Duckworth on Education: 5 PACES to Engage Critical Thinking

During a trauma lab, your student sees a mannequin with facial trauma and instantly calls for a surgical airway kit. “They’re not breathing,” they insist. You look at the BVM still sitting on the counter and think: “What led you to skip every step in between?”

That moment is the essence of teaching critical thinking. Students of all backgrounds, but especially newer students, tend towards linear thinking under stress. In tense situations, it can be difficult to quickly evaluate options and choose the best one for the situation. One of the best ways to structure these critical thinking moments is to use the PACE model—Primary, Alternative, Contingent, Emergency—which guides decision-making under pressure.

Building on that foundation, I add one more letter: S for Steps. The result, PACES, provides educators with a straightforward tool to assist providers (new and experienced) to practice the rapid critical thinking required to care for patients in the most challenging situations. This mnemonic can be applied to virtually any clinical skill or scenario.

P — Primary

Every provider has a “go-to” tool or technique—the one that feels safest and most familiar. Start there. Ask students:

• Why is this your primary choice?
• What are its strengths and limits?

Encouraging them to explain why clarifies when that choice fits and when it doesn’t. This is especially useful when engaging experienced clinicians who have strong preferences for their primary “go-to.” The first goal is to help students appreciate that different clinicians can have different “primary” tools and techniques for the same situations. The second goal is to help clinicians identify conditions that require a different approach, where their “primary” isn’t the right choice, and they need to move on. This is the heart of critical thinking.

Example: During airway practice, a paramedic defaults to a supraglottic device. You ask, “Why that first?” The student recognizes it’s speed, not always best-fit, and refines criteria for when BVM control may be the smarter start.

A — Alternative

Alternatives aren’t failures; they’re flexibility. Help students develop a Plan B before things go wrong. If working individually, clinicians need to be ready to smoothly transition from primary to alternative. If working in a team, team members should be ready to respectfully alert the primary clinician if they see the primary plan isn’t working. They must also be coordinated, ready to help with the same alternative. If everyone is working toward a different alternative plan B, then patient care stalls out right when it needs to move forward.

Example: After two failed IVs, a student reaches straight for IO. You ask, “When does IO make sense, and when might another provider, site, or technique be better?” There isn’t one right answer, but if the student responds with something like, “because I’m supposed to,” a quick debrief can reinforce problem-solving over reflex.

C — Contingent

Contingency planning means considering the alternative path to take if the first plans fail. It’s one of the most under-taught habits in EMS education.

Prompt learners to verbalize:

• “If this plan fails, what’s our trigger to move on?”
• “What’s the best way to move from primary/alternate to the contingent option?”

Example: During a multi-patient MVC, your crew plans to RSI a head-injured driver. The paramedic states:

“If first-pass intubation fails, and oxygen saturation drops below 90%, we’ll immediately move to supraglottic airway. If that also fails, our third step is BVM while we prep for cricothyrotomy.”

When the laryngoscope view turns out poor, the alternate provider is already poised with the supraglottic device. The transition is smooth—no argument, no confusion, no delay. Because the contingent path was declared up front, the team executes calmly and efficiently under stress.

E — Emergency

Sometimes you truly have to do what you have to do. However, too many students go there first. Teaching when to escalate is as important as teaching how.

Example: Your crew is treating a patient in severe respiratory distress from CHF. Despite CPAP, oxygen saturations are falling. A student immediately pushes for intubation.

You ask, “What tells us we’re out of noninvasive options?”

They reassess: the mask seal is good, but pressure and flow are not yet optimized, and nitrates are still being titrated. After a brief adjustment and medication bump, the patient stabilizes—no tube needed.

By discussing “Emergency” as a last-ditch tool, not a shortcut, you preserve field realism while discouraging premature extremes. Escalation isn’t failure; it’s timing. “Emergency” should mean we’ve exhausted optimization, not we’ve run out of patience.

S — Steps

Once the immediate action is done, what’s next? The “S” turns PACE from a choice model into a closure model.

Ask learners:

• “Now that you’ve used your Primary (or Alternative, etc.), what Steps complete this call?”
• “Who needs to know what you did?”

Example: After using their last trauma dressing on a severe bleed, the crew debriefs en route back to quarters.

“We’ll restock trauma kit first. Note: need larger chest-seal inventory—used two today.”

They update the supply log and jot a brief reflection: “Tourniquet timing communication worked well—repeat next shift.”

Outcome: Equipment readiness and self-assessment both close the loop; the next patient benefits immediately.

These follow-through steps build professional discipline as much as technical skill.

Bringing It Together

Used together, PACES turns routine scenarios into dynamic discussions:

• Primary: Define your bull’s-eye and recognize its limits.
• Alternative: Prepare to transition to backups before you need them.
• Contingent: Plan to pivot if things continue to fail.
• Emergency: Act only when you truly must.
• Steps: Communicate and review to be ready for next time.

Each conversation reinforces the same critical-thinking rhythm: pause, reason, act, and review. When we train EMS providers to think in PACES, they stop memorizing responses and start managing situations with critical thinking. That’s how we build smarter, safer clinicians one deliberate decision at a time.