Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Evaluating EMS Competence and Priorities – Part I

One of the problems with EMS education is with our priorities. We put much more emphasis on time served hours in the classroom, than on competence.

I don’t believe that.

Try to take a certification test without demonstrating a minimum number of hours first. Competence does not come into play until after providing proof of hours in the classroom. Usually long after.

But you still have to demonstrate competence, don’t you?


How do you evaluate competence? There appears to be a lack of confidence in the evaluations, since the evaluation alone is not trusted. We have been approaching this entirely the wrong way and we show no signs of changing.

Hours do not mean competence. If they did, would there be any need for the test after providing proof of hours in the classroom? Yet we place much more importance on hours in the classroom, than we place on these tests.

Some of the problems with education in EMS –

Is this going to be on the test?

As students, shouldn’t we be more interested in being able to provide excellent care to patients, since the patients’ lives may be in our hands?

We have to avoid even the possibility of discrimination in evaluating students.

This is part of the problem with putting politics ahead of patient care. Evaluation is discrimination. We need to discriminate between the people we would trust to take care of our loved ones and everyone else. Some of the everyone else will be able to understand the material much better a second time through. Some will never get it.

Discrimination is an important part of our lives. Discrimination is how we differentiate between those things we like and those we do not. When discrimination is based on color of skin, or gender, or any other irrelevant sterotype, discrimination is bad.

The problem with evaluators discriminating on those grounds is one that should be addressed by removing the evaluator from the evaluation process. These biases are problems for all of us. They lead people to make stupid mistakes. The NR (National Registry of EMTs) response has been an equally stupid mistake. We have removed thought from the evaluation process and replaced thought with a strong inducement to teach to the test.

For the NR, the problem of discrimination is addressed by preventing the evaluators from actually evaluating candidates. The solution that the NR uses is to have a bunch of check-off boxes. Did the candidate do X, or not. There is no assessment of quality. No assessment of understanding. Just an acknowledgment of memorization.

This is not quality or competence, but this is the goal of modern EMS education.

We have students memorizing their way through a bunch of scripted exams. Exams that they have had the opportunity to rehearse over and over, so that their response becomes automatic. This might be a good thing, if it came after developing an understanding of what one is doing.

After understanding what is likely to be happening in the patient’s body, the possible effects of the medications, and the ways to reassess and respond to changes in patient presentation. After these, then work on ways to prompt treatment, but only if the treatment is actually indicated. Recognizing the atypical patient, and atypical is not uncommon, and not mistreating the atypical patient is important. Atypical is not on the test.

Without the understanding, the graduate can only try to make the real world situation resemble the stimuli from the classroom.

Crackles = Lasix (furosemide).

Wheezes = albuterol (Proventil, Ventolin).

More than an 18″ dent = helicopter.

Decreased level of consciousness = coma cocktail (naloxone, dextrose, thiamine, and maybe flumazenil).

Bleeding = large bore IV with wide open fluids.

Cardiac arrest = IV, endotracheal tube, epinephrine, and amiodarone.

Abdominal pain = do nothing.

Chest pain = NTG (NiTroGlycerin).

The reality is that – Wheezes often are a sign of pulmonary edema. Crackles should not be treated with furosemide by EMS (even if the crackles are due to pulmonary edema). Helicopters should not be dispatched based on mechanism. Assessment of the reason for a change in level of consciousness is more important than pushing a bunch of drugs that may make things worse. Bleeding = bleeding control. Cardiac arrest = excellent chest compressions and defibrillation. Abdominal pain is safe for EMS to treat with opioids. Chest pain may not be cardiac, but abdominal pain may be cardiac, so sometimes abdominal pain = chest pain.

These presentations do not fit easily into rules that may be memorized. These presentations require understanding to be treated appropriately. Or luck. Don’t count on luck.

There is no right number of hours to understand this.

There is no check-off box way to assess understanding.