# New NREMT Critical Failure



## emt1972 (May 16, 2012)

NREMT has added "Failure to perform as a competent EMT" as a critical fail.

This is based on a trauma assessment I did yesterday

Would you use this as a critical fail, if...

The student only asks two A+O questions, then determines the patient is A+Ox1?

The student ascultates blood pressure without even using a stethoscope and gives you systolic/diastolic and says it was done by palpating?

The student treats secondary injuries (abrasions throughout the upper extremities with minor bleeding) with ice packs?

I'm just curious, again... I value all input and opinions


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## KnightVision (May 16, 2012)

Original thought was this is subjective based on the examiner. Later told many things were added to look for during assessment - but didn't get specifics. Prob going tonight to sit in on a few stations to get a better understanding as soooo many I've spoken to have the same question. For now, I just keep it simple like giving instruction to your partner, or verbalizing yourself doing something boneheaded.  Should know more tonight.


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## Medic Tim (May 16, 2012)

emt1972 said:


> NREMT has added "Failure to perform as a competent EMT" as a critical fail.
> 
> 
> The student only asks two A+O questions, then determines the patient is A+Ox1?
> ...



How can you auscultate a bp without a stethoscope????? and giving systolic and diastolic numbers from a palp bp shows that the person doesn't know what they are doing or are making up the numbers.

were the secondary injuries bandaged or was the ice pack put directly onto the bleeding abrasions?


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## Martyn (May 16, 2012)

emt1972 said:


> NREMT has added "Failure to perform as a competent EMT" as a critical fail.
> 
> This is based on a trauma assessment I did yesterday
> 
> ...


 
 As far as I am aware this is NOT a new critical fail. Sorry to say this but most if not all of the things you mentioned above only goes to reinforce that the individual testing has not reached the required level for NREMT therefore "Failure to perform as a competent EMT" is the end result.


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## Trauma_Junkie (May 16, 2012)

Martyn said:


> Sorry to say this but most if not all of the things you mentioned above only goes to reinforce that the individual testing has not reached the required level for NREMT therefore "Failure to perform as a competent EMT" is the end result.



+1

However, I'm aware that on the NREMT Paramedic skills sheets "Failure to manage the patient as a competent EMT" is a critical criteria. I completely agree with them on that because if someone is testing for the Advanced/Paramedic level they should be a competent EMT. It just reiterates that medics should remember the basics and apply them.


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## bstone (May 18, 2012)

How in the world do they define who is a "competent" EMT based upon acting? When you go into the room for your practical exam you are acting. You've rehearsed over and over, you've memorized your lines, and now you're in front of the audience and you're doing your absolute best not to screw up the script. Are they judging you based upon your ability to be a convincing actor? Otherwise I just don't understand what this new critical failure is trying to accomplish. That stage fright requires a fatal punishment?


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## Pavehawk (May 18, 2012)

bstone said:


> How in the world do they define who is a "competent" EMT based upon acting? When you go into the room for your practical exam you are acting. You've rehearsed over and over, you've memorized your lines, and now you're in front of the audience and you're doing your absolute best not to screw up the script. Are they judging you based upon your ability to be a convincing actor? Otherwise I just don't understand what this new critical failure is trying to accomplish. That stage fright requires a fatal punishment?



I have to agree with bstone here. The other thing that worries me is that this is totally subjective on the part of the examiner. Anytime you have a something subjective you open the door to having someone decide... oh that guy/girl is "fat, black, handicapped, gay, speaks funny, looks funny, whatever"... and bingo  critical fail for not being competent.

I am sure we have all known people in the business who are jerks. Many of these types tend to get involved in EMS education/evaluation because it strokes thier ego to be "teaching" or evaluating. Having a cookbook checklist to follow with little boxes is one thing, allowing an evaluator to offer thier opinion as to the competency of someone based on intangibles is not a good thing.


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## Martyn (May 18, 2012)

To be able to pass a test, ANY test, competence HAS to be shown and proven. Would you want a law enforcement officer that can't shoot straight to attend a bank robbery? Would you want a taxi driver that doesn't know the area? (OK, I know there is GPS available on this one) So why would a future EMT saying that they took a blood pressure by auscultating then saying it was over palp be competant without even using a stethoscope? Or the other things the OP posted? Just think on this, this was in a classroom setting, the ONLY pressure was to pass the test. What is that incompetant 'EMT' going to be like when confronted in real life with a car crash with multi victims? Or someone going into cardiac arrest? Or even a kid with a cut finger? These 'mistakes' the OP posted about beggar belief, to be quite honest. They are basic, basic skills that should have been learnt and conquered early in the course so that they become second nature. The incompetant clause is there for a reason, to weed out the idiots and I make NO apologies for stating this. 



> Anytime you have a something subjective you open the door to having someone decide... oh that guy/girl is "fat, black, handicapped, gay, speaks funny, looks funny, whatever"... and bingo critical fail for not being competent.


