Education Pitfalls

We have a strong desire to create thinking, intuitive students from our classes. One way to foster this is through realistic practical training. This training begins in the scene size-up and initial assessment. In a recent instructor class, we discussed pitfalls of practical education. I'll summarize a bit of that discussion and add a few thoughts on how to improve the practical or practice portions of EMT classes to create more intuitive students.

Scene Size-Up
     Scene size-up is a somewhat abstract concept when practiced in the classroom. The five traditional components (BSI, scene safety, number of patients, MOI/NOI, resources) become more of a rote recitation with instructor approval. Quite frankly, it is challenging to simulate many of these situations on a routine basis in the classroom. With minimal effort, however, we can help foster a thinking process. For example:

The "BSI/scene safety Hokey-Pokey" (you know the one-students approach a scenario and say "scene safe/BSI" while waving their hands in the air) should be avoided. This pitfall allows students to think that BSI is only about gloves and won't change throughout the call. Protecting the eyes and facial mucous membranes is a critical concept that may become necessary later in the call when the patient becomes unresponsive and requires suction.

Do you ever have more than one patient in medical or trauma emergency scenarios? The concept of multiple patients should be reinforced at the proper time in the class. Near the end of the class, after students gain a foundation of the basics and some confidence, prepare a scenario for "chest pain" or "broken leg." When students arrive they find two patients. Perhaps one patient develops chest pain after care begins on the first.

Initial Assessment
The initial assessment begins with a "general impression." Taken from medicine, this concept is similar to the "from-the-door" assessment taught in peds classes.

I began teaching in Maine several years ago. My first class was second-year medic students. In one of my first practical sessions, a student came in, did the "BSI/scene safety Hokey-Pokey" and said, "What is my general impression?" To this I replied, "How would I know? It's YOUR general impression."

Of course, the ability to do this depends on your patient. If the scenario calls for a 56-year-old man with chest pain, a disinterested 23-year-old student/patient won't work. But students can be taught to simulate critical patients effectively.

The general impression is a foundational concept, but one that is more often than not glossed over as another step in the process. Experienced providers call this the "look test," and this cuts to the heart of Lt. Scotch's thoughts.

Our training must provide students a realistic starting point for decision-making. They won't see actual patients in class. They won't see every possible combination, but they should see patients in class who are simulated as unresponsive, fist-to-chest (Levine's sign), tripod position and altered mental status. When they see these conditions in class, they should create mental links and 1) immediately assign a high priority, but more important, 2) take steps to expedite the call (e.g., plan for prompt transport) and call for additional help if it could reasonably be needed, and 3) begin to formulate a plan in advance in case the patient crashes.

The bottom line: When we see a gray, sweaty patient with chest pain from across the room, we instantly think: "I hope this person doesn't go south before we get him downstairs." This is what we want our students to think as well. Realistic scenario practice is key to this ability.

Finally, don't let your students look at a patient and say, "He's conscious and talking with me, so the ABCs are OK." I firmly believe that an initial assessment isn't complete if the EMT hasn't touched the patient; checked skin for color, temperature and condition; and felt the pulse-not counted the pulse, but felt the pulse. Our students can tell the difference between normal, tachycardia and bradycardia without a watch. Abnormal skin plus a fast or slow pulse equals a serious patient. You don't get that from the fact the patient is conscious and talking.