Practical rules/ guidelines

[WarDance]

I just took my practical today and aced everything but my trauma. I was wondering if any of you guys knew what the policy was on letting students know why they failed.

I had the entire sheet memorized and there was a long deliberation about whether I failed or not going on in the next room. I could hear some of the things that were being said and I believe that there is a very grey area concerning my failure.

 

[Epi-do]

At every practical I have been at, whether as a student or a proctor/patient, people were not told why they failed. If you feel you have a legitimate complaint, there are rules/guidelines in place for what can be appealed and how to go about doing it. It may just be easier to retest the one skill station though.

 

[WarDance]

No I did retest on trauma once already. The first time I failed I figured out why. They guy had a sucking chest wound, I didn't see it, I didn't treat it. I will admit that.

I would like to explain what went on during my retest. I honestly think it will just make me feel better by explaining it here. Please point out if you see anything wrong.

First off I was called to the scene of an altercation at a bar where a man was beaten with a baseball bat. The police were on scene.

I took BSI, the scene was safe (cops everywhere). I put my partner on c-spine, directed my other partner to take vitals, I put him on O2 15L/ min nonrebreather. I called for ALS. The pulse was rapid, breathing fast and shallow w/ paradoxical motion. BP was fairly normal. I exposed and found nothing. I assumed a flail segment. Based on the vitals I determined that this was a priority patient and we should transport. I put him on a backboard and went. I also said I was going to treat for the possibility of shock. During transport I did a rapid trauma while my partner took vitals. The rapid trauma was neg. for any other injuries. The proctor said the respirations were becoming "agonal and inadequate." I said we should switch to a BVM with O2 at 15 L/min. At that point I determined there was nothing more I could do as a basic and the treatment I was already providing would be continued until rendezvous with ALS or arrival at the hospital.

Do you guys see anything there? I know I don't.

 

[Epi-do]

We have had discussions on here before about flail segments, but if you were taught to splint it, did you remember to do so? Did you do anything to "protect" the airway? NP? OP? When respirations became agonal did you reasses for a pulse? I really can't help but think that you did miss something on your assessment, and that there were other injuries.

 

[Ridryder911]

No I did retest on trauma once already. The first time I failed I figured out why. They guy had a sucking chest wound, I didn't see it, I didn't treat it. I will admit that.

I would like to explain what went on during my retest. I honestly think it will just make me feel better by explaining it here. Please point out if you see anything wrong.

First off I was called to the scene of an altercation at a bar where a man was beaten with a baseball bat. The police were on scene.

I took BSI, the scene was safe (cops everywhere). I put my partner on c-spine, directed my other partner to take vitals, I put him on O2 15L/ min nonrebreather. I called for ALS. The pulse was rapid, breathing fast and shallow w/ paradoxical motion. BP was fairly normal. I exposed and found nothing. I assumed a flail segment. Based on the vitals I determined that this was a priority patient and we should transport. I put him on a backboard and went. I also said I was going to treat for the possibility of shock. During transport I did a rapid trauma while my partner took vitals. The rapid trauma was neg. for any other injuries. The proctor said the respirations were becoming "agonal and inadequate." I said we should switch to a BVM with O2 at 15 L/min. At that point I determined there was nothing more I could do as a basic and the treatment I was already providing would be continued until rendezvous with ALS or arrival at the hospital.

Do you guys see anything there? I know I don't.

Chances are the patient developed a tension pneumo. With the cursors of a a flail segment with paradoxical movement, immediate splinting and re-assessment of the lower airway should had been initiated. What was the lung sounds? Where they performed as part of the rapid trauma assessment? Not identifying or recognizing a tension pneumo can be grounds for failure.

NREMT and most states do not allow one to "find out" as this is part of the rules of maintaining credibility.

R/r 911

 

[WarDance]

I have the 2nd set of vitals. I forgot I wrote them on my hand!

BP 98/70
HR 120
R 26

I just realized something. The proctor described them as "agonal" but there's no way if they were 26. We were taught not to splint a flail segment...just put 'em on O2 and drive fast. I don't think it would have made a difference if I would have diagnosed it as a tension pneumo because as a basic treatment is the same....O2 and drive fast. I have a feeling I heard "agonal" and I just said let's go to a BVM without any thought. When I heard that word I think "about to die." Maybe he meant gasping?

I've just had a really hard time accepting that I failed. I had one of the highest grades in the class and I've always done well on everything.

 

[Ridryder911]

I have the 2nd set of vitals. I forgot I wrote them on my hand!

BP 98/70
HR 120
R 26

I just realized something. The proctor described them as "agonal" but there's no way if they were 26. We were taught not to splint a flail segment...just put 'em on O2 and drive fast. I don't think it would have made a difference if I would have diagnosed it as a tension pneumo because as a basic treatment is the same....O2 and drive fast. I have a feeling I heard "agonal" and I just said let's go to a BVM without any thought. When I heard that word I think "about to die." Maybe he meant gasping?

