Best Practices, Commentary, Spotlight

The Current State of Critical Thinking in EMS

A critical thinker must be sufficiently open-minded to other ideas and be willing to challenge current knowledge and experience. (Photo/Adam Mason)

Emergency medical services (EMS) journals regularly discuss a lack of critical thinking evident in paramedics and how this deficiency is a significant flaw in the profession. Some provide tips and tricks to paramedics looking to develop their critical thinking. Others outline examples of mindsets to follow and biases to avoid. These articles stand by the need for further critical thinking training in EMS, but there are some significant absences that limit their ability to assist practitioners seeking to develop their skills.

Before continuing, we must ask whether critical thinking is a valuable skill for paramedics. Is there a benefit to having paramedics make decisions on their own? Should we instead have them strictly follow flowcharts in patient assessment, initial treatment and prompt transport to a hospital where a doctor can oversee definitive care? Alternately, do we want more basic practitioners to follow the flowcharts and those of higher levels to think critically?

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The current system is largely based on the third option. Paramedics working at advanced levels are expected to be able to critically think. Certain treatments available to these practitioners may be detrimental to the patient, so it falls on the practitioner to assess, reason and treat appropriately. Paramedics working at a more basic level do not have such expectations. Their training encompasses a more limited scope, prioritizing treatment of only more severe conditions. While critical thinking skills may be a goal of advanced care education, at the basic level, the goal is to create technicians. Technicians prioritize practical skills, with less focus on the theoretical. Thus, it is possible to educate a technician rapidly – basic life support programs are thus much shorter. As explained by Daniel Limmer in his EMS World article, “A technician is not expected to use high levels of reasoning skills. Technicians are strictly protocol driven and respond in a specific way when a certain group of signs and symptoms appear.”1

Why, then, is there all this frustration with a lack of critical thinking in our profession, even with practitioners working at the basic level? The simplest answer is that when the practitioner aspires to the next level of training, critical thinking becomes more important. Unfortunately, to become an advanced level practitioner, the technician must then re-learn a fair amount of their practice. The second reason critical thinking is necessary for all paramedics has to do with the fluidity of patient assessment and treatment. Every skill performed requires an element of critical thinking. The practitioner must be able to select an appropriate diagnostic to perform or therapy to administer. They must then be able to verify the information received or confirm the therapy was effective. Kelly Grayson supports this point, noting that our current focus is more on what skills paramedics can perform, rather than the underlying knowledge necessary to determine when the skill is required and the ability to perform it proficiently.2 A further avenue of exploration is whether the skill was even necessary in the first place.

Further, paramedics must be able to determine which algorithm for patient treatment will provide the greatest benefit. They must also be able to identify treatment priorities, and which hospital is most appropriate for transport. Finally, there is no effective flowchart for the patient who is suffering from a serious medical condition and wishes to stay at home. Paramedics of any ability level forced to operate in these novel situations without clear directions must then be able to think through the situation and work through the problem.

Two Elements of Critical Thinking

Current EMS articles on how to develop critical thinking fall into the trap of providing guidelines without going into enough depth. Scott Cormier’s two-part article on critical thinking provides a few examples of approaches to critical thinking as well as biases to avoid.3,4 Unfortunately, they do not touch on the foundation of critical thinking, such as the traits of a good critical thinker, or provide examples to the reader to be able to apply these approaches in their own practice.

Others are more mechanical in nature than cognitive. In Daniel Limmer’s article, he states that practitioners should aspire to be clinicians instead of merely technicians. Where a technician identifies a symptom and works to treat it, a clinician strives to obtain a complete picture of the patient through a thorough assessment and the use of a differential diagnosis, prior to initiating a treatment. Performing thorough assessments of the patient, prioritizing focus on immediate threats to airway, breathing and circulation, and creating a differential diagnosis do not require as much critical thinking as might be expected.

