We generally have to take an exam created by the NR (National Registry of EMTs), or a similar test, in order to work in EMS at the EMT-Basic or EMT-Paramedic level. A lot of us worry about taking the test and wonder what we can do to prepare.
First – recognize that the exam is just a game.
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Perhaps you think that the NR exam is not a game.
What is a game?
Playing a game is the voluntary attempt to overcome unnecessary obstacles. – Bernard Suits.
Is there a better definition of what a game is? Feel free to provide a different definition of a game, but I will work with this definition.
Is the NR test voluntary?
Absolutely.
Nobody has to work in EMS. The NR test is just what comes between us and the goal of working in EMS.
Are the obstacles (test questions and test stations) necessary?
Absolutely not. There are many ways of assessing understanding, and this methodology is not even good at assessing understanding. What this is best at assessing is the gaming ability of those being tested.
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Is it necessary to ask about oxygen in half a dozen different ways, just to be able to confirm that the gamer has not escaped the oxygen is good – and more is better dogma?
This may be necessary to confirm adherence to the dogma, but it is not at all necessary to assess competence at patient care. Since dogmatic poisoning with oxygen harms patients, this is not only unnecessary, but it is counterproductive.
Understanding of what is good for the patient will probably interfere with an excellent score, but this is not about evaluating how well people provide patient care.
Hey, it’s better than nothing.
Why does anyone assume that the only other choice is nothing? Why would anyone think that the options do not fall into the category of something? But they do not think clearly, which is a big problem. Why are we going to people, who do not think clearly, for a way to assess the understanding of beginner EMS personnel?
Is the NR exam better than nothing?
Please provide some evidence that patients do better because of the dogma deficiency detector that is sold by the NR.
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I NEEED A TRUCK-LOAD OF HELP TO PASS THE NREMT EXAM…. I have been approved to take the Exam, yet I feel completely overwhelmed with fear that I am NOT ready to take it. I don’t want to subscribe to a Three Month Subscription only to get a few weeks out of it. There HAS to be some FREE practice tests for 2012 out there. I want to score 100% !!!! I want to feel 100% READY !
I just took mine in December and I will caution you against the online or computer based practice tests. At least the ones I took as they will provide you with a false sense of security and really do not compare with the NR written. Know you drugs, pharmacokinetics and mechanism of action in paticular, your ACLS and the most recent updates, and patho-phys of disease processes. These are the things that will get you to pass and do not expect a perfect score, just a passing score.
As someone who skated through Paramedic School when it came to the book work I felt like a complete idiot when I walked out after the test shut off at about 80 questions. I was sure I failed it and did not. The point you are at at the end of class is you will know it or not and the online tests will not teach you the material. Good Luck!
Guys, all I am looking for are a bunch of practice Exams for EMT Basic NREMT for 2012…. Can ANYone send me some for free? Or, a FREE Subscription. I don’t want anymore time to pass before I call the NREMT to Schedule the EXAM. I have been approved to take the written, and no one said anything about a hands-on Practical. PLEASE !!!!! I need to drill, and drill, and drill somemore.
Paul E. Morris CMA RMA MST EMT
I don’t know of any free preparation.
Talk with your EMT instructors. They should have prepared you for the test.
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Your condemnation of the National Registry, if logically applied, would also mean that all education past the age of consent (i.e. no longer forced to attend school) is a “game”. Nobody is forcing a person to pursue {career xyz}, and your arguments apply to any written test depending on the opinion of the test writers’ skill.
Exactly what options are there for evaluating new EMTs and paramedics? That’s not sarcastic, I’m seriously wondering. The only other method I know of is measuring actual performance on the job in front of an evaluator; and god knows there’s enough problems with Paragods(C) and so on twisting the preceptor system in EMS.
Life is a game. Sometimes you win, sometimes you lose, but you need to always try to have fun.
Also, I agree, that there are better options, are there any options that are reasonable? Sure, it would be better to have, say, oral boards, but the time and expense is simply not worth it. Finally, any system of testing can be used to assure adherence to dogma, especially if the argument against said dogma is presented at a level beyond what is expected from the candidate.
