Worship of False Prophets...

[Guest guest]

Gene-

Great points (as usual) regarding the initial assessment and what I like to call

the " laying on of hands " approach. Don't discount the emotional value to the

patient of having someone who they just called for help holding their hand for a

few moments.....

But I have to take exception with your view on the value of written tests and

skills exams. (Can't agree with you on EVERYTHING can I!?)

As an educator I have an absolute need for some method of determining minimum

levels of comprehension, and within the current system, that is going to mean

some sort of written and skills testing.

How I administer these tests, however, is up to me.

Being blessed with an exceptionally open minded department chairman, My testing

philosophy is specifically designed to reduce this unneeded " Test Anxiety " :

a.. Written testing shall only be used to prove how well I have instilled

information in the student. Until my student can provide evidence of a minimum

level of comprehension I have failed as an instructor to meet that students

needs, and it is my responsibility to find an acceptable educational method that

will either raise the students performance to the required level or I must pass

the student on to higher authorities for additional remediation. The student

that meets our programs minimum criteria, have all done well on the state and

NREMT exams. Our last pass rate analysis was approaching 80% on the first try

and 99% on the second.

b.. Skills testing is a continuous process. Although we use the NREMT skills

testing forms to verify comprehension for the students files, skills testing is

not just performed on one day out of a semester. Time in the skills lab is

provided during each class period, and we relate the didactic covered that day

with the necessary psycho-motor skills required. I generally have the student

who is a " poor test taker " teach ME how to do a particular skill to prove

competency, and then have that student drill the others on the " NREMT Method " .

I find most students can achieve that " Minimum Level " if given enough time in

the lab, and I can reduce test anxiety by total immersion in the testing

environment. Slap em with enough quizzes and major exams and it just wears em

out,

Yes, I admit it. I drill my students on " test taking skills " (how to pass the

NREMT). But that occurs AFTER they have proven competency to me. How else are

we going to get these guys the red patches?

Regardez-

T.A. Dinerman EMTP

Pulse Timers and Worship of False Prophets...

Henry,

No, I feel the pulse for 10 seconds and multiply by 6. I have pretty

accurate sense of time, so counting 1/1000 and so forth works for me. I

wasn't implying that this is the way to pass a skills test. But often the

ways we do things to pass a skills test bear little resemblance to what we do

in the field. Skills tests are for testing purposes.

Upon my initial contact with the patient, I am interested in whether the

pulse is within normal limits and regular or irregular. If it's too fast,

that tells me one thing, and if it's too slow, that tells me another. I

don't, at that time, need to know precisely what the rate is. I do that

during the secondary survey. Same thing for BP. If there's a radial

pulse, I know the BP is 80 or better systolic. That tells me what I need to

know right then. I'll get the true BP later.

I suspect you were joking with me a little, but I feel that everybody ought

to be able to do PRACTICAL estimates of pulse rate and BP very quickly as a

part of the initial assessment. If I obtain a pulse rate of 30 estimated,

which would be one beat every two 1/1000 counts, and my patient seems to be

nodding off, then I can stop right there for the moment because that

triggers a lot of more important things to get started. Or if I feel a pulse

that is obviously 4 beats every second, then I don't need to spend 15

seconds counting it out exactly right then. That's all I'm saying. I'll get

the absolutely accurate pulse rates and BPs after I get the initial

interventions going that I know I'm going to need. If there's no radial

pulses and the patient is symptomatic, then I'm not going to spend time

searching for pulses until I've got the basic interventions going.

That's what I was attempting to say.

And one more thing. What good are skills exams anyway? All they prove is

that you have memorized a set of directions and can repeat the actions they

require in a totally fake setting. They are absolutely worthless for any

other purpose. The only way I know that I'm comfortable with a student's

ability to take accurate blood pressures is to see that student take them in

a variety of situations over time. A good animal trainer can probably teach

a chimp to take a BP according to the skill sheets given enough time and

bananas. The good medic will be able to get a usable BP under all kinds of

adverse circumstances. Try taking vitals in the helicopter.

Reliance on written exams and skills tests gives a false sense of security

about a student's true abilities. True, we have to have some means of

letting people through the gate, but merely passing the NREMT or a state

exam means little in terms of ability to perform under stress and in

challenging situations.

That's where I have fallen out with some of the medical directors who have

insisted that we retain a written exam to insure that people are minimally

capable. What hogwash. Some people can pass almost any multiple choice exam

just because they're good exam takers. Others have difficulty with written

exams but give excellent hands-on care. Observation and evaluation of

performance in the field is the gold standard. Next is performance in

scenario based situations IF THEY ARE DONE CORRECTLY, and that's very, very

hard to do.

Nobody wants to spend the money to set up systems for true QA. A good QA

system must be a part of a larger concept, that of Continuing Performance

Improvement systems. Instead, we like to fool ourselves and hope we can fool

the public into thinking that holding a certification or license insures good

performance.

Gene Gandy