Should EMS have tests for their clinicals?

[Veneficus]

Ok, I know I am getting crazy with 2 threads in one day.

Here it is:

In medical school there are tests in clinical time. You can actually fail a clinical rotation. They have defined learning objectives including diseases and cases you might not see because there are no patients admitted with them.

The preceptor has to grade not only your raw academic performance but constantly questions about thought process as well.

All of this is presented in a clearly defined format that is prescribed.

There are psychomotor skills to be checked off.

So it makes me wonder...

Why aren't EMS clinicals set up the same way?

Should there be more focus and more direction in EMS clinicals?

I see it from both sides. When I was in paramedic school, after a few weeks I was basically treated like a minor staff member. If a patient needed an IV, I simply went and did it. (including the proper documentation) If I had a question or a problem I went to whoever was around for help. I had a designated preceptor on paper, but reality was different.

I learned a lot, especially critical thinking and making use of available resources.

I still have enough autonomy, more infact, to do real damage, but I also have defined responsibilities.

What's more, clinicals take place in a designated academic facility. A specific amount of skills, patient contact, and types of patients are required. Along with a trail of paperwork for such. I have seen a lot of paramedic programs where clinical sites were whatever local hospital there was. Practicing whatever form of ancient medicine they had.

All physicians come out of academic facilities. Some paramedics do. One medic could go to an academic center and do 30 IVs and 50 ALS assessments in 12 hours. Some might struggle to get that in their entire clinical time.

Does something about that seem wrong to you too?

 

[medicRob]

Ok, I know I am getting crazy with 2 threads in one day.

Here it is:

In medical school there are tests in clinical time. You can actually fail a clinical rotation. They have defined learning objectives including diseases and cases you might not see because there are no patients admitted with them.

The preceptor has to grade not only your raw academic performance but constantly questions about thought process as well.

All of this is presented in a clearly defined format that is prescribed.

There are psychomotor skills to be checked off.

So it makes me wonder...

Why aren't EMS clinicals set up the same way?

Should there be more focus and more direction in EMS clinicals?

I see it from both sides. When I was in paramedic school, after a few weeks I was basically treated like a minor staff member. If a patient needed an IV, I simply went and did it. (including the proper documentation) If I had a question or a problem I went to whoever was around for help. I had a designated preceptor on paper, but reality was different.

I learned a lot, especially critical thinking and making use of available resources.

I still have enough autonomy, more infact, to do real damage, but I also have defined responsibilities.

What's more, clinicals take place in a designated academic facility. A specific amount of skills, patient contact, and types of patients are required. Along with a trail of paperwork for such. I have seen a lot of paramedic programs where clinical sites were whatever local hospital there was. Practicing whatever form of ancient medicine they had.

All physicians come out of academic facilities. Some paramedics do. One medic could go to an academic center and do 30 IVs and 50 ALS assessments in 12 hours. Some might struggle to get that in their entire clinical time.

Does something about that seem wrong to you too?

Yes. I would even go so far as to say that individuals in paramedic programs should have a dosage calculation quiz at the beginning of each class, just like we did in nursing where you either make a 0% or a 100%, nothing in between,
with 1 chance to make up a 0% at the end of the week via a bonus quiz. With this in effect, students who average below 90% on dosage calc quizzes would not be allowed to participate in clinical.

As far as tests during clinicals, I feel that a good preceptor asks tons of questions and allows the student to take the reigns (within reason) on calls, ESPECIALLY the paramedic student. I feel that a preceptor who is constantly keeping you on your toes is a great thing for developing your critical thinking abilities.

For instance, when I was in nursing school, there was this one RN at a local medical center that no one wanted to have as a preceptor (Myself included) that would say something along the lines of, "The patient needs X, what are you gonna do?". Once you named an intervention she would say something along the lines of "That didn't work." What's your backup plan? If you were smart enough to have a backup plan, she would then ask... well why will that work? You do know right?

She gave us hell, but in retrospect I learned so, so much from her. When I was in paramedic school, I had the fortune of being able to do clinicals in a medical center where I worked as a nurse.. There was a specific doctor in the ER who loved to teach, it was her calling.. She loved nothing more than to swoop a paramedic student from the floor and say, "Come here.. I want to show you something... This patient is getting X procedure.. Do you know what that is and why it is needed?"