Joe,
As was said below, an oral board can simply take the place of the existing skills testing. Instead of six or seven skills station where people perform by rote memorization, three more in-depth stations that require some decision-making and differential diagnosis (oooh, the “d” word 🙂 ). An ideal replacement for the skills stations would be the more realistic simulation manikins, where instead of just verbalizing things, the students would actually have to DO what is on the skill sheets; but those are still too expensive for wide-spread use.
My point exactly. Even the best testing system can give crappy results depending on how it is implemented.
Certification and/or licensure (doctor, nurse, medic, etc.) testing never has validity in the viewfinder of those successful but is the cornerstone of public trust and the essential gate keeper of those who don’t possess your abilities. Change the public’s need for “something” that communicates trust as well as the lack of ability in people and you’ll change the need for “dogma deficiency detectors” forever.
Good luck! If that doesn’t work out for you, maybe you could build a new and improved NR model.
“Don’t be a cynic and disconsolate preacher. Don’t bewail and moan. Omit the negative propositions. Challenge us with incessant affirmatives. Don’t waste yourself in rejection, or bark against the bad, but chant the beauty of the good.” – Ralph Waldo Emerson
I can honestly say that there are really only 2 things that are necessary for success on the computerized exam:
1. Rudimentary knowledge of ACLS and PALS
2. Skill at taking standardized tests
There will always been a need for validation of basic knowledge and/or skills to enter certain professions. While I do agree that the NR model is complete crap, no one else out there that I am aware of is making any strides toward a better test or testing method. My home state had no choice but to go to the NR exam because someone filed a lawsuit to open up the State’s test bank under the sunshine law. Instead of trying to fight it, the EMS Board opted for the NR. I point this out because it shows that there are more than just “bad tests methods” to overcome. And to be perfectly honest, the practical test was not much different than the NR anyway.
I am personally more in favor of a panel type oral board for paramedic. Sure there will still need to be a written test to ascertain certain base levels of knowledge, but the practical is a joke. As opposed to “BSI, scene safety, C-Spine, O2” accounting for the majority of the practical score, I’d rather sit down and go through a complete patient encounter from start to finish. Let’s see how people think. Are they going to simply try to bluff their way through with the NR practical mantra, or are they going to get to a point and say that they honestly do not know what’s happening? Personally, I prefer the person that says “I don’t know” and asks for help. I would like to see maybe three separate patient scenarios for these boards, one of which is meant to lead to the “I don’t know” answer simply to see how they react. Unfortunately the current testing scheme does not require any thought processes outside of rote memorization. This is what we must change, especially for the paramedic level.
…and how much are we going to expect paramedics to pay for it given the current pay range for paramedics? It’s over $1000 for the USMLE or COMLEX Step 2 CS (practical) exam for physician. This doesn’t include the cost to travel to the limited number of locations that offers it. Given the volume of applicants and the cost, how would an oral board be feasible for EMS licensure?
You already have the basis for this with the current practical. There is a medical scenario, trauma scenario, and the dynamic cardiac station where paramedic candidates basically experience an oral board. Do away with the other skill stations, move a couple of proctors over to increase the number of panel members, give a complete in depth scenario for each panel, and voila! The start of something better. I’m sure there are enough people with enough ideas and experience to take that basic premise and turn it into a usable testing method.
Joe,
If the instructors are already showing up at the school to teach, why would there be a requirement to send students elsewhere, just because that is the way doctors do it?
A half a day of instructor time should be adequate to assess each student. If we can’t tell if a student has a clue in less than half a day, we have much more serious problems.
Why shouldn’t the EMS licensing agency pay for this? If their job is to protect the public from the clueless? One good investigation of FUBAR treatment by a medic may cost the agency more than preventive assessment.
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First off, having the paramedic’s own instructors themselves do licensure testing will always seem like a case of the fox guarding the hen house.
