Critical Thinking- Shore EMS Conference 2010

2. Paramedics
And
Probability
Bridging the Gap between
Critical Thinking & Critical knowledge

3. What is Critical Thinking?
Critical thinking is the intellectually disciplined
process of actively and skillfully conceptualizing,
applying, analyzing, synthesizing, and/or
evaluating information gathered from, or
generated by, observation, experience, reflection,
reasoning, or communication, as a guide to belief
and action.
In its exemplary form, it is based on universal
intellectual values that transcend subject matter
divisions: clarity, accuracy, precision, consistency,
relevance, sound evidence, good reasons, depth,
breadth, and fairness.

7. What is Critical Thinking?
Critical thinking can be seen as having two
components:
1) a set of information and belief generating and
processing skills, and
2) the habit, based on intellectual commitment, of
using those skills to guide behavior.

8. Science in collaboration with Caring
 Adult Learning  Clinical Trials
 Statistics  Practical’s
 Optimization  Probability
 Modeling  Simulation

9. Operational Management
 Staffing Schedules
 Response Staffing
 Response Criteria
Treatment Priorities
 Vehicle Staging

10. Operational Management
 Response Staffing
 2 Paramedics
 1 Paramedic & EMT - B
 Response Criteria
 9 minutes response times

11. Operational Management
Treatment Priorities
 IV, O2, EKG, Transport
 Maintaining BP at 120/80
 Fluid Bolus
 Vehicle Staging
 System Status Management

12. Classroom Management
 Schedules
Blue Prints of Knowledge
Exams
 Make-Up Exams

13. 20 Students, 10 Subjects, 53 Make-up exams!
Time, Effort, and Schedules are all a concern
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0
Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0
Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0
Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0
Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0
Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0
Anatomy 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
Pharmacology 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0
Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1

14. How do you schedule Make-up Test for each Subject?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0
Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0
Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0
Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0
Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0
Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0
Anatomy 0 0 0 0 1 0 0 00 1 0 0 0 0 1 0 0 0 0 1
Pharmacology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0
EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0
Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
Students 2, 7, 12, and 17 have conflicts if Technical Writing and Algebra
are schedule at the same time.
Students 1, 3, 6, 8, 11, 13, 16, and 18 have conflicts if Chemistry and
Pharmacology are scheduled at the same time.

15. As the Program Director, how do YOU
resolve the Make-Up Exam issue?
Methods:
 Create 30 hours Days
 Specific Make-Up Test Times
 Trial and Error
 Other ??

16. WELL !?!?!
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0
Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0
Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0
Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0
Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0
Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0
Anatomy 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
Pharmacology 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0
Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1

17. As the Program Director, how do YOU
resolve the Make-Up Exam issue?
Make the Solution a:
“COLORING Problem”
A
Welch – Powell
or
Chromatic Number Algorithm

18. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
EMS History 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0
Technical Writing 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 0
Algebra 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1 0 0 0
Chemistry 1 0 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0 0
Biology 0 0 0 1 0 0 0 01 0 0 0 0 1 0 0 0 0 1 0
Physics 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0 0
Anatomy 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
Pharmacology 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
EMS Law 0 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 0 1 0
Ambulance Operations 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
Anat
Tech Wr
EMS Hx Amb Ops
Algebra
Chem Bio
EMS Law
Phys
Pharm

19. EMS Law 8 Physics 4
Algebra 5 Ana 3
Tech Wr 5 Amb Ops 3
EMS Hx 4 Bio 2
Chem 4 Pharm 2
Anat
Tech Wr
EMS Hx Amb Ops
Algebra
Chem Bio
EMS Law
Phys
Pharm

20. SO. . .
How many Testing sessions are required ??
Anat
Tech Wr
EMS Hx Amb Ops
Algebra
Chem Bio
EMS Law
Phys
Pharm
FOUR !!

21. Let’s Look at Another Example
G 6 H 5 I
4 3 7
D 9 E 4 F
5 9 8
A 6 B 10 C

22. Which is the Fastest Route ??
G 6 H 5 I
4 3 7
D 9 E 4 F
5 9 8
A 6 B 10 C

23. What Method did you use to
Determine that ??
G 6 H 5 I
4 3 7
D 9 E 4 F
5 9 8
A 6 B 10 C

24. 3 X 3 Block = 20 routes
6 Operations per Block = 120 Operations
G 6 H 5 I
4 3 7
D 9 E 4 F
5 9 8
A 6 B 10 C

25. How about Dynamic Programming ?
11 5
G 6 H 5 I
4 3 7
8
15 D 9 E 4 F 7
5 9 8
20 A 6 B 10 C
15
17

26. 9 Routes
For a Total of 32 Operations
11 5
G 6 H 5 I
4 3 7
8
15 D 9 E 4 F 7
5 9 8
20 A 6 B 10 C
15
17

27. 1987, England
Commercial Airliner crashes
126 People onboard
87 Survived
HOW ? WHY ?

29. Injury Severity Scores of Passengers
Dead Survivors
(Scores) (Scores)
Min 12 1
Mid 66 12
Max 75 50

30. Injury Severity Scores of Passengers
The ISS is also an anatomically based
ordinal scale, with a range from 1 to
75.
To compute the ISS the nine AIS body
regions are grouped into six: head or
neck, face, chest, abdominal or pelvic
contents, extremities or pelvic girdle,
and external.