I think that adding actual written tests for the student at the end of the clinical (So long as it reflects the objectives of that particular clinical) would be great.. I don't think they should be weighted too heavily at first, after all .. you aren't going to learn all of emergency medicine in one clinical. However, perhaps if the student was tested on say, the last clinical of their OR rotation, the last clinical of ER, last clinical on ALS truck, etc before being able to move on to the next clinical, that would be good.

 

[MrBrown]

We have to complete mentor reports, clinica reflection exercises, case logs and a bunch of short question and answer activities about jobs we have been to while under clinical mentoring.

 

[cmetalbend]

During the clinicals through our College we use Perceptor forms that do include skills performed, your attitude, willingness to perform task, accuracy of skills, and general overall performance. It's filled out by a paramedic you ride with, and they give a pass/fail.

 

[JPINFV]

It's a pain and expensive, but I like how the medical licensing exams are set up.

Complete diadiactics? Ok, take NREMT- Paramedic Step 1. Don't pass? Get maybe get delayed starting clincals and retest. Fail a second time, get pulled from clinicals. Fail a third time, don't complete the program.

Done with clinicals, take NREMT- Paramedic Step 2 for full licensure.

I think the biggest problem with EMS education is that there are too many programs that are too lax with clinicals. For my EMT class, there was no one from my school at any of the clinical sites. Just have them fill out the form and return it. Yea, done. If you're going to test for clincals (like shelf exams), then the clinical faculaty needs to know what they're responsible for teaching and ensure that it is taught, instead of a, "Ok, just watch for a few calls" mentality.

 

[8jimi8]

I like where this is going, but implementation would be difficult.

Speaking from just finishing clinicals for my EMT-I. I could have written that i performed an off pump bypass on my paper after the Doc signed it.

I seriously was the master of my own education. While i took extreme advantage of it, got to watch a pericardial window, cardioverted a few people, ran from OR to OR grabbing every tube and LMA that I could, tried to butt in on EJs, started every drug or drip that i could get my hands on...grabbed and interpreted every ECG - asked docs about minutiae, started every difficult IV i could....

but this was all based on my impetus. I ran my own clinicals and was smart enough to get in neck deep. My clinical liaison couldn't even be bothered to send me a proper ID card. I had to print off a piece of paper and fold it up to fit in an ID holder.


Clinical tests would have made it more difficult, but rather than tests, in nursing school we had to do pathophysiology reports, as well as write out drug information, SE, dosage, Routes, indications, etc. As well as selecting 5 labs that were performed on our patients. This clinical paperwork was graded by our clinical instructors.

What I would suggest is that weekly clinical run reports / clinical skills performed, disease processes encountered be monitored by the clinical coordinator. Then important disease processes that have not been encountered could have attention.

Check offs should count, perhaps a summary test of the previous semesters didactic material. Perhaps checkoff should be counted heavier and without retries.

 

[firetender]

There's a bunch of people here who immediately jumped on the band wagon because they're enthused with what they do, and want to learn more and do better. They are the ones who LIKE the idea of mandated higher standards.

Will we here from those who would rather not have to deal with more regulations and testing and all that other crap that just forces stuff on us?

 

[JPINFV]

Will we here from those who would rather not have to deal with more regulations and testing and all that other crap that just forces stuff on us?

How many of those people are regularly active on here? I've always felt that the people who are regularly active on EMS forums are, in general, in front of the curve.

 

[8jimi8]

there's a bunch of people here who immediately jumped on the band wagon because they're enthused with what they do, and want to learn more and do better. They are the ones who like the idea of mandated higher standards.

(the original statement i meant to quote below)
Will we here from those who would rather not have to deal with more regulations and testing and all that other crap that just forces stuff on us?

no.

 

[abckidsmom]

I like where this is going, but implementation would be difficult.

Speaking from just finishing clinicals for my EMT-I. I could have written that i performed an off pump bypass on my paper after the Doc signed it.