 
Oh that guy/girl is fat...then call for a lift assist and a bariatric ambulance so that A) the patient does not get hurt more B) the crew don't get hurt. Black people have their own problems etc. Sickle cell anemia for example, a nasty debilitating disease. Handicapped? Extra hands may be needed on scene, a change in attitude whilst dealing with this patient may be needed. Gay? Not even going there on that one. Speaks funny? So learn to use sign language or find another way of communicating. Looks funny? So take their vitals, BP pulse BGL etc, there could well be a reason they 'look funny'. 

No it is NOT subjective on the part of the examiner. As I have said, you have to demonstrate a level of competence any deviation from that has to be INcompetance. The core skills are there for a reason and they are not intangible at all if you read the criteria for each skill station. As for teachers and there egos, yes I agree that there are some that fit your category but I bet the ones that don't are more.


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## bstone (May 18, 2012)

This competency requirement is as subjective as it comes. I am disturbed that they added this requirement as it will allow the examiners to fails someone for any reason at all under this general "competency" clause. I can just imagine it now:
Lawyer: "Why did the student fail the test?"
Examiner: "She didn't seem competent."
Lawyer: "Did she fail any of the critical criteria or miss something?"
Examiner: "No. I just felt she isn't competent."
Lawyer: "So you admit that she passed everything, was within time, and effectively assessed and treated the patient, but you failed her because you felt she wasn't competent?"
Examiner: "Well, yes."
Lawyer: "And what makes you come to the judgement that she isn't competent?"
Examiner: "It's just how I feel about her skills."

This is why this "competency" requirement is completely bogus. It's not based upon an objective assessment of skills but rather a *feeling*. Absolutely bogus.


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## nwhitney (May 18, 2012)

So I work as an evaluator for the state EMT-B testing and any time we mark a critical failure we have to document why we did otherwise the licensing officers will call us in to explain.  Personally I think this is a good critical criteria to have even though it is very subjective.  Someone might run through the skill sheet and not miss a thing and still not be competent.  Dropping a King LT on the ground and not stating they would get a new one for example.


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## bstone (May 18, 2012)

nwhitney said:


> Someone might run through the skill sheet and not miss a thing and still not be competent.



How? Did they miss something? Did they kill the patient? Did they do an improper treatment? Or are you just having a bad day and everyone is failing because of it? Subjective assessment has no room in a practical exam. If you do everything properly then you pass. If you don't then you fail. There is no wiggle room for "I don't think you're competent".


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## Pavehawk (May 18, 2012)

Martyn said:


> Oh that guy/girl is fat...then call for a lift assist and a bariatric ambulance so that
> 
> No it is NOT subjective on the part of the examiner. .



I think you need to read what I said a bit more carefully. I was not refering to a medic in the field being subjective about fat, race, etc, but rather the examiner doing so.

ANYTIME you have someone making a decision based on an ambiguous criteria such as "competency" you leave room to have abuse. If a person can perfrom the scenarios/stations as written on teh skill sheet, why shloud they be then judged on a hypothetical standard ofr competency. They either pass ro they don't pass based on the skill sheet NOT on someones judgement of if they were competent.


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## bstone (May 18, 2012)

Pavehawk said:


> I think you need to read what I said a bit more carefully. I was not refering to a medic in the field being subjective about fat, race, etc, but rather the examiner doing so.
> 
> ANYTIME you have someone making a decision based on an ambiguous criteria such as "competency" you leave room to have abuse. If a person can perfrom the scenarios/stations as written on teh skill sheet, why shloud they be then judged on a hypothetical standard ofr competency. They either pass ro they don't pass based on the skill sheet NOT on someones judgement of if they were competent.



Agreed.


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## KnightVision (May 18, 2012)

nwhitney said:


> So I work as an evaluator for the state EMT-B testing and any time we mark a critical failure we have to document why we did otherwise the licensing officers will call us in to explain.  Personally I think this is a good critical criteria to have even though it is very subjective.  Someone might run through the skill sheet and not miss a thing and still not be competent.  Dropping a King LT on the ground and not stating they would get a new one for example.



Confirmed - the list is no longer 1 point here or check critical fail there. There is a narrative that must support what the evaluator is saying. So although somewhat subjective, it has to be backed up as for the reason "why".  Besides, the intent should be validation - not try and fail everyone. Unless they shouldn't be there in the 1st place.       
Long bone splint?? Let's start compressions - hard & fast. LOL


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## Veneficus (May 19, 2012)

NREMT has added "Failure to perform as a competent EMT" as a critical fail.

This is based on a trauma assessment I did yesterday



emt1972 said:


> Would you use this as a critical fail, if...





emt1972 said:


> The student only asks two A+O questions, then determines the patient is A+Ox1?



No



emt1972 said:


> The student ascultates blood pressure without even using a stethoscope and gives you systolic/diastolic and says it was done by palpating?



Yes



emt1972 said:


> The student treats secondary injuries (abrasions throughout the upper extremities with minor bleeding) with ice packs?



If there was something more important that should be commanding attention. 

This is the danger of "experience."

It sounds to me like they failed you for not taking a BP and listed some other things that they felt could or should have been done better.

For myself and other instructors I know, generally the minor points are overlooked, but if you actually do something that rates a fail, generally we call attention to all the things that could/should be done better.


