CLINICAL REASONING €“ HEURISTICS AND ANALYTICAL REASONING IN HIGH ACUITY CASES.

SHORT ANSWER QUESTIONS

READ THE FOLLOWING CASE AND ANSWER THE 4 QUESTIONS.

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 4 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.

Crew member descriptions for module 1 clinical reasoning assignment

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, POSTURING

CREW MEMBER 4

Tanya

??Tanya is 22 years old and has just finished her internship.

??She has been a first aid volunteer at community events for the last 3 years and has been an ambulance volunteer for the past year.

??She has recently been working with her team leader to develop material for new internship participants and enjoys being part of the guideline/ policy development committee.

??She has recently started renting a unit with her older brother that is close to her work.

POTENTIAL DIAGNOSIS: ASTHMA ATTACK

TREATMENT: OXYGEN, POSTURING, IM ADRENALINE

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:

StudentDescription:

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. Omar3888@hot€¦

Support your answers using literature and reference to the case.

(200 words €“ provide at least two (2) references to literature regrading bias in clinical

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