What skills should we test?

In a recent article, I noted that by mid-2023, NREMT will sunset the ALS psychomotor exam, a measure that heralds a significant milestone in the maturation of our profession. No other allied health profession requires a skills exam for licensure, yet EMS still does. In that same article, I also noted that NREMT had removed its BLS psychomotor skill sheets from its website, leaving the states to either formulate their own, or to continue to use the old skill sheets they downloaded in 19-whenever.

People lost their minds.

There were a few commenters that applauded the move, but many on social media responded with the equivalent of “You kids these days ... ”

All that was missing was an old medic standing in the yard yelling at clouds, and a recitation of how hard he had it in his day when the skills examiners tried everything they could to fail you and they didn’t use no fancy schmancy computers, no sir, you chiseled your test answers onto a stone tablet and shipped via sherpa to the hithermost peaks of Cincinnati where a cabal of wise old National Registry elves passed judgment on your lifesaving smarts and if you were very smart and very lucky, sometime between two months and two years later, the Pony Express would deliver your card, patch and a certificate suitable for framing.

And by God, they were grateful.

Skills examinations aren’t going away, folks. Educational programs aren’t going to suddenly start turning out unskilled cretins by the hundreds ... at least, no more than they were already.

All this means is that the burden of documenting and ensuring skills competence is now on the education programs themselves. These are programs that, I remind you, already have to meet accreditation standards that require extensive documentation of skills and the maintenance of a skills portfolio, but also have to pass muster with the EMS agency leaders that hire their students. Consistently turn out crappy students that can’t do the job, and you’ll lose your agency support and maybe even your accreditation.

EMT skills rubrics

So if we’re going to develop and maintain these skills portfolios ourselves, the question becomes, “What skills are important enough to test?”

My own state’s (Louisiana’s) Psychomotor Skills Competency Portfolio consists of 26 skill sheets used in multiple assessments by instructors and peers, and we are required to develop and test scenarios on 14 different pathologies for pediatric, adult and geriatric patients. It’s a tall order, but thankfully, there are guides and resource documents on developing scenarios – sort of rubrics for developing rubrics, if you will.

It’s a lot to keep up with, but it’s doable. Basically, every single time a student performs a skill in class, you need to be documenting it and adding it to their skills portfolio. There is no longer room for “You guys look bored, let’s break out the manikins,” freeform skills sessions. I still break out the manikins and equipment when the students get bored, but the students practice with a purpose.

I use a clinical scheduling and skills tracking app that the students download onto their smartphones. Every time they perform a skill, I’m grading them on my phone, and they hand their phone to a fellow student to do a peer assessment. We perform the skill, sign and lock the assessments, and do a post-skill critique. Lather, rinse, repeat.

There are a number of skills tracking apps out there available for reasonable prices. Most of them have skills rubrics built in, or in some, you can develop and upload your own. At the end of the course, rather than contribute to the deforestation of our planet by keeping reams of completed skill sheets, you just export them into a zip file and store them electronically, easy peasy.

But if you don’t get any guidance from your state on developing Psychomotor Competency Portfolios, here’s a few things you should know when developing your own.

Formative vs. summative

Formative assessments are discrete steps in the learning process designed to see how the learner is progressing. They’re generally practice sessions of isolated skills and procedures, requiring little “big picture” thinking, whereas summative assessments are high stakes evaluations of how the learner has “put it all together” to achieve competency in a particular area. For example, “determining level of consciousness” and “opening the airway” are formative steps in the summative evaluation of “assessment of the trauma patient.”

Likewise, “assessment of the trauma patient,” might be combined with “leadership and scene management” and “interpersonal relations” might be combined as formative components of a summative “integrated out of hospital scenario.”

The idea is to learn in little bites, and build upon previous lessons. For example, as we cover the chapters involving patient assessment, we may simply start practicing the components of patient assessment as individual skills; scene size-up, primary survey and resuscitation, history and vital signs, secondary survey and reassessment. After they’ve demonstrated a solid grasp of those formative skills, we practice putting it together into a summative patient assessment scenario. As they learn about, for example, respiratory emergencies or chest trauma, now their patient assessment scenarios will include those variables.

When we’re near the course, we’ll practice and evaluate the student in a series of scenario labs where everything they’ve learned in class is fair game – no verbalizing allowed, and you may have to help a partner troubleshoot a procedure they’re having trouble performing. They may have to hand off a patient to a nurse, physician or intercept medic with a comprehensive yet concise report. They may have to manage an unruly and uncooperative patient in a professional manner. They may have to extrapolate from incomplete data; no patient ever follows the “book” presentation exactly.

What skills are most important?

Obviously, you can’t treat a condition if you don’t know how to find it, but there is little point in attaining competency in a skill that they’ll never perform in real life. Is treating a jellyfish sting necessary for EMTs in rural Iowa? Is there any point in learning the intricacies of a Hare traction splint necessary when all the agencies in your region use Sagers, and most of them are only used a couple of times in an EMT’s career anyway? Is there any point in learning to insert an iGel airway when your state’s EMS practice act stipulates a King LT?

Some skills are universal, but for many programs, the buffet approach works: a little of this and a little of that, tailored to your own local needs. The simplest framework of a skills competency portfolio might look something like this.

Formative assessments:

• Manual airway maneuvers and positioning
• Oral and nasal airways
• Suctioning
• Oxygen delivery devices (non-rebreather, nasal cannula, CPAP, etc.)
• Bag mask ventilation
• Obtaining vital signs and patient history
• Primary survey and resuscitation
• Secondary survey
• Reassessment and handoff
• Splinting techniques
• Wound management, burn care and bleeding control
• Decontamination
• Donning and doffing PPE

Summative assessments:

• Airway management scenarios
• Cardiac arrest scenarios
• Patient assessment scenarios – conscious and reliable patients (rather than “medical” assessment.”
• Patient assessment scenarios – unconscious or unreliable patients (rather than “trauma” assessment)
• Integrated scenarios – anything is fair game, but the student is graded on:
  • Leadership and scene management
  • Patient assessment
  • Patient management
  • Interpersonal relations
  • Integration of all elements, report and handoff

If your state intends to keep a psychomotor skills exam as a condition of state licensure, the only skills they should be testing, to my mind, are summative skills. Put the candidates through a few comprehensive scenarios to demonstrate competency at the big picture of an EMS call, and let the schools worry about evaluating the isolated skills; if the schools can’t be trusted to do that, then why are they currently allowed to teach students at all?

If all of this seems like a daunting task to you, there is no need to reinvent the wheel. It’s much easier to adapt something someone else has done to fit your program’s needs. An excellent resource document for helping instructors develop and maintain a psychomotor skills competency portfolio can be found here, on the Louisiana Bureau of EMS website.

Good luck, and strive to educate thinking EMTs, not skills monkeys!