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Being the Best We Can Be


In the comments made after last month’s article, I saw a response from a reader that goes by “SEAL Medic Trainer.” It started a train of thought that played into a discussion on the JEMS “Today in EMS” LinkedIn group that dealt with the subject of establishing some sort of “national standards” for training tactical paramedics. I felt a seizure coming on.

I’ve been watching our profession grow for 38 years now, starting when I served as a hospital corpsman in the U.S. Navy (1973–77). I’ve always had aspirations for higher standards and professionalization, and I continue to advocate for those improvements. Once upon a time, I thought the solution to “raising the bar” was through National Standard Curricula and state EMS regulations—just increase the number of hours, and the knowledge, skills and competence will rise in proportion.

It hasn’t worked. One would think that when a standard-setting process (such as writing standard curricula) or a regulatory process is complete, that would set the floor for the curriculum, level of EMT, or what have you. After all, that is the state-level regulatory mandate: to establish the minimum level of knowledge and skill so that a licensee doesn’t constitute a threat to public health and safety. That’s clearly a floor—the least acceptable professional that can pass the licensing exam, course of instruction, etc. The rest of us are free to rise as far above the floor as we wish to strive for excellence in our profession.

What I’ve seen, and what makes me feel that seizure coming on is that the legally established minimum becomes a ceiling once it becomes law and gets communicated to the world. In a recent discussion I had with a colleague who was once the director of a community-college paramedic program, I asked him why paramedic students seemed completely unable to perform basic EMS psychomotor skills a month after graduating paramedic school. He said, “If the state requires a minimum of 800 hours that is the maximum that my dean will budget for our course. Even if I wanted to use 1,200 hours to develop the kind of paramedic that I think our community needs, I would not be funded to do it!” The same, I’m told, is true for the many “puppy mills” that plague our industry. Their business model is to just do the minimum required by the state, nothing more. Feel that aura coming on …

So how does this connect to the TEMS certification discussion, and to SEAL Medic Trainer? Stand by, I’ll hook it up.

First, I have to tell you that tactical EMS is a favorite of mine. While I served as Oregon’s state EMS director, I moved mountains to bring the Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) course to the west coast. It’s another story, but that was a phenomenal task. After I completed CONTOMS, I served as a tactical medic for the Oregon State Police SWAT team—a professional, competent, well-trained and dedicated bunch of troopers. I learned a heck of a lot during those three years. I also completed a reserve law enforcement officer academy and worked the streets for five years. So this is something I feel is important.

The folks on the LinkedIn discussion want someone (the suggestions have ranged from NREMT, which doesn’t set standards, to the law enforcement community, which shouldn’t be setting medical standards, to state EMS offices, which don’t necessarily have the expertise). Their intentions are good; they want better training for TEMS medics. A lone voice, I dissent.

Not that I don’t want well-trained TEMS medics—quite the contrary. I want as much and as high-quality training for TEMS medics as can possibly be had. Simply, based on past experience with every other EMS training regimen, I know that as soon as somebody sets a standard, that’s it. The floor becomes the ceiling, and everything else is regarded as unnecessary. How about instead we let local teams and experts make these important decisions.

What I see are two processes that are consistent throughout these “best-of-the-best” training programs. First, they go to great lengths to make sure that the people in the class really want to be there and are motivated to continue training. But that’s another column. Second, they utilize and require a process called “overlearning” to make sure their graduates are able to perform psychomotor skills every time, under any conceivable condition.

I first encountered overlearning—you guessed it—back in my military days. One of the skills I had to learn was the stripping, cleaning and re-assembly of the caliber .45 semi-automatic pistol. After a few tries, I thought I had it down. “Not so,” said the corporal doing the teaching. Now you have to do it in the dark!” My wise-guy answer (which I thought would evoke yelling and push-ups), “What kind of an idiot would take a pistol apart in the dark?” was met with an intelligent and thought-provoking answer. “If you can do it in the dark with me yelling at you, you will be able to do it under any circumstances if something goes wrong.” And he was right. And I could—for a LONG time thereafter.

The same techniques are used in the PJs paramedic school. During “trauma lanes,” their skills-development laboratories, candidates practice skills first under controlled conditions, then in high-noise environments, then with instructors harassing them. And they have an appropriate number of instructors per student—often one instructor for every two or four students, assuring that students are always supervised, working, and learning. I’m hoping that SEAL Medic Trainer can chime in and tell us how they use overlearning to develop highly skilled medics at the Special Operations Medical Sergeants (18-DELTA) course, or other places where the SEALs send their corpsman to become good enough to care for their fellow SpecWarriors.

Discussing paramedic school with recent graduates, I learned (no surprise) that their skills lab experiences in school and in clinical are the furthest from overlearning as they can be. As soon as they get the needle in the very visible rubber IV vein, they’re “checked off” on the IV skills laboratory. And when they go to clinical, the same thing happens. As soon as the student gets the minimum number of “sticks” they are done.

As a sad sequel to this article, I happened to chat with a Field Training Officer in what I think of as a pretty good EMS agency the other day. Although he wasn’t training a new employee that day, he was supervising a clinical student from a nearby paramedic program. I asked how the student was doing, and I was surprised to hear the FTO respond, “I wouldn’t think of hiring him; he doesn’t have the right attitude.” When I asked how he’d made this determination, he told me about their last call, a serious but not critical respiratory patient. When asked if he wanted to provide the IV access, the student replied, “No thanks. I’ve got my five IV starts.”

Midazolam 5 mg for me please. It will make me forget the discussion, and it will forestall the seizure that I’m feeling coming on.

Until next time …


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