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“Your patient has cold, dry skin and cyanosis of the lips and nail beds,” I tell the EMT student. “He is apneic and pulseless, and the 911 caller is doing chest compressions.” The student playing the role of family member cries quite convincingly.
“OK,” the student says. “Partner, take over chest compressions.” He kneels beside the patient and attaches AED pads, asking the family member questions just as he’d been taught: “How long has he been down? How long have you been doing CPR?”
“I don’t know!” the family member wails. “I found him like this when I tried to wake him up this morning! He was fine when he went to bed last night!”
“OK, everybody stand back!” the student says as he presses the Analyze button on the AED.
“Analyzing heart rhythm … NO SHOCK ADVISED. Check pulse. If no pulse, resume CPR…”
“We have a no shock advisory,” the student says. “Partner, resume compressions while I get an airway and start bagging.”
“You patient’s jaw is stiff and unmoving,” I say. “When you try to tilt his head back, it won’t move.”
“OK, then I’ll switch to a supraglottic airway instead.”
Students need early lessons on handling failure
You can imagine how the rest of the scenario went. Despite being informed there was rigor mortis, dependent lividity and other obvious signs of death, the student continued trying to resuscitate. He was shocked when I stopped the scenario and asked, “Why do you insist on abusing a corpse? Do you think his wife will be less emotionally distraught watching you break his ribs than she would with a gentle word and an arm around her shoulders?”
The student was shocked because I had given him a dead, unsalvageable patient in a scenario, shocked because I was suggesting that he stop CPR instead of putting the responsibility of terminating resuscitation on the paramedic, shocked by the idea that compassion could be the greater part of care, and shocked because he had never seen this before in the field.
In this case, my student’s experience worked against him. He had been taught, and indeed accepted as an article of faith, that once someone else started CPR, the EMT was legally bound to keep going until a paramedic or doctor told him to stop. He had performed CPR on real patients before, and worked for an agency that still routinely transported working cardiac resuscitations.
Open students’ eyes to EMT reality
That led to an excellent discussion about resuscitation ethics, laws (and the myths he and his fellow students had been told were actually laws), and the validity of BLS Termination of Resuscitation guidelines. More eyes than his were opened that day, but the real value of the lesson was demonstrating that you need to be prepared for anything in my scenarios – including the possibility that you will be graded on how well you do nothing at all.
Being told that it was OK to stop performing CPR floored my student, but what was fascinating was his emotional reaction to it. He was distracted and off his game for the rest of class.
If he could be so shaken in a scenario using a manikin and role players, imagine how a real field termination might affect him.
The purpose of the exercise was to counteract a tendency of mine that Nancy Magee pointed out: If the student does everything right in my scenarios, the patient usually responds and gets better. The patients who die are typically the result of a student doing something wrong or missing an important finding.
“That’s not the way real life works,” Nancy said. “Sometimes we do things wrong and the patient isn’t harmed. Sometimes we do everything right and the patient dies anyway. We need to teach these kids how to deal with that before they experience it in real life.”
She has a point.
Innovative approach spans patient lives
One of the wrinkles we’re adding to the next EMT 360 class is an idea I stole from Dan Limmer. I’m such a fan of Dan Limmer’s innovative teaching methods that I grew a goatee just so I could look more like him.
In one of our conversations, Dan said, “In my next class, the students are going to follow six patients throughout their life spans – from childhood diseases to adolescent trauma, to adult diseases, to chronic disease pathophysiology and multiple comorbidities in the elderly.”
It struck me that Dan’s idea would be an excellent way to teach the progression of disease and the long-term effects of trauma throughout a patient’s life span. Not only is it an innovative way to integrate elements of life span development, pediatrics, geriatrics and special populations into every scenario, it also encourages students to think of the patients in these scenarios as real people, rather than simply the high-fidelity manikin of the day. You’re not treating Rescue Randy or Megacode Kelly or Sim Man, you’re treating Marge, mother of three, loving wife and emphysema patient.
Death is inevitable
I liked the idea so much, I immediately proclaimed it stolen and assured Dan that when I eventually ruled the EMS instructional universe, I would remember all the little people I crushed on my way to the top. In the next iteration of EMT 360, our students are going to follow real characters that we create, complete with personal dossiers and medical histories, baby pictures, graduation photos and family portraits. The only problem is that six patients aren’t going to be enough. That’s because some of these patients are going to die.
We’ll need 20 or more fleshed-out characters, because Nancy’s wrinkle on the idea is to have some of these patients die despite our best efforts. Their purpose is not in teaching EMS care, but in how to respond when EMS care fails. And just like with a real patient, once dead, these characters will never be used again. They won’t come back. There will be finality to the scenario.
I’d rather my students learn how to deal with bad outcomes in my classroom with a peer support network and a mentor in place than in the field where too often the response to provider emotional trauma is, “You’re not cut out for this line of work.”
Follow Kelly’s progress as he implements a new teaching strategy focusing on patient interaction. Read: EMT 360: A new approach to EMT education
