Practical rules/ guidelines

[WarDance]

I asked what my breath sounds were and he said "shallow and absent on the right side." I but him on a nonrebreather @ 15L to start out with. Then I switched to a BVM when the proctor said the respirations were "agonal." I have a feeling I missed something on airway.

I have to come in and practice over the next couple of weeks. I think I'm going to ask if I can run a trauma scenario where a guy got hit with a baseball bat and has a flail chest. I'll run it exactly like I did yesterday and then see why I fail. There's nothing wrong with that, right?

I don't know if I should look for another place to test sooner than 3 weeks or if I should just wait and retest at the same place. I think I might be freaking out because I know everyone there. My patient yesterday was a guy I know. I nailed my medical and my patient was some random girl I don't know. I might feel more detached and professional if I don't know anyone there.

NREMT is the only testing service I have encountered that won't tell you what you did wrong. College Board will return your SAT answers, the correct answers and the test book if you ask. They will also do the same for Advanced Placement. They'll even give you back your essays if you ask. I think the fact that you can find out what went wrong on their tests makes them the most respected testing service in the country. It is also probably what allows them to write such accurate tests.

On another note, I believe that NREMT should let you see your sheets even if you pass. It can be a learning opportunity since it is still possible to pass and not hit everything on the sheet. Something a passing candidate missed may not have been critical but it would still help someone provide better patient care. Isn't good patient care what NREMT strives for?

 

[redcrossemt]

I asked what my breath sounds were and he said "shallow and absent on the right side." I but him on a nonrebreather @ 15L to start out with.

No need to assess breath sounds. Do your ABC's first!! You don't auscultate breath sounds 'til further down the list, as I understand it. Think of the beginning as your CPR or airway station....

1. "Sir, sir, are you okay?" Open airway.
2. Breathing? If not, or if inadequate (shallow/slow), start bagging.
3. Pulse? Check pulse and for bleeding and shock.
4. Rapid trauma exam.... Lung sounds, pupils, DCAP-BTLS, etc.

You would have needed to start bagging him immediately to pass. I called a couple NR proctors, and when they say inadequate or shallow breathing, you need to immediately provide positive pressure ventilations via BVM, and attach the BVM to oxygen. It's a critical criteria (Failure to assess/provide adequate ventilation). They also said they could fail you for listening to lung sounds before opening the airway.

 

[WarDance]

No need to assess breath sounds. Do your ABC's first!! You don't auscultate breath sounds 'til further down the list, as I understand it. Think of the beginning as your CPR or airway station....

1. "Sir, sir, are you okay?" Open airway.
2. Breathing? If not, or if inadequate (shallow/slow), start bagging.
3. Pulse? Check pulse and for bleeding and shock.
4. Rapid trauma exam.... Lung sounds, pupils, DCAP-BTLS, etc.

You would have needed to start bagging him immediately to pass. I called a couple NR proctors, and when they say inadequate or shallow breathing, you need to immediately provide positive pressure ventilations via BVM, and attach the BVM to oxygen. It's a critical criteria (Failure to assess/provide adequate ventilation). They also said they could fail you for listening to lung sounds before opening the airway.

I actually said "I'm assessing his breathing" and I got # of respirations, breath sounds and adequacy all at once from the proctor. Well I guess I know why I failed now. It really helps alot.

Now the argument that I heard about whether I passed or failed doesn't make sense....oh well.

 

[bstone]

What did you hear through the doors?

 

[marineman]

"Better education" is not the issue... It can be very well argued that they have excellent education.

They simply taught us wrong.

Ok let me get this straight now, you went to major trauma blah blah blah with wonderful certified educators who taught you something that was wrong and you feel it's the national registries fault because your educators were certified?