I would suggest that a clinician’s approach has less to do with their ability to critically think, but more to do with thoroughness. In the example Limmer provides, the only difference between a technician and a clinician is the completion of a more thorough assessment that leads to a different diagnosis and, therefore, a different treatment plan. Though creating a differential diagnosis involves elements of critical thinking, it can also be a largely mechanical process – paramedics can easily memorize medical conditions to rule out in the case of a patient presenting with a specific complaint. Of the six steps suggested, only the last two involve critical thinking. Unfortunately, these are the shortest steps in the article. The best example I was able to discover is Rom Duckworth’s article, urging practitioners to assess sources of information for accuracy, validity, and a lack of bias, while also questioning currently-held beliefs.5 This article focuses on the cognitive skills inherent in critical thinking, avoiding the mechanical pitfalls other articles fall into. However, like the other articles, it is very brief and does not provide examples for practitioners to either follow or practice.

The second major flaw underlying these articles is the assumption that the readers have enough background knowledge of the topic in order to be able to make critical decisions. For example, students in an advanced care paramedic class are asked to create a treatment plan for a cardiac complaint. The patient has sudden onset chest pain, radiating to the left arm, as well as significant pitting edema to upper and lower extremities. The patient also has a significant cardiac history. At the chest, wheezes are auscultated. Several students in the class treat the patient with salbutamol and ipratropium bromide, working to improve air entry and decrease wheezing through bronchodilation. A subsequent discussion introduced the existence of cardiac wheezes, caused not by bronchospasm, but by the presence of fluid in the lungs due to diminished cardiac output. The therapy selected by the students would be minimally effective at best, potentially detrimental to the patient at worst.

Reflecting on this experience, are the students at fault for not determining the patient’s wheezing to be cardiac in origin? Prior learning at the primary care paramedic level focused on treating wheezing as a symptom. Little focus was given to other potential causes of wheezing and treatment plans had a linear approach. Wheezing at that level is an automatic indication for nebulizer therapy.

The flaw lies not in a lack of critical thinking, because there was no room for the students to critically think. The assessment revealed wheezing, the students presumed that it was caused by bronchospasm, and then followed the appropriate protocol. The issue is that the students lacked enough background knowledge to understand the anatomy and physiology of the lungs and the pathophysiology of cardiac wheezing. A critical thinker with this background knowledge would have been able to determine the cause of the wheezing, weigh the benefits of available treatments and choose to initiate or withhold treatments based on the information given to them.

The Next Step

Critical thinking is not something that one can just begin to do. It is a skill that must first be taught, developed over time and regularly maintained. It is a combination of traits that one must possess and processes that must be developed and followed. A critical thinker must be sufficiently open-minded to other ideas and be willing to challenge current knowledge and experience.

This skill should be introduced at the earliest level possible, to benefit practitioners from the beginning of their career. Alongside critical thinking, a foundation of strong clinical knowledge must be present to allow for effective decisions to be made.

References

1. EMSWorld. Beyond the Basics: The Art of Critical Thinking Part 1 [Internet]. Emsworld.com; April 2008 [cited 2020 Jul 21]. Available from: https://www.emsworld.com/article/10321160/beyond-basics-art-critical-thinking-part-1.

2. EMS1. EMS 2.0: Critical Thinking in Prehospital Training [Internet] EMS1.com; Oct 2009 [cited 2020 Jul 21]. Available from: https://www.ems1.com/ems-products/education/articles/ems-20-critical-thinking-in-prehospital-training-eCjskymt7gQYBFLe/.  

3. JEMS. Critical Thinking: Part 1 [Internet]. JEMS.com; May 2017 [cited 2020 Jul 21]. Available from: https://www.jems.com/2017/05/15/critical-thinking-part-one/.

4. JEMS. Critical Thinking: Part 2 [Internet]. JEMS.com; May 2017 [cited 2020 Jul 21]. Available from: https://www.jems.com/2017/05/15/critical-thinking-part-two/.

5. EMS1. 5 Critical Thinking Skills Crucial to EMS Professional Development [Internet]. EMS1.com; August 2017 [cited 2020 Jul 21]. Available from: https://www.ems1.com/ems-management/articles/5-critical-thinking-skills-crucial-to-ems-professional-development-fQIz2bctBpYHktUP/