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## Pavehawk (May 19, 2012)

KnightVision said:


> Confirmed - the list is no longer 1 point here or check critical fail there. There is a narrative that must support what the evaluator is saying. So although somewhat subjective, it has to be backed up as for the reason "why".  Besides, the intent should be validation - not try and fail everyone. Unless they shouldn't be there in the 1st place.
> Long bone splint?? Let's start compressions - hard & fast. LOL



At our local college during final skills for both EMT and medic they use two evaluators per station AND audio record the session. This allows one run the station, read the scenario, etc, and one to hit the check boxes on the form. If there is a situation where the student says "Well I did say ""Call ALS back-up..."" and it was marked off they use the recording to double check.

I have never tested for NREMT-P skills (was not required back in the day by the state I lived in) but I understand the institution must fly NREMT authorized instuctors to thier venue (or go elsewhere) to perfom skills testing. The reason they give is that they want the students to not be tested by the training staff to "AVOID SUBJECTIVITY" i.e. meaning that they are afraid of candidates either passing or failing because of bias from the people who taught them.

If they have indeed added a subjective assessment then they are invalidating thier own reasoning for disallowing institute testing. You also have to remember that there is finacial incentive for NREMT if someone fails and they must pay again for a retest. This alone should have them avoid subjectivity like the plague. While it may not be a conflict it could certainly look like that, and perception is key in situations like that.

If the skills evaluators are required to document thier findings in narrative for critical fails then this may help a bit.


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## mycrofft (May 19, 2012)

If you failed me for a strictly subjective point you might be seeing me in court. "Subjective grading" is like "mental checklists", shaky and not defendable. I assume there either is a list and they don't want to release it, or there will be a list very soon, of criteria for this catchall category of fails.

This is generic, not in response to the OP's woes specifically.


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## nwhitney (May 21, 2012)

bstone said:


> How? Did they miss something? Did they kill the patient? Did they do an improper treatment? Or are you just having a bad day and everyone is failing because of it? Subjective assessment has no room in a practical exam. If you do everything properly then you pass. If you don't then you fail. There is no wiggle room for "I don't think you're competent".



I would argue that a few things on the skill sheets are subjective.  For example a critical for supine is "Manipulated or moved the patient excessively causing potential for spinal compromise"  Define excessive?  Excessive to me might be okay for someone else and a third person will have a completely different idea.  

"Or are you just having a bad day and everyone is failing because of it?"  That seems a bit harsh and I never said I failed everyone.  In fact I have yet to mark the new critical fails for anyone during a practical test.  

No one said the exams are perfect.  All exams will have a deficiency somewhere.  I see the new critical fails as another tool to help in the educational process of EMT students.


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## bstone (May 21, 2012)

nwhitney said:


> No one said the exams are perfect.  All exams will have a deficiency somewhere.  I see the new critical fails as another tool to help in the educational process of EMT students.



I agree, but this new criteria makes the exam even more deficient, not less.


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## Veneficus (May 21, 2012)

I think the thing that everyone is missing is that you need a competent examiner. 

Objective grading has lead to standardized testing in excess. It measures neither competency nor knowledge, just the ability to take the test. 

Standardized testing is one of the main reasons AMerican education is not keeping up with the rest of the world. 

Having said that...

The duty of the examiner is not to "weed people out" it is to make sure they can function at abasic level of a person with no experience. 

If there is a reason to fail a student, it must be because of some obvious error. (Like believing you could palpate a diastolic BP) not because you think you wouldn't want this person in the field, to take care of your parents, etc.

It is the responsibility of the testing center to ensure their instructors are properly doing their job, with proper oversight, and a fair appeal process.

Rather than try to sue a hired proctor, you would probably have better luck demonstrating the school was negligent in their role and oversight which caused you actual damage. 

Trying to sue a proctor over subjectivity is not only frivolous, I can't imagine any reasonable judge or jury seeing it as anything but sour grapes. 

In this case, if I were proctor and you palpated a diastolic BP, you fail, period. Not because I said so, but because you have made an error which even the most inexperienced and basically educated people would not make.

As I said, the other stuff maybe just incidental things to improve on. 

A proctor taking it upon themself to defend the one and true faith should be fired on the spot without pay and asked not to come back. There are no secrets on these tests. If somebody is failing students, word travels fast. If it is a national registry test, there should be a chance to retest the skill the same day.

I cannot imagine the NR rep which must be there would let that slide. 

WHich brings us to the question, if the person failed the same station twice, with two different proctors as is the custom and asI understand rule, then only part of the story has been told. 

In my experience it is also customary as a proctor to inform the instructor who should be there in person as a student advocate why the student failed and how to improve before the retry. That way it can be sorted out if it is anxiety or a deficency in knowledge training.

As an anecdote, I was once proctoring the intubation, combitube, peds intubation station of a NR paramedic practical. A student testing that day intubated and then told me he had never seen a combitube or other supraglotic airway before. He related his instructor said the technique was the same as the ET tube so there was no need to go over it. 

The test was instantly halted, a meeting called with the NR rep, the instructor of the institution hosting the test (aka student advocate) and when other students confirmed this story, a training session was held to bring these people up to speed before testing. 

They all managed to pass.


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