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Trauma Education

Dr. Bledsoe s column last month about prehospital care providers who don t understand why they have to do continuing education when docs and nurses don t really got me thinking.

A lot of people (including me) feel that although primary education prepares you to begin your career, it s experience and continuing education that make the biggest contribution to the type of EMT or paramedic you ll become.

Don't get the wrong idea from that statement. It in no way diminishes the importance of the highest quality possible primary education. Skilled educators all over the world are teaching and inspiring students who deliver the best that prehospital care can offer to our patients. What I'm saying is that what happens after class truly makes us who we are.

Experience lends maturity to our fledgling careers. We hone our skills and make applications of classroom experiences to real patients. What began as ideas that made sense in classroom scenarios become fact and part of our unconscious response to the needs of our patients. The problem is that experience is just that: By definition, it's limited to what we get a chance to do. The National Registry Practice Analysis describes what we really do in the field. It turns out (which is no surprise to most of us) that we do a lot of some things and almost none of other things. We get a lot of opportunities to take care of people with difficulty breathing or belly pain, but much of what we learned in our primary program doesn't happen often in our practice.

Another consideration is change. As we move to a more evidence-based practice that measures patient outcomes, may of the truths of old give way to the dictates of science. Our practice becomes more about what the patient needs us to do rather than what we want to do with our patients.

The most important opportunity for continuing education is the reality bridge. This is where we look at what we think we re doing and what we re actually doing. We measure performance against protocols ad outcomes to get a handle on what we are and aren t doing and how to close the gap between objectives and performance.

So we have three items to address. First, how do we maintain the knowledge and skills to address situations we don t often see? Second, how do we do keep up to date with changes in our practice? Finally, what do we do about optimal performance vs. actual performance?

Three Steps
This is where continuing education comes in. Our primary education makes us smart enough to get to work; continuing education makes us wise. It provides the bridge between what we ve seen and haven t seen, what we know and what we don t know, what we remember and what we ve forgotten.

Let me say that if you re not a fan of continuing education, I hear you. I ve been there. I'm in my 30th year of being a paramedic, and during those 30 years, I ve been subject to CE that was based strictly on portioned curricula, delivered with little or no enthusiasm. On the other hand, I ve also participated in continuing education that was productive, even imaginative and inspiring. So let s consider how CE can be most productive.

As I said at the outset, I was initially inspired to do this piece by Dr. Bledsoe's column. I also got an e-mail from a reader who said he sometimes felt lost by the depth of medicine beyond what we ve learned in school. This medic said he knew that I had gone on to nursing school after 15 plus years as a medic and wondered if that would help with the gap he felt between what he knew and what there was to know.

I think continuing education well engineered can fill the needs I ve expressed and the needs of the medic who wrote me looking for more.

Let's start with maintaining skills, especially those that are seldom used. Many published studies have looked at specific skill retention, including intubation. The studies point out that many medics don t get frequent opportunities to intubate, which may affect their success rates. However, studies have also shown the benefit of containing education in skill compliance. (These studies can be viewed on the PHTLS website at www.phtls.org.)

An example of such a study, with which I'm intimately familiar, is a study done by Dr. Jameel Ali that looked at skill compliance and patient outcomes before and after PHTLS training. Not only did his study show increased skill compliances but improved patient outcomes. So it has been demonstrated that skill compliance and patient outcomes both benefit from CE that s designed for specific skill compliance and targeted patient populations.

The second item on our list is change. Continuing education can and should address changes in practice dictated by science. Although we need to maintain skills in areas that are part of current practice, we must also update providers to changes in practice in a manner that shows relevance to practice and patient outcomes.

Our third item is compliance. We have protocols in place and skills appropriate to patient situations. QI/QA programs should determine agency specific reality vs. what our protocols call for. CE should be designed to address the gap and bring providers into compliance. Such studies as the one by Dr. Ali have showed the value of these endeavors by improving compliance and patient outcomes.

The last point to consider is if we can make CE relevant, interesting and useful. I say, Yes, we can. Besides the obvious benefit pointed out by the studies, con ed can be imaginative and collaborative efforts that create opportunities to cover new material and change, review protocols and skills, and create a professional interdisciplinary atmosphere that puts prehospital care providers in place with other medical professionals dealing with our patients.

Trauma education
Because this is a trauma column, I'll focus for this last moment on trauma training. Besides the benefit I've already described from courses like PHTLS, efforts by trauma professionals all over the trauma world are creating an atmosphere of professional cooperation and scholarly pursuit.

Trauma Grand Rounds many of you may have heard of this and even had the chance to participate. It's done in many different manners and always presents and interesting CE alternative.

A while back, I had the chance to sit in on Trauma Grand Rounds in Kansas. In this particular presentation, the prehospital care providers presented their patient history, and then the ED, surgical team, ICU and rehab folks presented their parts. Not only was it a valuable experience that revealed the effect each part had on the patient, but they also saw their place in the total patient care package. One of the concerns expressed by the medic who recently wrote to me was that he didn't feel included in the medical profession. This type of presentation makes clear where the prehospital piece fits in, it's value to the whole and the professional cooperation of each of the aspects of team care.

Another approach I worked on was at Good Samaritan in suburban Chicago where trauma surgeons did monthly CE on specific cases. Again, medics saw their patient care as a part of the whole; professional cooperation and camaraderie was strengthened while best practice and outcomes related to care were defined.

In closing, I want to emphasize a few points: QI/QA should be agency specific, and trauma systems should be actively involved in CE that includes all members of the patient care team from the field to rehab. Continuing education is our greatest burden and our greatest opportunity. If we recognize its potential, we can work to make it more relevant and productive for the benefit of providers and the profession.


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