It is the "Five Differentials" Challenge
Our objective as educators is to craft “entry-level paramedic” candidates. When done correctly, this “crafting” is an art.
It is also a “science”–of trial and error. Many educators struggle with how to push their students up the heights of Bloom’s taxonomy into the realms of “application”–getting them to the levels of “analysis” and “evaluation” is even more challenging.
But the educator’s job is to reverse-engineer the process…to get students to travel the path seemingly on their own (like it was their idea). THAT is where the artistry really happens.
It doesn’t have to be difficult. By employing this one technique over time, we build the synaptic pathways which make application, analysis, and even evaluation an almost automatic process (habit) for our students. No more being scared of the big, bad NREMT “Clinical Judgment” questions!
How it Works
By approaching patient cases and scenarios the same way every time, we are establishing a process. Once built and established, this pathway will become the student’s default way of thinking about a patient…almost a reflex.
How to Do It
When discussing (virtually any) patient presentation–challenge the students to come up with five differential diagnoses (DDx):
- worst case possible (deadliest or quickest killer)
- best case (easiest to fix)
- and “three in the middle“. Usually, they will struggle with a 5th one, so I usually allow “something I never heard of before” (which is a thing in the prehospital setting!).
What is a DDx? It is an underlying pathology which could explain the patient’s presentation. Ideally, our DDx guide us as we gather medical history to 1) rule out (or detect) the “worst case” as soon as possible and then 2) help us zero in on a working field diagnosis which will inform our treatment plan.
From this seed of DDx, clinical judgement naturally grows with branching discussions such as:
- What do we have to do (assessments to complete, questions to ask) to figure out the actual working field dx (most probable of our 5 DDx?)?
- Alter history, age, or even a single vital sign to ask how that might shift the focus within the five.
- Add an assessment detail. Which DDx which are more likely now that you know that?
- Discuss treatments each different DDx might need.
- Complete a risk-to-benefit analysis for each possible treatment (especially “will it do harm if the diagnosis is not the one we *think* it is?)
When To Do It
You don’t ask all of these questions all of the time–focus on the branches which are relevant for the day. Some examples are below.
Basically any time you are discussing any signs/symptoms you can ask the question, “What are 5 possible pathologies (conditions, injuries) which might cause a patient to present with this complaint?”
Even a brand-new EMT-Basic student can start working DDx with just introductory anatomy.
Here, pt presents with leg pain. DDX include issue with bone, muscle, skin, vessels, or “something I never heard of before.”[/caption]
Example: pt has pain in lower leg. What are five possible causes? Responses should include:
- A problem with their bone
- a problem with their muscle
- a problem with their skin
- a problem with their blood vessels
- something I never heard of before (you could briefly talk about how heart issues might cause fluid to leak out of vessels and cause leg swelling, but that we’d expect this in both legs–this action instills a curiosity which will help the student once you DO reach cardiovascular emergencies!)
Of course, as students’ vocabularies grow, we should elevate our expectations of how they describe or name their DDx.
Another example might be when you are introducing a new condition (patient presentation). For instance when you’re teaching airway emergencies and talking about one set of s/s, you should than also ask your students how this condition is similar and different from the last one we talked about. What can we do in the field (assess, ask) to tell the conditions apart?
The key is to always be looking for opportunities to inject the discussion. This requires we educators are 1) ourselves PREPARED and 2) able to keep quiet and allow the students to struggle just the right amount (too little and they don’t engage, too much and they give up).
Debriefs after full-moulage simulation are PRIME times to do the exercise.
This is also an extremely effective way to have small groups verbally work a scenario. The facilitator (instructor) should stop at each stage in the call to ask the questions to initiate and lead the students’ thinking. Make each group COMMIT–this will force them to quit waffling and over time help to quiet fears of “looking stupid” or “doing something wrong” which can paralyze the practitioner once they are alone out in the field.
- after “en route” info: what are the five?
- What do you want to do, what do you want to know? (Force them to consider the primary assessment FIRST–always)
- after gaining Primary Assesment info: have any DDx become more likely or less likely?
- What do you want to know, what do you want to do? What assessments are PRIORITY based on DDx?
- What is your working Field Dx (the most probable DDx)?
- What interventions are you considering?
- Can that intervention hurt the pt if their actual diagnosis is one of the other differentials (an example would be intubating a hypoglycemic pt)? Are there other assessments we need to do to minimize the risk that our Field Dx is wrong?
- Did the patient’s response (or lack thereof) to treatment inform your DDx?
After each group or student has COMMITTED to an answer, it is your job as facilitator to gently get everyone onto a more correct track by asking the questions that logically take them back there. It is almost more important to POSITIVELY praise and reinforce when the majority are on the correct track.
And would ya look at that–though this technique has been around and proven successful for many years, it just so happens to mirror what we see in the “new” NREMT Clinical Judgment question scaffold!
Keep in mind, “Correct” is a relative term in these conversations. As long as their brains are engaged, logical, and looking for defensible rationale the session is PRODUCTIVE. In fact, we learn more quickly from our mistakes.
All The Time
If you as the facilitator/educator are disciplined and employ this framework ALL THE TIME, your students will irresistibly begin to think this way. And then you know what you have accomplished? CLINICAL JUDGMENT!
NREMT Clinical Judgment question scaffold. Click to see Sample Packet.