There is no reason to inform people as to why they failed, in fact it is counter productive. If you fail the first time there are two reasons, either you forgot it or you don't know it. If you forgot it there is no reason you shouldn't be able to pass the second time after having some time to think about it and run through it in your head. If you just plain old don't know it there's no reason you should be allowed to pass the test. Are you hoping that if you fail the written they will send you a list of all the questions you got wrong along with the correct answers? I'm sorry you were taught wrong and I really hope that you brought it to your schools attention after you found out where you went wrong but expecting the NREMT to change it's practice in case bad educators still exist is just a ridiculous idea. All the sheets are posted online and you can print them off and memorize them word for word, I have a hard time putting all of the blame on the school as it seems far fetched that they would teach you something that goes against a critical criteria.

 

[marineman]

No need to assess breath sounds. Do your ABC's first!! You don't auscultate breath sounds 'til further down the list, as I understand it. Think of the beginning as your CPR or airway station....

I'm much too lazy to look right now but not long ago we had a discussion about this very subject and a very good case was made for listening to lung sounds immediately when assessing the breathing.

 

[bstone]

Ok let me get this straight now, you went to major trauma blah blah blah with wonderful certified educators who taught you something that was wrong and you feel it's the national registries fault because your educators were certified?

This couldn't possibly be further from the truth. But I did get a good laugh at this.

There is no reason to inform people as to why they failed, in fact it is counter productive. If you fail the first time there are two reasons, either you forgot it or you don't know it. If you forgot it there is no reason you shouldn't be able to pass the second time after having some time to think about it and run through it in your head. If you just plain old don't know it there's no reason you should be allowed to pass the test. Are you hoping that if you fail the written they will send you a list of all the questions you got wrong along with the correct answers? I'm sorry you were taught wrong and I really hope that you brought it to your schools attention after you found out where you went wrong but expecting the NREMT to change it's practice in case bad educators still exist is just a ridiculous idea. All the sheets are posted online and you can print them off and memorize them word for word, I have a hard time putting all of the blame on the school as it seems far fetched that they would teach you something that goes against a critical criteria.

Or a third reason- you were taught wrong. If you're taught wrong then you can be caught up in an endless cycle of continuing to be taught wrong, failing, going back and being taught wrong again, failing, etc. Logically, if you are being taught wrong by a certified instructor in a certified training facility then you must be told this by an outside entity- in this case the testing organization- in order to get the correct training. It behooves the training organization to ensure that it identifies patterns of failure and report it to the training facilities in order to ensure that a full loop of communication and reporting it made. Otherwise things go into a nebulous void and never get resolved.

The institute I went to felt so bad they paid for my re-test and even the motel stay. The instructor was canned, as well, but not until the following class also had a 100% failure rate on the same test. In fact, just today I was this institute for my refresher course and I was speaking to another instructor there who said she was aware of the then-Intermediate instructor in teaching the class wrong. It seems the state OEMS was alerted to this and other issues about him and he was removed from instructing at all.

 

[marineman]

So now what you're saying is your instructor really wasn't that great? I would agree that he wasn't that great because he taught you something wrong. At the end of the day the national registry has one job and that is to test us on the information not teach us just in case we had a bad instructor that taught us the wrong thing. Like I said it's unfortunate that you wasted so much time and ran in so many circles due to a poor instructor but that's no reason the national registry should change it's guidelines.

Out of curiosity what part was it that you were taught wrong that caused you to fail? I understand instructors having different methods but between a text book, a state SOP book and various other assistant instructors in the room helping with practice I can't figure out what part would have gone unnoticed.

P.S. your third reason of being taught wrong fits into my second reason category, unfortunate but that's life.

 

[bstone]

So now what you're saying is your instructor really wasn't that great? I would agree that he wasn't that great because he taught you something wrong. At the end of the day the national registry has one job and that is to test us on the information not teach us just in case we had a bad instructor that taught us the wrong thing. Like I said it's unfortunate that you wasted so much time and ran in so many circles due to a poor instructor but that's no reason the national registry should change it's guidelines.

Out of curiosity what part was it that you were taught wrong that caused you to fail? I understand instructors having different methods but between a text book, a state SOP book and various other assistant instructors in the room helping with practice I can't figure out what part would have gone unnoticed.

