Many of you have seen the “new” National Standard Curriculum put out last year for subsequent implementation. This is NOT the first National revision. Many of you old timers remember the 1996 revisions that saddled us with the ‘five part’ patient assessment (initial assessment, focused assessment - medical and trauma, the detailed assessment, and of course the on-going assessment) that only served to take a simple concept and make it something confusing and complex without real justification. Ok, so we sucked it up and did it like they wanted everyone to do it. We didn’t have to like it, just do it. That was the position of the national standard. “Try it, this is better” I heard; “give it a chance, you will like it, it will grow on you,” they said. Ok, so we did it and now over 15 years later we are back to Primary Survey and the Secondary Survey, performing to almost the identical assessment of the past (albeit having it tweaked by the brains at PHTLS who abandoned the ‘five part’ over 7+ years ago in favor of the “simple is better” approach).
Ok, fabulous, right? Yes, in many ways it is fabulous. They even added a precursor to EMT Basic called Emergency Medical Responder (EMR). The problem with EMR is it is 30 years too late! This is what we needed back when we were transitioning from “regular” fire departments to the modern professional Fire Service of today that has EMS fully integrated. Today it appears to be a stepped down version of EMT Basic suitable for the ‘hose puller’ of yesteryear. I truly wish that my old Fire Captain had EMR Training. Maybe then he would not have been screaming “get him to the hospital” at my Paramedic partner and me. We were on a trapped roll-over and as we freed the victim, slipped him straight into the “Mast Pants” on the backboard. We had already hung two lines waiting for the extrication and swiftly transported him. The good part is that EMR is NOT required for EMT Basic. It is NOT a prerequisite course for the latter. EMT Basic has been the standard for many years and many Departments have made this the level to which all firefighters are trained. EMT Basic certification is often a requirement to even test for the various entry level fire service positions out there. In many ways this was also a ‘screening tool’ to keep the hiring pool competent and to weed out many who might be unsuitable, on an academic level, considering many departments may require their new hires to become Paramedics. There are very few firefighters in today’s modern professional departments who do not wear two hats and, in fact, many have come through the ranks integrating Professional EMS into their practices and their departments.
Gradually over the years all of health care has come to objective and competency based learning. Practical learning objectives in all domains (cognitive, psychomotor, affective, and a new domain for the 21st century: interpersonal) have been created to best outline for the student what is expected in their professional evolution. Competency based testing challenges the student to demonstrate their abilities acquired within the learning domains. The ‘new’ curriculum does not disappoint in this area but in many ways leaves the objective writing to the textbook authors and fully outlines the expected competencies. This is beautifully done using a depth and breadth model. The outline for this is slated at every level in all areas:
The depth of knowledge is the amount of detail a student needs to know about a particular topic.
The breadth of knowledge refers to the number of topics or issues a student needs to learn in a particular competency. For example, the Emergency Medical Responder needs to have a thorough understanding (depth) about how to safely and effectively use the bag valve mask; however, the EMR is taught a limited number of concepts (breadth) surrounding management of a patient’s airway.
To describe the intended depth of knowledge of a particular concept within a provider level, the Project Team uses the terms simple, fundamental, and complex. This terminology better illustrates the progression of the depth of knowledge from one particular level to another. For example, the EMR’s depth of knowledge for bleeding control is simple while the EMT’s depth of knowledge for bleeding control is fundamental.
To describe the intended breath of knowledge of a concept within a provider level, the project team uses the terms simple, foundational, and comprehensive. This terminology also better illustrates the progression of the breadth of knowledge from one particular level to another. For example, the EMT’s breadth of knowledge for cardiovascular disorders is foundational while the Paramedic’s breadth of knowledge for cardiovascular disorders is comprehensive. 1
While I love this educational model and feel the education consortium that developed this application for EMS education should be applauded, it does leave one thing to be desired. What are the expected time parameters necessary to achieve expected competencies? The ‘old’ curriculums had many set hours (not set in stone, but an expected time to achieve the necessary goal in the individual learning domain) for the individual units. (i.e. EMT Basic Cardiac; 7 hours in the cognitive domain). If it took you less, then there was more time for other problem areas; if it took you more, then you had to spend the time securing the learning. Either way, there was a general guideline on how to physically structure the learning. With total competency based learning, hours are totally scrapped in favor of the educational goals. This is, in many ways a good thing, but can be a very bad thing overall.
My current EMT Basic class is 112 hours in the cognitive or didactic (classroom) domain, 42-45 hours in the psychomotor domain (lab), and 56 hours in the clinical setting for integration. The affective and interpersonal domains are integrated in all three instructional areas. The assessment of these competencies are solidified in objective based exams. It really does not matter which textbook is used as objectives from one to another vary only slightly and no one text is superior to another, at least in my opinion, as I really do not care which text we use.
Also solidified is the necessary remedial instruction. These are set instructional hours (only partially due to my being from an institution of higher education) used to lay the foundation for a comprehensive class. Now hypothesize this: What would happen if these hours are stripped from the curriculum and I was told to use only the necessary hours to achieve student competency based on the depth and breadth model? Instead of the current 200+ hours I use to teach EMT Basic, why can’t I teach it in 150 hours? 120 hours?
What would keep me from “teaching to the test,” a practice abhorred by all sound educators. Nothing. That’s right, nothing; nothing but integrity that is.
Also, each of the levels (EMR, EMT, AEMT, EMTP) sets its knowledge base on the previous level forward. This means that EMT is predicated on the knowledge of EMR, AEMT on EMT, and Paramedic level on AEMT. That’s fine, but what’s to prevent me from shortening EMT Basic and just including the depth and breadth necessary to achieve competency? What’s to say I cannot skip AEMT? That’s actually allowed now as you can go directly to Paramedic training as an EMT Basic; the EMT-I or AEMT as it’s called now, was originally conceived for rural and small communities unable to meet the rigor of Paramedic level services.
This ability in the new curriculum is unclear unless justified on competency alone. Nothing prevents it as the curriculum calls for the competency standards but does not state how to get there. It is going to be left to the regulators and the educators to seek the mean, find the happy medium that will satisfy the demand for high quality EMS providers.
Aristotle argued that the search for happiness came in seeking the mean and avoiding the evils of excess and deficiency. He called it the search for eudemonia (u-dem-o-nee-a), and human kind could not be truly happy unless the mean could be achieved. I have heard from colleagues that this is just another swing of the pendulum and that sooner or later we will swing back to the center. I’m not sure this was the mean that Aristotle was referring to.
The benefit of EMS Education is that we often learn by trying. This is very much the same as modern medicine as medicine is a ‘practice’ not a science.Doctors and all health care professionals ‘practice’ on their patients.
This has been the way since the beginning. We attempt to do better by practicing much as a musician practices their craft to achieve proficiency. We also bury our mistakes; literally. We tried the five part assessment only to end up back where we started. Yes, probably better, but just as the CPR Standards (how many times since the 70’s?) have changed due to advances and discoveries in research, so must the education standards and specifications for EMS.We will survive.
1. National Emergency Medical Services Education Standards; NHTSA, pg. 9.