Second, if we’re looking at the best way to run a physical exam scenario, then it’s going to have to include a standardized patient, not a verbal scenario where the contestant (err… applicant) simply has to say the magic words. It’s gotta be something where the contestant has to go in, talk to a patient and run basic non-invasive physical exam techniques (heart sounds, lung sounds, cranial nerve exam, look/listen/percuss/palpate the abdomen, etc) and verbalize the invasive techniques.
Third, if you want to have an oral board to discuss treatment, you need to have paramedics who are actually experts at what they do. Jimmy Jones, the paramedic instructor who’s been a paramedic for 15 years yet can’t look past the cookbook-ocol for treatment isn’t going to be the guy to discuss why a paramedic would give one drug over another. Unless the licensing authority controls who is giving their oral exams, I don’t think it’s too much of a stretch to see a situation where an applicant fails because they’re too smart.
Heck. I’ve had an RN running an EMT refresher get mad at me because I had the audacity of pointing out the uselessness of putting a hypotensive stroke patient both in semi-fowlers and shock position since apparently “science” is too advanced for EMTs.
Fourth, why shouldn’t licensing exams be paid by user fees? Why would tax dollars be a better source of paying for this? Furthermore, if we want a national system, like physicians, nurses, and PAs, then you’re going to need a non-government agency to provide the testing (like is done for physicians, nurses, and PAs). NGOs don’t have a tax base to raise funds off of.
I agree with your first point. One of the biggest problems with EMS education is the lack of quality instructors and instruction. I can only imagine what would happen if they were allowed to proctor an exam.
On your second point I don’t necessarily agree that we need to be exhibiting or performing these skills. They may have a place, or they may not. The education and clinical settings, to me, are the place to perform these skills on “real, live, patients”. The boards/practical/psychomotor phase (or whatever you want to call it) is not the place to supposedly exhibit proficiency by sticking an IV needle in a plastic arm. I do agree that if the system is not managed correctly, it could become a “nail the key words” type thing, but then again, isn’t the NR practical already like that? I think that if there were say three experienced individuals on a panel, with an extensive scenario, they could manage to effectively evaluate a candidate/contestant 😉
You’re third point is spot on. My state doesn’t allow instructors to proctor exams, even at other institutions. Our proctor system may not be the best, but it is a start. In order to proctor paramedic practicals there is a minimum level of acceptable experience (it’s something like 3 years of experience), being actively employed in the medical field, certain merit badge courses (ACLS instructor for the cardiac station for example), and there is a one day proctor course to attend. Like I said, it’s not perfect, but it is a start.
Your last point is one that is vital to EMS moving out of the gray area it has occupied for the first 30 years, and being accepted as true medical profession. Unfortunately EMS does not have an organization like this. The NR would like to think that it is one of the Big Boys, when in reality it’s not. The NAEMT is even further back. I agree that we need some standardization and a national body to provide standards from coast to coast. I really don’t understand how this can be so for nearly ever medical profession, but not for EMS?
I think also that we should remember that the exam and it’s proctors are not gate keepers, but rather evaluators. The practical as it exists now is more about key words and jumping through hoops. It acts as neither gate keeper or a solid evaluation. We can do better.
With the patient simulators available out there today and the reality, or as close to it as possible, available with the senerio based testing afforded by them the NR needs to completely rethink it’s testing processes. A Trauma station and a Medical station that incorporates all skills tested now in a fluid testing enviroment would be a better judge of a candidant’s ability than a Trauma Assessment or Oral Station where all you have to do is remember to ask what a BP or a Pulse is.
The written is a Bitch, plain and simple. It is a hoop to jump through much more than it is a measure of entry level compentancy. I know plenty of people that took three and four attempts to pass it that were excellant medics and a few that passed it first time that amounted to nothing when put on the street. The course itself has way too many hours of instruction built into it to cover basic knowledge and it is almost pointless to start at a EMT-B level prior since all of it is covered to hold the hand of those with no experience in EMS prior to taking a Paramedic class.
I guess what I am saying, having recently completeing the class and becoming certified, it has no bearing on anything other than meeting minimum qualifications to gain employment and does not prepare a student for work as a Paramedic. Your first certification card gives you the right to learn how to be a Paramedic over time. The whole process is a joke and needs to be redone.