I've just had a really hard time accepting that I failed. I had one of the highest grades in the class and I've always done well on everything.

Unfortunately, you were taught wrong. Lower airway obstruction (yes, tension is considered one) should be assessed in detail in rapid trauma assessment. As well, flail segment/paradoxical movement should have been treated as part of the airway treatment. Continuation of paradoxical movement can cause lung, vessel damage. You were not taught even manual stabilization, bulky dressings... as they are definitely in all EMT textbooks?

As per NREMT skill exam sheet Critical Criteria: ...."Did not find, manage,associated with airway, breathing, hemorrhage or shock, hypoperfusion"....

Let's refrain from using the emphasis of load and run and more emphasis to examine on the way the possibility of why your patient is crashing.

 

[bstone]

At every practical I have been at, whether as a student or a proctor/patient, people were not told why they failed. If you feel you have a legitimate complaint, there are rules/guidelines in place for what can be appealed and how to go about doing it. It may just be easier to retest the one skill station though.

May have been your experience, but certainly not mine. I failed advanced trauma assessment on my first try for Intermediate. I contacted my training facility, the testing company, the state OEMS and even wrote a certified letter to the NREMT asking why. Simply saying "you failed" but providing no additional information is ridiculous. In the end I was able to find out from a little birdy that everyone from my school failed due to our instructor and facility teaching us wrong. The school even paid for my retest and the motel stay. I retrained with a medic instructor and passed on my 2nd try.

However, the policy of not telling students why they failed is counter to proper instruction. It's wrong and absolutely must be changed.

 

[WarDance]

I clearly remember my instructor saying, "don't bother to try splinting or anything. ALS or a hospital is the only thing that will help." My proctor was someone from a different EMS station. I'm kind of losing confidence in the program that I just went through. Did I mention that 5 of the 9 people failed today? I think that's a good indication that we were not prepared.

 

[bstone]

I clearly remember my instructor saying, "don't bother to try splinting or anything. ALS or a hospital is the only thing that will help." My proctor was someone from a different EMS station. I'm kind of losing confidence in the program that I just went through. Did I mention that 5 of the 9 people failed today? I think that's a good indication that we were not prepared.

That totally could be the issue. My training facility totally trained us wrong and we all failed. Call the testing company and ask about a good instructor you can study with. I bet you're THIS close to passing. Good luck!

 

[Ridryder911]

Simply saying "you failed" but providing no additional information is ridiculous.

It should NEVER BE CHANGED! This is a Board Examination, not a teaching event! You should have been taught before the event. You will never find any credible testing event as what you specifically failed at. Even such as oral boards, are never discussed on what specific you failed at.

Testing should NEVER be confused with the education process and learning portion. By the time the candidate reaches the testing portion they should be well prepared. Again, they are only asking the minimum qualifications to ensure public safety.

One should be prepared for the examination. Again, it is used for verification for the candidate to demonstrate that they have the knowledge and ability to meet the minimal standard criteria for testing. I personally wish they would no longer even allow the skills sheet to be publicized as it was before. We now have persons passing due to memorization of such and no longer are screened, to show exactly or even details upon the areas of failure is reviewing and coaching. Credibility of the test is immediately lost.

I have taken several EMS and Nursing Board examinations, I have yet seen or heard of any that would discuss the test, nor would I ever should expect them to. Tests are designed to screen not teach!

R/r 911

 

[bstone]

Rid, we will agree to disagree. But that's not really new, is it?

After I finish med school I plan to be actively involved in EMS. I will strongly encourage for this to be overturned.

 

[Ridryder911]

Rid, we will agree to disagree. But that's not really new, is it?

After I finish med school I plan to be actively involved in EMS. I will strongly encourage for this to be overturned.

Good luck, as soon as you get the USMLE and Law Boards, NCLEX, etc to disclose what specific areas their candidates fail at, NREMT will as well.


Encourage better education then one will not have this problem.

R/r 911

 

[bstone]

Good luck, as soon as you get the USMLE and Law Boards, NCLEX, etc to disclose what specific areas their candidates fail at, NREMT will as well.


Encourage better education then one will not have this problem.

R/r 911

"Better education" is not the issue. The EMS academy I went to is part of a major trauma hospital, has every accreditation (including CAAHEP), every instructor is a state certified I/C (Instructor/Coordinator) and is a paramedic or higher. You get college credit for going there and they are developing agreements to have their medic program to be part of a BS in EMS, at the same time fulfilling the pre-PA requirements for direct entry to New England's largest PA school. It can be very well argued that they have excellent education.

They simply taught us wrong. And because of that everyone who took the NREMT-I failed. Period.

