Administration and Leadership, Commentary, Exclusives, Patient Care, Training

Even Wolves Get Scared: Replacing Test Taking Competency with Real World Application

In the image above, paramedic students Ciera Pettway and Jeremy Chatfield attempt intubation. The author, Daniel Gill, is at the bottom right. (Photo by Daniel Gill)

Paramedic school is over, your new patch is sewn on, and you have your stethoscope around your neck. The last 16 months have been some of the toughest and miserable moments of your life. You have passed all the tests and the state cleared you for your license. You walk in the door at the station and it suddenly hits you – you have no idea what you are doing.

As an emergency medical technician, you were able to follow and assist, but now you are in charge. You read the book, you tried to listen to the lectures, you sat in on clinical, but you were not adequately trained for real life patient care and situations. You were not trained for 3 a.m. when suddenly the sweet 85-year-old woman becomes violent, and you were not trained for when the 50-year-old male who just lost his wife of 30 years all of a sudden had chest pain and collapsed.

For years, paramedic programs have produced quantity over quality and had pushed for minimal competency. The instructor would give the student the information and he or she had to retain it. We must start putting a higher standard on initial education. A culture change has to be allowed. We must prepare students for their careers and give them the tools to be confident. In the classroom, it is imperative that we become multi-dimensional.

First, the student needs to be introduced to the information and made aware of the material. Next, the instructor must elucidate the information by explanation, discussion and inquiry. After this, the instructor needs to demonstrate the concepts and express its importance. Once these concepts are achieved, we should have the students utilize application of the material, then articulate it back to their fellow students and instructors.

With this approach, we are attesting to a more multi-faceted approach to education that allows students to learn from their mistakes in a controlled environment, interpret information instead of just made aware of, and to be more prepared for real world implementation.

Furthermore, we must focus on key concepts during our education. The focus, as educators, should be two-fold if we want to produce more qualified and assertive paramedics. We must not only change our teaching techniques to allow for deeper understanding, we must also emphasize key subject matters to assure capability and mastery. These include emphasizing pathophysiology, utilizing critical thinking and placing emphasis on our assessment. These three concepts, as long as they are taught and understood correctly, should guarantee confidence.

Prominence must be applied to pathophysiology to create confidence. Pathophysiology is the study of the physical and biological abnormalities occurring within the body as a result of disease. Pathophysiology should be applied early in education because those who can effectively demonstrate the ideas will be more successful. It helps define the paramedic’s responsibilities and purpose. It will help the clinician recognize signs and symptoms of the patient with a deeper root of understanding and will allow for more advanced care.

It is imperative that there is an apprehension for what is normal and what is abnormal. It is also critical that the paramedic understands everything starts at the cellular level. An example of this would be if a patient was short of breath after being in a fire. The patient would not receive any oxygen through the blood stream. The tissues would be deprived of oxygen and would become necrotic. They would be unable to unload carbon dioxide, which is a normal byproduct of metabolism and needs to be eliminated. The patient would become acidic and would not be able to compensate, creating shock.

If pathophysiology was a focus, the paramedic would be able to comprehend the situation and realize that carbon monoxide is taking the place of oxygen and that the simple solution would be high flow concentrated oxygen. Another key explanation of importance is in order to understand pneumonia and anaphylaxis you must first understand ventilation and circulation.

There is a pathological cause for every sick patient encountered. If the clinician recognizes signs and symptoms, then they should be able to differentiate disorders and apply appropriate treatment. Pathophysiology aids in anticipation of subsequent findings, thus preventing further complications and symptoms. This allows the paramedic to stay calm because anticipation, preparation and understanding create confidence.

Critical thinking is essential to creating thorough confident prehospital clinicians. Critical thinking is reevaluating not only the information given but reevaluating how you act on the information as well. The old way of educating students was preaching memorization. Critical thinking challenges assumptions and creates a thinking outside the box concept, which can be more encompassing and can create retention.

The simplest way of assuring critical thinking is always asking why or why not. Why is this patient’s blood pressure high? Why is this patient having a seizure? Why does this patient need these medications? Why not backboard this trauma patient?

Utilizing critical thinking eliminates previous experiences and prejudices, as well as stereotypes because these concepts can cloud judgement and obstruct our patient care. Under normal circumstances, our brains rely on memories and experiences to guide decision making and fix problems with previous solutions. If a person calls you out for chest pain, but calls every two days, you could be inclined to go through the motions. If you utilize critical thinking you would realize that the patient took different medications in an attempt to harm herself, and it caused her heart to race, which became unsettling.

It would also allow you to realize that the medication taken needs a specific treatment and could have been detrimental if not recognized. The paramedic and patient can benefit from utilizing implementation of decision making and problem solving based on critical thinking. We must understand our purpose and objective. Critical thinking helps simplify and clarify our rationalization. It allows the clinician to be more efficient and express themselves clearer. This philosophy gives the paramedic additional skills and knowledge which leads to better preparedness creating confidence.

Perhaps the most important tool for any paramedic is their assessment. As a prehospital clinician on an ambulance, resources are scarce. There are no x-ray machines, no labs, no research teams, and under normal circumstances, no physicians. Without resources, the paramedic could demonstrate aghast behavior. It is imperative that the assessment compensates for this.

Utilizing an assessment creates a plan of action, dialogue and thought before even reaching a patient and allows for continuation during patient care. It assures that measures are not missed or overlooked and allows for the possibility of higher-quality care. Paramedics are encouraged to use their senses when practicing patient care, including: auscultation, inspection, observation, palpation, perception and olfactory awareness.

Furthermore, without senses a person would become vulnerable to the dangers of the environment. Senses are how we perceive and adapt to our surroundings, so entrusting on them while performing our assessment creates confidence. If a person calls out for help and is limited in reciprocating your questions, frustration could entail. Reliance on our assessment would be beneficial in this situation. If specificity is implied, then more in depth responses will be given.

The more remarkable or unremarkable findings that are discovered, the more confident the treatment modality will be. A paramedic would be more inclined to give Lasix to a patient if they discovered peripheral edema, ascites, and jugular vein distention and assured the renal system was adequate. Discovering assessment and creating best practices allows for more thorough treatment, better patient care and more confidence.

Albert Einstein once said: “education is to open the way to thinking and knowing. It is not the learning of facts, but training the mind to think.” Our path starts with education and the foundation should always be strongest. We have to promote education and allow students to see the importance first hand. We should be creating an environment that promotes further understanding and application as well as generating best practices. If we allow students these notions, and encourage them to cogitate on what they have been demonstrated, we should produce confidence instead of competence.