The one thing I don’t like about patient simulators is that they lack the ability to actually interact with a real patient. Physical exam findings? Sure. Ability to perform interventions? Sure. Ability to actually talk with a patient, introduce yourself, and elicit information in a meaningful way? Nope. The interpersonal communications aspect should be addressed someplace as well.
Joe,
We’ll find a way for you to work on your social skills.
Trust me. I’m Mr. Charm. 😉
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Patient simulators simply suck. They are for nothing more than the most basic, rudimentary use by stark beginners. Maybe they have a few more uses than that, but not many. Sure they’re great in an educational setting to learn the basics before moving up to “simulated live patients” (ie classmates), and for use in drills, more to avoid hurting a someone than anything else, but still useful there. Outside of those uses, I can’t really think of a time I would want/need one.
Dewayne,
Any chance to use the most basic intubation mannequin is an opportunity to practice.
You are not practicing as if it is human anatomy, but you are practicing how to position the head properly, how to hold the laryngoscope, how to perform bimanual laryngoscopy, how to use a bougie, how to intubate in a variety of positions. There is a lot to be gained from using even the most basic mannequins. It is our mistake if we do not take advantage of the opportunities.
I think that every medic should have to intubate Fred The Head, or some other intubation mannequin, 5 times in a row before being allowed to start each and every shift. Inflate the cuff, connect the EtCO2 and secure the tube, et cetera. Too many times people do not manage these things well on scene, because they are not familiar with their equipment. Of course, this would mean taking our patients more seriously. Isn’t this the least preparation they deserve.
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A little hyperbole and literary license on my part to make a point.
Dewayne,
How many paramedic Students have you been around that are not “stark beginners”? How many Paramedic Students have you had that actually take the lead to assess a patient and have good verbal communication skills. The simulators now offer the ability for someone to be in another room and speak or be the voice of the patient with an added reality of the patients condition changing.
I came to class with 5 years civilian EMS experience as an Advanced EMT and 10 years Combat Medic experience prior to that. I was not the stark beginner. I was the only exception in my class though. These simulators serve the same purpose as Basic Rifle Marksmanship in basic training did for me and my fellow trainees. Handling the rifles for three days doing function tests, dry firing with a dime on the barrell not allowing it to drop off, clearing malfunctions, etc.
It made these absolute essential functions second nature for a weapon we had not even put a bullet down range with. If you ask the same questions in the same order and get feedback on what you did right and wrong you will begin to obtain a style that works for you and completes the objective. Testing someone in a scenerio that requires them to ask a pt for a Hx and then actually obtaining the pulse/BP. Looking at the eyes, not just saying you are and asking “are they PERRL”. Putting your hands on a patient and listening to breath sounds. All those things that we do now in the field that are second nature can be incorporated into training and testing instead of just being able to ask the correct question at the correct time. That is as close to reality as it gets.
The actual skills such as intubation, IV starts, etc are no more than muscle memory and anyone can be taught them. What is being accomplished by testing those skill stations? Not a damn thing, they test the instructor more than the student. The Oral Station is probably as close to a real test as it gets right now and it is the only one that really allows the evaluator freedom to decide and not just a box to check.
Best test yet, have a student ride with one preceptor for all clinicals and make it pass/fail for the course after their 400 or so hours. They either feel a student has the ability to do the job as an entry level medic or you do not get your authorization to test and start over, takes the need to change away from the NR…
Now I’m getting confused. Here is what you said at first…
“With the patient simulators available out there today and the reality, or as close to it as possible, available with the senerio based testing afforded by them the NR needs to completely rethink it’s testing processes. A Trauma station and a Medical station that incorporates all skills tested now in a fluid testing enviroment would be a better judge of a candidant’s ability than a Trauma Assessment or Oral Station where all you have to do is remember to ask what a BP or a Pulse is.”
But then you said…
“The actual skills such as intubation, IV starts, etc are no more than muscle memory and anyone can be taught them. What is being accomplished by testing those skill stations? Not a damn thing, they test the instructor more than the student. The Oral Station is probably as close to a real test as it gets right now and it is the only one that really allows the evaluator freedom to decide and not just a box to check.”
