The microwaved EMT

“OK, so I don’t know what I keep doing wrong,” he complained. “I watched the presentation, and took the test five times, but I keep getting a failing score. You really shouldn’t expect an EMT to pass a paramedic-level continuing education class. Most of that is outside my scope of practice!”

“Well,” I answered, “first of all, it’s a ‘scope of practice’, not a ‘scope of knowledge.’ Second, it’s not paramedic level. Everything in that session is BLS level, and the answer to every test question is found in the recorded material.”

“There was stuff in there I’ve never seen before, and I’ve been an EMT 18 months!”

“Oh, really?” I asked. “Where did you go to school?”

“I went to XYZ Academy! I went to school 40 hours a week for a whole month! I passed the NREMT exam on the second try!”

“I’m beginning to understand the problem now,” I nodded.

What became immediately apparent is that I had an EMT refresher student who had managed to memorize a great deal of facts, but learned precious little of how to apply them. He could regurgitate all the medical trivia found in an EMT class and recite rules of EMS care – “Apply oxygen via non-rebreather at 15 lpm,” or “When a patient is breathing less than 12 or faster than 30, you must ventilate them with a BVM” – but failed to understand test questions at the higher tiers of Bloom’s Taxonomy, such as application and synthesis of information.

So, when faced with a scenario where a patient was obviously hyperventilating due to emotional stress, but breathing entirely effectively, he defaulted to the rules, including forcing her to lie down and hold still while he bagged her.

I’ve had similar encounters with other students in other classes. Several years ago, Nancy Magee and I were contracted to conduct an EMR refresher for a group of forest rangers who had gone through a boot-camp EMR class; six straight days at 10 hours per day. Four hours into the refresher, it was painfully obvious they had retained nothing, and I mean nothing. They struggled to even obtain vital signs and were absolutely terrified they might have to render lifesaving care to someone.

Nancy and I were terrified too.

EMT training: Rest, digest and absorb

The microwave oven was invented in 1946, and affordable microwave ovens became widely available in the late 1970s. They revolutionized home cooking, making it possible for culinarily inept bachelors to create hot and tasty meals for themselves using a minimum of ingredients and even less cooking talent.

But anyone who has ever burned popcorn in the microwave, or smelled the break room stench after a coworker nuked his fish dinner in one, knows that some things just don’t belong in the microwave, even when the label says “microwave safe.”

EMT training is one of those things.

The problem when you’re a new EMT is that you have no frame of reference for what is a good class and what isn’t. You don’t know what you don’t know. All you know is that you passed the certification exam on the first try (if the education program didn’t totally abandon you after your final tuition check cleared), so you must have what it takes to be a good EMT, right?

Well, maybe you do and maybe you don’t. You certainly can’t fault your work ethic; it takes a lot of dedication to devote yourself to 40 hours a week of EMT class. What has yet to be determined is if you know what you need to be more than minimally competent. That’s all the certification exam is designed to do: separate the minimally competent from the dangerous.

When you microwave a TV dinner, the directions tell you to cut a vent in the film covering the dish, stir it halfway through the cooking process, and to let it cool for a minute afterwards. EMT students are a lot like that; if you just bombard them with information like microwaves bombarding your Hot Pocket, what you wind up with is a provider for whom some pieces of information are warm, some are burnt crispy and others are still half-frozen. The student needs some time between classes to simmer and stir the information around, ponder the meaning and see how it applies.

I typically teach in a hybrid, flipped classroom; our students do their classwork at home and their homework in class. That is to say, they focus on knowledge acquisition at home using whatever resources work best for them – a print textbook, the Internet, our online learning management system, an electronic textbook, and a multimedia library – while we focus our classroom time on application of that information. It works well, and this approach has allowed us to lop a couple of months off the length of our EMT course without sacrificing any content.

But what makes it work is the time allowed the students between classroom sessions, to let the information simmer and heat evenly. They need time to rest, digest and absorb. You can’t do that in a boot camp-style EMT class that runs eight hours a day, five days a week. I’ve even heard of some classes that run 10-12 hours a day. There is no time to absorb the information and learn how to apply it properly. It’s like drinking from a fire hose, and by the end of the day, both the students and the instructors manning the hose are exhausted.

Memorization might be possible with such an approach, but learning isn’t. There’s an adage about medical training that states, “Half of what you learn in (insert medical specialty here) school is wrong. The problem is, nobody knows which half.”

There’s a lot of truth in that statement, and good clinical experience will make you a better evaluator of the information you acquired in school; what was useful and what wasn’t, what was still relevant and what was outdated, and what was instructor preference when another approach was equally valid.

But when you’ve graduated from a boot camp EMT class, the chances are that you haven’t even acquired the knowledge or critical thinking skills to even make use of the clinical experience you’ll get on the street.

I know we’re facing a pandemic and critical staffing shortages throughout the EMS profession, and something needs to be done to increase the flow through the training pipeline, but I don’t believe boot camp EMT classes are the answer. When you microwave your EMT training, you need to realize that the meat you put in the seat is only half-cooked and still raw in some places.

It isn’t healthy to eat raw meat, and it isn’t healthy to our patients or profession to staff it with raw EMTs.