. Answer: Tunnel vision results from focusing on one aspect of a patient’s condition, and it prevents the paramedic from being open to all possible causes, as well as potentially preventing changes in the treatment plan that would be supported by findings during the ongoing assessment. Patients may present with atypical symptoms or respond to treatments in a way that suggests the paramedic should revise the field impression and change focus in treatment accordingly. p 700 9. Identify and describe the final stage in the critical-thinking process. Answer: The last stage is reflection. This process is commonly associated with reviews or critiques of calls. It allows the paramedic the opportunity to evaluate what went right and anything that may have gone wrong during the call. This includes identifying skills that could be improved. Reflection also allows the paramedic to consider the adequacy of his or her knowledge base and critical-thinking skills, as well as the ability to grow and learn from mistakes. pp 700-701 10. What are the six Rs in the critical-thinking process? Answer: Read the scene; Read the patient; React; Reevaluate; Revise the Plan; and Review the performance. pp 702-704. Unit Assessment 1. Describe what is meant by “cookbook medicine,” and list four reasons why it can lead to ineffective patient care. 2. Discuss the three components of the first cornerstone of paramedic practice. 3. Discuss the importance of patient care protocols or standing orders in developing and implementing a patient care plan. 4. Explain why use of judgment and independent decision making is a cornerstone of paramedic practice. 5. Describe how use of the triage process can enable the paramedic to think clearly in an emergency. 6. Describe concept formation as the first stage of the critical-thinking process in prehospital care. 7. Discuss the significance of data interpretation in the critical-thinking process. 8. Explain the concept of tunnel vision and how it can negatively affect the success of the treatment plan. 9. Identify and describe the final stage in the critical-thinking process. 10. What are the six Rs in the critical-thinking process?