Which is it?
I happen to agree that the practical (or psychomotor exam in the new parlance of educators) proves naught. So, why would we want to place the focus on using a patient simulator to perform all these skills and distract the student, proctors, and the entire evaluation process away from what we are trying to evaluate…. a candidates knowledge and critical thinking abilities. I mean you could include Mr. Plastic Man in one of the settings if you felt there was this overwhelming need to validate the skill set. I could live with that if it helps to change the over testing method.
And since you mentioned it, using the intern model is only as good as the preceptor and fraught with all of the same perils as a bad test proctor mentioned in an earlier post. One point I do disagree on in this type of setting, is having the same preceptor the entire time. A student or new medic should be exposed to as many different scenarios as possible. This includes preceptors as well. Not only does using more than one or two preceptors over the course of a year provide a much more objective evaluation of the student/new medic, it will also allow the student/new medic to see that there are different ways to approach the same problems, write the run report, start IVs, etc, etc, etc.. It affords them a broader learning opportunity, including the chance to see what not to do in some cases. We are all different, with both professional and personal strong points and weak points.
I do like the idea of using an internship or restricted license of some sort for new medics. Maybe the oral exam boards should be after this internship period? Of course this is all just wishful thinking for now… and it only raises more questions. Why don’t nurses have a practical or an internship, yet have a written exam? Doctors have an internship and oral boards, but no practical? The list goes on.
The main point in all of this is that the current system of testing is not adequate. We all pretty much agree on that. The problem is where do we go from here? And how do we there?
Just to clarify something.
Physicians have a practical called the Step 2 Clinical Skills exam. It’s an 8 hour exam where applicants perform 12 assessments on standardized patients and write a SOAP note for each encounter. The encounter and SOAP notes are graded independently of each other, so it’s possible to pass the SOAP note, but fail the encounter, or vice versa. There’s no practical, however, on individual interventions. Of course the problem is that until a student is matched into residency no one knows what skills an individual physician needs. A cardiologist doesn’t need to know how to intubate. An anesthesiologist doesn’t need to know how to do a cardiac cath. However, legally speaking, an anesthesiologist can perform a cath and a cardiologist can intubate (unrestricted medical license being…well… unrestricted).
However, there are no oral boards when it comes to medical licensing. The oral board comes into play with specialty certification. The catch, however, is that virtually all physicians outside of the military are specialized in some field, including the primary care specialists (i.e. family practice or internal medicine).
Joe,
Unrestricted, except by the hospital. The hospital decides which specialists may use which medications and procedures. Procedural sedation may be the most familiar of these disputes among specialties, such as anesthesia vs. the “poachers and dabblers.”
“Poachers and dabblers?”: ASA president’s incautious comment riles emergency physicians.
Flynn G.
Ann Emerg Med. 2007 Sep;50(3):264-7. No abstract available.
PMID: 17712877 [PubMed – indexed for MEDLINE]
Dabblers and poachers: who is to blame?
Phillips WJ.
Ann Emerg Med. 2008 May;51(5):682. No abstract available.
PMID: 18436056 [PubMed – indexed for MEDLINE]
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That’s why I limited my discussion to the license. Of course physicians also practice medicine outside of hospitals. Unrestricted applies to location and time, as well as scope. The catch, of course, is the issue of liability and malpractice. However that’s a significant different than discussing EMS levels where the legal scope of practice has to be considered.
I stand corrected on that point. But do you not think it’s possible for EMS to do better?
Dewayne,
I was referring to using simulators in the testing. It is as close to having a patient that you can react to with changing conditions. The skill stations currently used can be incorporated in each scenerio just as it is in the field. A candidant has to assess and then treat with all skills they have been taught,
The adult intubation skill station is just an example I used. I could take any person with common sense that can comprehend basic instruction and teach them to pass the skill station in probably less than an hour. You cannot quickly teach the ability to know when it is right or not, That is where the NR skills testing needs to incorporate more reality based testing. As I said the Oral Station is the closest but, there is no patient contact. In my opinion the best station would incorporate the Oral Station with a high quality simulator requiring an actual assessment and giving the test the ability to control patient response vs treatments given and evaluate the candidant on actaully treating a patient from “Hi my name is…” to the handover.