31. Injury Severity Scores of Passengers
The ISS is then calculated as the sum
of the squares of the highest AIS
scores for the three most severely
injured body regions.

32. AIS Score Injury
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Unsurvivable

33. An example of the ISS calculation is shown below:
Region Injury AIS Square
Description Top Three
Head & Neck Cerebral 3 9
Contusion
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion 2
of Liver 5 25
Complex
Rupture Spleen
Extremity Fractured femur 3
External No Injury 0
Injury Severity Score: 50

34. Injury Severity Scores of Passengers
Highest ISS score obtainable is 75.
ISS below 25 = minimal mortality risk
ISS of 50 = mortality of 50%
ISS is 70 = it is close to 100%

35. Injury Severity Scores of Passengers
Dead Survivors
Min 12 1
Mid 66 12
Max 75 50

36. Does the ISS provide us with the Answers?
Probably NOT!
Researchers looked at all the passengers
Vital Signs including:
Pulse pH
Respirations Mental Status
PO2 Blood Pressure

37. pH became one of the greater predictors
of survival
Survivors
Range: 7.45 – 7.58
Only one of the Dead had a pH within
this range

38. What Value Does this information have
for US ?!?
Can it provide us with a method to
determine which Patient to care for
first?
Which Patient has the greatest potential
for survival?
Something else?

40. “Today the triage officer has to play God!”
Noted Paramedic
Which two are first to be
transported?
Victim Respiration Pulse Mental Status
1. elderly lady seems unconscious... <30 Yes Obeys Commands
2. unconscious man pulled from train... <30 Yes Localizes
3. middle age woman awakes confused... <30 Yes Obeys Commands
4. unconscious patient .. pulse is slow... >30 Yes Withdraws pain
5. unconscious woman… breathing slow... <30 Yes Extends from pain
6. woman on stretcher .. breathing rapidly… >30 Yes Pushes away pain
7. Amtrak porter found .. breathing rapidly… <30 Yes Pushes away pain
8. unconscious victim ... trouble breathing... <30 Yes Extends from pain
Based on START criteria

41. Which two are first to be
transported?
Victim Respiration Pulse Mental Status
1. elderly lady seems unconscious... <30 Yes Obeys Commands
2. unconscious man pulled from train... <30 Yes Localizes
3. middle age woman awakes confused... <30 Yes Obeys Commands
4. unconscious patient .. pulse is slow... >30 Yes Withdraws pain
5. unconscious woman… breathing slow... <30 Yes Extends from pain
6. woman on stretcher .. breathing rapidly… >30 Yes Pushes away pain
7. Amtrak porter found .. breathing rapidly… <30 Yes Pushes away pain
8. unconscious victim ... trouble breathing... <30 Yes Extends from pain
Based on START criteria

42. Which two are first to be
transported?
Victim Respiration Pulse Mental Status
1. elderly lady seems unconscious... 28 56 Obeys Commands
2. unconscious man pulled from train... 20 130 Localizes Pain
3. middle age woman awakes confused... 8 40 Obeys Commands
4. unconscious patient .. pulse is slow... 44 36 Withdraws pain
5. unconscious woman… breathing slow... 6 20 Extends from pain
6. woman on stretcher .. breathing rapidly… 36 130 Pushes away pain
7. Amtrak porter found .. breathing rapidly… 40 44 Pushes away pain
8. unconscious victim ... trouble breathing... 8 38 Extends from pain
Based on START criteria

43. Which two are first to be
transported?
Victim Respiration Pulse Mental Status
1. elderly lady seems unconscious... 28 56 Obeys Commands
2. unconscious man pulled from train... 20 130 Localizes Pain
3. middle age woman awakes confused... 8 40 Obeys Commands
4. unconscious patient .. pulse is slow... 44 36 Withdraws pain
5. unconscious woman… breathing slow... 6 20 Extends from pain
6. woman on stretcher .. breathing rapidly… 36 130 Pushes away pain
7. Amtrak porter found .. breathing rapidly… 40 44 Pushes away pain
8. unconscious victim ... trouble breathing... 8 38 Extends from pain

44. Which two are sent first to the ED?
Victim Transport Order / Treatment Order
1. elderly lady seems unconscious... Fifth
2. unconscious man pulled from train… Sixth
3. middle age woman awakes confused... Third
4. unconscious patient .. pulse is slow... First
5. unconscious woman… breathing slow... Eighth
6. woman on stretcher .. breathing rapidly… Fourth
7. Amtrak porter found .. breathing rapidly… Second
8. unconscious victim pinned.. trouble breathing... Seventh

45. Summary
Many tools available to increase the
quality of care we provide to OUR
patients
Numerous processes that can be taught
in the classroom and clinical settings
which promote better utilization of
resources = HIGHER QUALITY OF CARE
Allows EMS providers to become an
active participant in the Practice of
Emergency Care

46. Summary
Provide a scientific basis from which the
“Hands of Medicine”
“Cares”

47. Bob Waddell II
bobwaddell@bresnan.net
(307) 920 2020