Had we retrained with our institute we would have been re-taught incorrectly. And failed again. And then a third time. Oops! We would have just ran out of chances to take the NREMT-I without additional ALS instruction.

The obvious answer is so very, very clear. Tell people where they are deficient. Then they can go back and do better. Simply giving a blanket "YOU FAILED!" is against all mature philosophies of education.

 

[reaper]

May have been your experience, but certainly not mine. I failed advanced trauma assessment on my first try for Intermediate. I contacted my training facility, the testing company, the state OEMS and even wrote a certified letter to the NREMT asking why. Simply saying "you failed" but providing no additional information is ridiculous. In the end I was able to find out from a little birdy that everyone from my school failed due to our instructor and facility teaching us wrong. The school even paid for my retest and the motel stay. I retrained with a medic instructor and passed on my 2nd try.

However, the policy of not telling students why they failed is counter to proper instruction. It's wrong and absolutely must be changed.

Before you take your practicals, They will read you a statement that tells you all about this. NREMT is not a teaching or training org. Telling you what you did wrong is considered teaching. They try and stay away from that grey area.

I agree that these schools should make sure that their instructors know what they are doing. But, it does fall back on you. Every EMT text book states that a flail segment should be supported. It is up to you to know what is in the text books!

 

[Shishkabob]

At my school, if you failed a skill you got to see the grading sheet on the day of remakes, but chances are you already knew why you failed during the skill.

And before anyone says it's some crappy mill type school, it's considered one of the best in Texas and 1 of the only 16 accredited.

 

[bstone]

At my school, if you failed a skill you got to see the grading sheet on the day of remakes, but chances are you already knew why you failed during the skill.

And before anyone says it's some crappy mill type school, it's considered one of the best in Texas and 1 of the only 16 accredited.

Your school is very progressive and should be complimented. Bravo!

 

[reaper]

But was this NREMT testing?

They are not aloud to show you the sheet, when you take registry.

If it was your school testing, then I think you should be able to know what you need help with.

 

[redcrossemt]

I took BSI, the scene was safe (cops everywhere). I put my partner on c-spine, directed my other partner to take vitals, I put him on O2 15L/ min nonrebreather. I called for ALS. The pulse was rapid, breathing fast and shallow w/ paradoxical motion. BP was fairly normal. I exposed and found nothing. I assumed a flail segment. Based on the vitals I determined that this was a priority patient and we should transport. I put him on a backboard and went. I also said I was going to treat for the possibility of shock. During transport I did a rapid trauma while my partner took vitals. The rapid trauma was neg. for any other injuries. The proctor said the respirations were becoming "agonal and inadequate." I said we should switch to a BVM with O2 at 15 L/min. At that point I determined there was nothing more I could do as a basic and the treatment I was already providing would be continued until rendezvous with ALS or arrival at the hospital.

ABC's in order...

A. Did you ever verbalize something about airway? E.g. "Do I hear any respiratory noises? No? Okay, the patient's airway is patent because he's breathing" or just perform a jaw-thrust maneuever from the beginning...

B. Proctor says "shallow", you say "BVM". You have to be careful here because of the flail chest, but positive pressure ventilation is still indicated for patients with inadequate tidal volume.

C. Did you immediately check a pulse, skin color, and assess for major bleeding? You can't do anything else first.

You also could have lost a few points for MOI/nature of illness, number of patients, thinking about additional help, etc. if you didn't mention it. Could just be that you didn't write it here.

In any case, to fail, you probably hit one of the following critical criteria:

• Failure to assess/provide adequate ventilation (No PPV despite being told "shallow" breaths)
• Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock [hypoperfusion] (no airway maneuever or assessment, no treatment/splinting of flail chest, no assessment of circulation/hemorrhage)
• Does other detailed/focused history or physical exam before assessing/treating threats to airway, breathing, and circulation (ordered partner to take vitals before checking ABC's)

The skill sheet for Basic Trauma Assessment/Management can be found on NREMT.org at http://www.nremt.org/nremt/downloads/patientassessmentmanagementtrauma.pdf.

 

[Ridryder911]

So many students blame instructors for their failure. In reality, with the disclosure of NREMT skill(s) sheets, how can really fail and in point blame an instructor? Even if they were not taught each specific area, it is right there in plain written sight of what is expected. Step by step, and even more so what will automatically fail you and as long as one performs a decent performance examining all areas, and or recognizing and identifying life threatening injuries; one should be able to pass.

As an educator I feel that it is my responsibility to know how the license and certification examinations are performed. It does not matter how well I instruct and educate an individual if they cannot ever receive their license. One maybe one of the brightest and sharpest individual, but unless they can meet the States requirement it will not matter. So again, I re-taking proctor course to become one. To test other schools and candidates and to witness the "flow" of the testing arena. Again, just part of the responsibility of teaching.

R/r 911