I seriously was the master of my own education. While i took extreme advantage of it, got to watch a pericardial window, cardioverted a few people, ran from OR to OR grabbing every tube and LMA that I could, tried to butt in on EJs, started every drug or drip that i could get my hands on...grabbed and interpreted every ECG - asked docs about minutiae, started every difficult IV i could....

but this was all based on my impetus. I ran my own clinicals and was smart enough to get in neck deep. My clinical liaison couldn't even be bothered to send me a proper ID card. I had to print off a piece of paper and fold it up to fit in an ID holder.


Clinical tests would have made it more difficult, but rather than tests, in nursing school we had to do pathophysiology reports, as well as write out drug information, SE, dosage, Routes, indications, etc. As well as selecting 5 labs that were performed on our patients. This clinical paperwork was graded by our clinical instructors.

What I would suggest is that weekly clinical run reports / clinical skills performed, disease processes encountered be monitored by the clinical coordinator. Then important disease processes that have not been encountered could have attention.

Check offs should count, perhaps a summary test of the previous semesters didactic material. Perhaps checkoff should be counted heavier and without retries.

I like this model a lot. I find it to be practical to implement without having an MD PHD clinical faculty member getting involved.

 

[Veneficus]

There's a bunch of people here who immediately jumped on the band wagon because they're enthused with what they do, and want to learn more and do better. They are the ones who LIKE the idea of mandated higher standards.

Will we here from those who would rather not have to deal with more regulations and testing and all that other crap that just forces stuff on us?

I paid a considerable amount for my community college paramedic education compared to the local medic mills at the time. My clinical experience was awesome because of my efforts.

But I have to say. Knowing what I know now, I really feel cheated. The preceptors had to fill out a form that asked about attitude, skills performed, etc. Many had me fill it out and signed it. I was responsible for making sure it got back to the school. How many preceptors do you think didn't write or sign something that said I was wasn't the greatest thing since sliced bread?

I had no idea where my strenghts and weaknesses were until I was the paramedic in charge on a truck. Believe me, I had a few weaknesses because when you are directing your own clinical, you tend to stick with things you like and ignore things you don't like. (which seems to correlate to how good you are at them)

Since there was no structure, I saw lots and lots of "true emergencies" when they came through the door. If things were slow, I'd ask to go hang out in another department I was interested in.

But I couldn't be bothered with the non acute or non critical care stuff. All I knew was the patient was dying or wasn't. I didn't know what disease stages looked like, except for end stage. I didn't know how to tell apart the people who didn't look sick but were from the people who looked fine and were.

It never occured to my preceptors in medic school that I probably should have been forced to see "routine" patients.

It is probably the main reason in my early career I adopted the attitude if you weren't dying, then you didn't need 911. ("I have since seen the light and repented" as one of my former coworkers liked to say.)

I never saw a PE for almost a year after I got out of medic school. Somebody probably should have menioned what they really look like.I thought those 3 firemen killed the lady and I was trying to figure out how I was going to fill out the incident report. Were it not for the receiving ED doc who casually remarked that prehospital PEs always seem to die, I most likely would have erroneously gone and written those guys up.

Yea, the paperwork and extra layers would have been a major pain in the A**. It is still a major pain in the A** now. But I am definately better for it.

Which not only benefits patients, it makes it a lot easier for me to be comfortable with myself for what I do.

 

[rescue99]

There's a bunch of people here who immediately jumped on the band wagon because they're enthused with what they do, and want to learn more and do better. They are the ones who LIKE the idea of mandated higher standards.

Will we here from those who would rather not have to deal with more regulations and testing and all that other crap that just forces stuff on us?

Do so few come from accredited programs? Expectations for clinical rotations and internship evaluations is quite extensive.

 

[mgr22]

In medical school there are tests in clinical time. You can actually fail a clinical rotation. They have defined learning objectives including diseases and cases you might not see because there are no patients admitted with them.

The preceptor has to grade not only your raw academic performance but constantly questions about thought process as well.

All of this is presented in a clearly defined format that is prescribed.

There are psychomotor skills to be checked off.

That pretty much describes the clinical portion of medic school for me.

 

[thegreypilgrim]

I wish we could do something like that for paramedic clinicals, but around here the major problem is the profound apathy regarding EMS from the rest of the medical community.

When I was in paramedic school and doing my rotations, I technically had a RN preceptor who was dedicated to my learning, but in reality I was just sort of passed around and used more or less as a "free nurse" in an incredibly unstructured way. Basically I'd start the lines and give the meds with little evaluation of what I was doing apart from the first couple instances.