So now that you see and understand that having a poor (albeit certified) instructor can lead to test failure, I do not see how you can stand by your assessment that there can be only two causes of test failure- lapse of memory or missing something.

Our instructor repeatedly taught and told us to BLS the "advanced trauma patient assessment" station. He told us not to start IVs, not to intubate, not to apply a monitor. He tested us in depth and hammered this point home. All of us who went in and BLSed this station all failed it. Failure to start an IV it is immediate failure for this ALS station. However we simply did that our instructor and training facility repeatedly taught us to do. Remember, the instructor is a medic and certified. The facility is also CAAHEP certified. Months and months later a kind little birdy told me why we failed, but it took a lot of pleading and appealing to intellect to get this info. Once I realized
this I found a medic instructor who went over the test with me and I passed on my next attempt.

However, some of my fellow students were not so lucky. They took the station three times in one year, failing each time. They had to do remedial ALS training before they were allowed to take ALL the practicals again.

Thus, feedback on specific points of failure is essential to a student. They may not have forgotten anything or messed anything up. They simply were taught wrong and suffered the consequences for it.

 

[marineman]

I will stand by my assessment that because you were taught wrong, you simply didn't know aka reason #2 for failing it. Not saying it's your fault but in the simplest form you didn't know so you failed. That said I will also stand by the point that all of the NR check sheets are available online and yes IV is stated on the ALS version of the rapid trauma assessment so again while it stinks that you got stuck with an instructor that told you something wrong I don't feel bad for any of the students that failed because if they failed 3 times without looking at the check sheet and seeing that IV therapy is stated on there you cannot blame an instructor. Use all resources available to you in order to understand what you will be tested on and you will do just fine. Take short cuts and expect everything to be spoon fed to you and you can see the results.

 

[redcrossemt]

I'm much too lazy to look right now but not long ago we had a discussion about this very subject and a very good case was made for listening to lung sounds immediately when assessing the breathing.

I agree that a good case can be made for listening to lung sounds immediately, especially at the ALS level (you can fix a pneumo, and should right away). At the BLS level, I think it's okay... although it wouldn't really change treatment much.

In any case, this poster got respiratory rate, depth, and lung sounds at the same time but failed to act on inadequate respirations; probably hitting a critical criteria.

 

[BossyCow]

I agree that a good case can be made for listening to lung sounds immediately, especially at the ALS level (you can fix a pneumo, and should right away). At the BLS level, I think it's okay... although it wouldn't really change treatment much.

In any case, this poster got respiratory rate, depth, and lung sounds at the same time but failed to act on inadequate respirations; probably hitting a critical criteria.

Not everything we do is to determine our treatment. Being able to tell that during my 30 minute transport the missing lung sounds in the lower lobe cleared up with the neb tx enroute or that the original lung sounds equal bilaterally changed en route is information that is important.

This is similar to the BLS discussion on another thread. There is value in getting information about the patient, even if its something BLS can't treat. Being able to show glucose readings that are getting better or worse or remaining stable is good. So what if I can't give glugagen, the ER has a better idea of what's going on with the pt than if they arrived by taxi.

If the pulse ox (combined with a proper visual assessment of perfusion) shows a steadily declining O2 sat or one that gets slowly better, this is good information. Or with the pt I had with pulmonary embolisms (yes plural) her sat would plummet suddenly then rise again.

BLS is to stabilize and transport. Determining if a pt is stable or not is done by monitoring their vitals. Even if it doesn't 'affect their treatment much'

 

[TechWho]

Only tangentially relevant, but shortly after reading this thread, I ended up with at least one question regarding flail chest on my written exam and recalled a lot of the discussion here. Thanks folks! :blush:

 

[WarDance]

So I did fail because I didn't splint it. I asked a hypothetical question last night and found out. I also did very well on every trauma scenario I ran through last night. I think our medic instructor just made me so afraid of the fact that basics can't do much I got way too into the priority patient thing.

Now I just have to worry about forgetting all of those other stations I had memorized before I retest.