Quality Corner: Teaching Critical Thinking

Much of EMS education is like education in general—it’s not all that effective at actually teaching. Education in the U.S. is still traditionally rigid, students sitting lined up in perfect rows at their desks, facing the focal point of the classroom—either a teacher pontificating or a flat screen PowerPoint. According to most experts, logic challenges, problem solving exercises and practical scenarios that require critical thinking are much more effective for student learning.

Incorporating realism into training is gaining popularity in medicine. High-fidelity simulation manikins, patient actors coached to demonstrate realistic signs and symptoms, along with wound simulation and moulage, are being included with increasing frequency to add realism to practical training scenarios. But even more important than adding visual clues to training exercises is creating challenging scenarios that require critical thinking and problem solving for successful mitigation. Of course, designing these scenarios takes more time and thought, but they will ultimately end up being much more educational than just about anything else you can do in a class.

Here’s an example of one of my favorite practical trauma scenarios. As a team of two students approaches the mock scene of a motor vehicle crash, I advise that having arrived on-scene just prior to them, I can answer any questions that are answerable. I also inform them I’m a police officer and EMT, so I can help them as a third provider if needed. My name is Officer Murphy, but my friends call me Murphy’s Law. Many of the students roll their eyes or moan, realizing the double entendre.

The students are then presented with a 50-year-old male trapped in a mid-sized car, which has struck a bridge abutment. The patient is conscious but anxious, pale and diaphoretic with a weak radial pulse of 88, delayed capillary refill, with cool digits, and respirations are slightly tachypniec but non-labored at 22 a minute. The patient was restrained with air bag deployment and recalls the entire frightening event, which was precipitated when he hit something in the road, his tire blew out and he careened into the abutment.  

As the students perform a quick trauma survey they find no obvious injuries to the head, neck, chest, abdomen or pelvis. The patient is trapped from the mid-thigh of both legs by the seat being displaced forward and the dashboard collapsing around the patients’ legs. The patient says he can feel and move the toes on both legs, but both legs hurt equally as far as he can tell. The distal legs cannot be directly assessed because of the wreckage, but a puddle of blood can be seen on the floorboard. Fire rescue’s arrival is reported to be delayed.

Perplexed by the ambiguousness of the scenario, most students review their findings out loud. “No head, chest or abdominal injuries, but the patient looks shocky.”

“How long ’til extrication?” they inquire, half asking and half pleading.

“Unknown,” I reply.

They start to feel the heat. This is also where there is an almost equal divergence in patient care management among students. Half decide to default to doing what they’re comfortable with doing—starting IVs. For those who do, they’re told there is no venous access; all attempts are unsuccessful. All quickly transition to IO, as most of EMS is now well trained to do. Some have a moment of pause when they realize the site which they’re most familiar with starting IOs—some exclusively so—is not available due to the leg entrapment. In all cases vascular access is eventually established via the humeral head. After IO access is established, the vascular access enthusiasts end up returning to the problem at hand, which the other half of students remained struggling with—where is the patients’ life threatening injury?

Most repeat assessment questions, but eventually all come back to the reality that the only obvious injury is the legs. Some attempt to drag out more information from me, but there is none to be had; legs trapped, blood puddle on the floor board. So time to turn the heat up a notch and force some action.

“The patient is losing consciousness,” I announce.

“He’s bleeding out,” several students quickly conclude.

“Where from?” Murphy’s Law sometimes inquires.

“His legs. It must be his legs,” most now conclude. “And we can’t get to them?” they ask again, hoping I’ll change my mind.

“Nope! What you see is what you’re stuck with.”

“So, there’s no way we can get to his legs?” some repeat in disbelief.

If looks could kill at this point, Murphy’s Law would be put out of his misery. But, as in real life, it’s never that easy.

About half of the providers grudgingly realize the necessary intervention. Those still unsure are prompted by an ever needling Murphy’s Law.

“So what do you want to do?”

“Tourniquet!” almost all of them ends up concluding at this point. And at this point I remove a tourniquet that was hidden in the first-in bag I have. If the tourniquets would have been left out in plain sight it would have been an unfair hint.

“Great!” I reply.

“Which leg?” either they or their partner ask out loud.

A brief pause and then, “Both!” they reply, with a combination of exaltation and resignation. At which point I produce a second tourniquet. Each student takes a leg and starts cranking down on the tourniquets, much to the delight of the victim whom we could never pay enough.

The vast majority of students struggle through the scenario to save the patient, but only after some fits and starts, a lot of stress and some occasional stumbling.

One of the most common questions asked in the post-course critique was why the patient wasn’t tachycardic if he was in shock. I cite a couple reasons. The obvious, and most familiar, to EMS providers is the patient was on a beta or calcium blocker, which blunted the increase in their heart rate. Another less common but not unheard of reason is they just weren’t. There is a subset of otherwise healthy patients out there who, for whatever reason, just don’t tach in response to physiological stress. No physician has ever been able to explain to me why, other than they’re basically one of those patients who didn’t read the book and didn’t know they were supposed to be tachycardic. Unfortunately, these patients not only don’t present without the most common sign we’re looking for as a clue of their cardiovascular stress, they also don’t have the benefit of that compensatory mechanism and therefore tend to crash quicker, as our practical scenario patient did.

The other point frequently made is the possibility of our patient having significant internal injuries, which we simply weren’t able to appreciate during the head-to-toe trauma survey in the less than optimal environment we were presented. Liver rupture, aortic tear or other major vessel bleeds are all other possible life-threatening injuries this patient could have had. Of course, there’s presently nothing EMS providers can do about any of those injuries, but uncontrolled hemorrhage from inaccessible leg trauma is an injury we can treat.

Among the many challenges of convention and management in this scenario, the life-saving treatment employed was not the textbook indication for tourniquet application. Traditionally, tourniquets are reserved for arterial bleeds. In the case of our scenario though, do we ever actually know whether the bleed was arterial or venous?

The answer was discovered about year after we first ran this exercise. One of the students who took this class ended up facing an almost identical situation on an actual call. Instead of a car crashing into a bridge abutment, a tractor trailer crashed into a tree. The patient was heavily entrapped with an extended extrication time. The only identifiable injury to this real patient, as in our training scenario, was trapped and injured legs with a copious amount of blood evident on the floorboard.

As devious as the Murphy’s Law of our trauma training was, life can be even crueler. The real patient happened to be on Coumadin. After hearing that I kicked myself for not thinking of it on my own. The student turned real-world rescuer, having seen a training scenario so similar, was surprisingly quick to control bleeding by applying bilateral tourniquets even though only one leg ended up actually requiring it. And, amazingly, just as in our training scenario, IV access was unobtainable, so the well-trained medic quickly and efficiently placed a humeral IO. It’s also worth noting that, just as in our training scenario, the real patient also had a good outcome.

These types of training scenarios are worth their weight in gold, and we need to be presenting them more frequently to challenge our students to think critically and solve the difficult problems of prehospital emergency medicine. An evil genius capable of thinking like Murphy’s Law, or borrowing from real-world cases, will be your best resource in designing these scenarios.

Traditional education that disseminates the latest standards in patient care is important, but practical scenarios that require critical thinking in order to successfully mitigate are invaluable in preparing EMS providers for the real-world challenges that will inevitably be thrown their way.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.