I got to do many of my rotations at an academic medical center, which was great, but where exactly did my getting to complete skills, assessments, etc. compare to that of the residents? Pretty low. The only time I ever got to intubate someone in clinicals was in the OR, none in the ED. One of the hospitals I did rotations at had an actual policy stating paramedic students were not permitted to intubate patients even with physician supervision. I never got to do any sort of thoracostomy or cricothyrotomy or other really invasive procedures or anything like that.

So, somehow this is going to have to change. The medical community is going to have to value the concept of paramedics getting a quality experience from clinicals and make sure they don't just get bumped so the residents can get what they need.

 

[Veneficus]

I wish we could do something like that for paramedic clinicals, but around here the major problem is the profound apathy regarding EMS from the rest of the medical community.

When I was in paramedic school and doing my rotations, I technically had a RN preceptor who was dedicated to my learning, but in reality I was just sort of passed around and used more or less as a "free nurse" in an incredibly unstructured way. Basically I'd start the lines and give the meds with little evaluation of what I was doing apart from the first couple instances.

I got to do many of my rotations at an academic medical center, which was great, but where exactly did my getting to complete skills, assessments, etc. compare to that of the residents? Pretty low. The only time I ever got to intubate someone in clinicals was in the OR, none in the ED. One of the hospitals I did rotations at had an actual policy stating paramedic students were not permitted to intubate patients even with physician supervision. I never got to do any sort of thoracostomy or cricothyrotomy or other really invasive procedures or anything like that.

So, somehow this is going to have to change. The medical community is going to have to value the concept of paramedics getting a quality experience from clinicals and make sure they don't just get bumped so the residents can get what they need.

Hate to be the bearer of bad news, but since in the US, residency is the primary time of learning for physicians, they are always going to be at the top of the list.

The other problem goes back to EMS education. I have tried to point out many times, medicine largely does not value EMS. Why would any hospital accept the liability that comes with permitting students to do invasive procedures with the absolutely abysmal requirements of many EMS programs?

How much do destroyed teeth cost now a days to replace? Couple thousand for some implants. (probably more than the medic student paid the medic mill for their "education.")

 

[thegreypilgrim]

Hate to be the bearer of bad news, but since in the US, residency is the primary time of learning for physicians, they are always going to be at the top of the list.

The other problem goes back to EMS education. I have tried to point out many times, medicine largely does not value EMS. Why would any hospital accept the liability that comes with permitting students to do invasive procedures with the absolutely abysmal requirements of many EMS programs?

How much do destroyed teeth cost now a days to replace? Couple thousand for some implants. (probably more than the medic student paid the medic mill for their "education.")

Believe me I understand that the residents will always be number 1, but at some point someone is going to have to ensure that the paramedic students they're supervising are actually getting opportunities to do things.

Of course, the abysmal education most training programs impart on their students is the primary problem. No one doubts that, but certainly they're not all horrible and you'd think that hospitals would be at least somewhat familiar with the schools they contract with so as to be able to eventually distinguish between the legitimate ones and the mills.

They also have an opportunity to intervene here by uniting with one another and refusing to accept paramedic students at all until they raise standards. Indeed, that seems to be the more responsible decision as opposed to letting these students come in only to get a really half-assed and severely limited experience. This attempt to find a "middle way" only contributes to the vicious circularity of the problems with EMS education. The problems compound and exacerbate one another.

 

[Veneficus]

They also have an opportunity to intervene here by uniting with one another and refusing to accept paramedic students at all until they raise standards. Indeed, that seems to be the more responsible decision as opposed to letting these students come in only to get a really half-assed and severely limited experience. This attempt to find a "middle way" only contributes to the vicious circularity of the problems with EMS education. The problems compound and exacerbate one another.[/SIZE][/FONT]

I think they are taking a unilateral approach because EMS education seems to be the party unwilling to change.

If hospitals were to start working together with EMS, they would have to offer a compromise, is what causes the issues with EMS education.

Then when EMS providers are not skilled parties set up studies showing the ineffectiveness of EMS to perform or quality of intervention. The inevitable response is to suggest taking things away from EMS, because again, the EMS failure is not stepping up to the challenge and instead of taking concrete steps to improve just critisizes the study with anecdote.