I would agree with you on the preceptors if the students today were more like the student I was. Someone who had thousands of hours with actual patient care prior to entering into a Paramedic Class. Problem is the majority of the student’s experience today is required clinicals for an EMT class. A lot of students do not like to here they need to improve or be lectured on a mistake. Allowing them to move around allows them to go on to the next person and repeat the same things and then move again when they do like what they are being told. The result is a student that never improved.
I found the Medics that everyone always said were the biggest assholes to ride with. If I went to the ones that felt I was leaps and bounds above others because I could do an assessment and talk with a patient comfprtably or I could start an IV with my eyes closed I would have never been challenged and pushed to improve and start thinking completely differently. I did half of my time with one crew then worked with other Paramedics that were highly respected and I learned something from each as you suggested. I did not need the basics or to be built from the ground up, I needed to be refined and taught how to think like a Paramedic and no longer an Advanced EMT.
Most of my classmates had maybe taken ten BPs in an ambulance and had a couple of IVs in the classroom or ER setting prior to stepping in the back of a truck as a Paramedic Student and they would have benefited from one preceptor that could structure their progress and build on each area.
In an ideal world a brand new Paramedic without any prehospital experience prior to class would work in a large ER for a period of one year where they could be afforded the experience to see multiple patients of all acuity levels and not be the primary care giver. This only works though when the Paramedics, RNs, and MDs are able to talk about what they see and learn from it. So much of what we do hinges on the “I’ve seen this before” and I cannot see a way the NR can prepare a student for that.
Combat Medic,
I thought that was how it did work. I know in this state, you need to pass that internship before being allowed to test for NR. There are horrible problems with the preceptor system; not the least of which is that in many systems, the preceptorship are the ones who continue the blind following of tradition rather than critical thinking (i.e. “That’s how I learned it, if you don’t do it that way, you fail.”)
Unfortunately, IMHO there are just as many problems with the people who are appointed as EMS educators as there are with the system itself.
Unfortunately around here pass/fail is more tied to completing required hours than anything else.
The biggest problem with the preceptor system is no one having the ability to actually tell someone they need to improve. If a preceptor is only giving good remarks and positive feedback to someone they either do not give a shit or do not want to hurt someones feelings. My EMT and EMT-A students as eventually will my EMT-P students get positive feedback every oppertunity I can give it. No student will ever climb off my truck after twelve hours without something they need to improve on. I am doing them a huge injustice if I do not give that to them. Some get pissed and complain, some never come back, and others cry. But, most listen and when they come back they do not repeat the same thing or do better at something. I always encourage a student to be their own person, not me.
Hm, sounds like the systems we’ve seen are pretty much opposites. I was lucky enough to have a preceptor who taught me, corrected me when I screwed up, but treated me with respect. Too many of the preceptors around here are known to try and make the intern “piss down their leg” as one person put it; concentrating more on the “breaking” aspect than the teaching aspect.
Maybe it’s a function of who is allowed to precept. One county around here allows a medic to precept after 3 years in the field. Another county allows medics to precept after only one year in the field, which is insane IMHO. It could be a medic needs a lot more time in the field before they’re comfortable teaching an intern and don’t feel the need to show the intern that they’re in charge.
CombatDoc,
There are many ways of providing scenario and oral assessments. They can be combined. They can be separate. There can be several of one and only one of the other.
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Good EMS agencies will not put a new medic on the street on his own for months, because the NR exam does not evaluate whether someone is ready to work as a medic. Neither do any of the similar tests.
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I completely agree.
As with many things, there was a solution proposed. Nobody had to prove that the solution evaluated competence, or anything else, except the ability to take standardized tests. Now that this is the way things are done, change is unlikely, because it has become the traditional way of doing things.
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How is it that a damn computerized test can’t give you the results immediately? I took my test yesterday, got cut off at 81 questions and have been in limbo ever since… makes no sense.