The long and short of it is the problem is really not on the hospital end.

Another thing that has been tried is to have the EMS school pay for hospital employees to come in on their "time off" and act as preceptors. That has gone over very well with the hospital staff, but often causes substantial tuition increases to the EMS program.

then the cycle starts, students look for a cheaper alternative, an EMT/paramedic mill presents the low cost, low entry requirement, less time opportunity, and students choose that.

These mills then find a hospital who will take the students, and there is always one that will, even if they severely restrict what the students can perform.

In EMS education, volume, not quality is the money maker. Many hospitals attempting to increase quality started their own EMT/paramedic programs. However, when they take a loss for a while because they are front end selective, they close the program down, just like any responsible business manager when faced with a company division that always loses money.

I think EMS is going to have to make some major changes by itself before anyone else is willing to even listen to the possibility of working together.

 

[thegreypilgrim]

Then when EMS providers are not skilled parties set up studies showing the ineffectiveness of EMS to perform or quality of intervention. The inevitable response is to suggest taking things away from EMS, because again, the EMS failure is not stepping up to the challenge and instead of taking concrete steps to improve just critisizes the study with anecdote.

The long and short of it is the problem is really not on the hospital end.

It may not be on the hospital end in the sense that they're not the "efficient cause" of the low standards, but functionally the medical directors and hospitals of the land are really the only party in any sort of position to do anything about it.

I think it's quite clear at present, that EMS is unwilling to come together, organize, and make meaningful change. The closest thing we have to a professional organization is the NAEMT in which something around 2% of active personnel hold membership, and is far too closely aligned with organizations like IFSTA/IAFF to be of use. Change is going to have to be externally applied.

To practice in EMS you need a physician's license to function under, therefore physicians have all meaningful legal authority over EMS. Physicians also have a much better track record of organizing professionally and setting up what are as close to universally agreed upon standards as can be obtained. So, given the unwillingness/inability of EMS to come together as one voice, and given that there is need for an increase in standards so as to impart greater utility to EMS, it's puzzling why the option of just forcing the issue hasn't been pursued.

Then again, maybe it has and has somehow failed, but I'm not aware of how/where the breakdown occurred.

 

[Veneficus]

To practice in EMS you need a physician's license to function under, therefore physicians have all meaningful legal authority over EMS. Physicians also have a much better track record of organizing professionally and setting up what are as close to universally agreed upon standards as can be obtained. So, given the unwillingness/inability of EMS to come together as one voice, and given that there is need for an increase in standards so as to impart greater utility to EMS, it's puzzling why the option of just forcing the issue hasn't been pursued.

Then again, maybe it has and has somehow failed, but I'm not aware of how/where the breakdown occurred.[/SIZE][/FONT]

I have spoken on this with more than a few medical directors.

The major problem is that most med directors are expendable. If they don't play ball with what the organization wants, they are replaced. It makes change very difficult.

Another problem is most doctors are focused on being doctors and advancing not only themselves but the medical profession. EMS is largely an after thought. Who could blame them for focusing their efforts on things they can improve?

 

[thegreypilgrim]

I have spoken on this with more than a few medical directors.

The major problem is that most med directors are expendable. If they don't play ball with what the organization wants, they are replaced. It makes change very difficult.

Another problem is most doctors are focused on being doctors and advancing not only themselves but the medical profession. EMS is largely an after thought. Who could blame them for focusing their efforts on things they can improve?

No one to be sure.

However, I wonder if that problem may be averted by zeroing in on the schools themselves as opposed to organizations already in place. It wouldn't require a concerted effort on the part of medical directors in the sense of them actively taking on the project of developing new standards - they could just say, "We're not licensing any new graduates until they all have AS level degrees (at minimum)."

Get ACEP and the NAEMSP to issue official position papers on the subject (NAEMSP already lobbied for the removal of the "Advanced Paramedic Practitioner" level from the new NHTSA standards so it's not as though they haven't had success in this regard).

The paramedic schools themselves have no power. They're just a constellation of unrelated community colleges and obscure vocational schools with no professional body.

Perhaps that's an avenue wort pursuing, since it'll force EMS to do the legwork of standard development and the docs will get to feel like they're still in charge