BY BARRY S. DASKAL
Effective in-service EMS training is one very critical yet overlooked element in fire service-based EMS organizations. In many departments, EMS is considered a by-product or backburner service to fire suppression. With lower staffing levels, more calls for service, and administrators’ demands to do more with less, time for drilling and training is greatly reduced. EMS is often the first area to be sacrificed despite representing a disproportionately higher percentage of responses. In the volunteer environment, this is further exacerbated by time spent attempting to maintain necessary firefighting qualifications and Occupational Safety and Health Administration mandates. EMS training might only get brushed up on during the periodic refresher course time or, worse yet, might become nonexistent. Many agencies rely on patient contact through call volume as the way to keep their providers’ skills sharp.
Maintaining EMS skills is just as critical as maintaining fire suppression proficiency. Like any profession, fire service trends run the gamut from basic firefighting operations to collapse rescue, trench rescue, hybrid vehicle extrication, hazardous materials, and weapons of mass destruction. Like other industries, our major focus in the fire service is “back to basics” firefighting.
EMS responses are second nature. We encounter patients all the time, and their problems are generally the same. So why do we train? Don’t train only when a new intervention technique, medical device, or procedure is introduced. Train every day. Using skills on real patient encounters is not training; it might actually reinforce bad habits without our knowing it.
Many EMS drills are just a by-product of firefighting drills. Vehicle extrication leads to a patient (generally a mannequin) being removed and then verbalizing and stabilizing injuries or a mannequin “rescued” from a structure fire or collapse that is dropped at the feet of the EMS crew relegated to “standby.”
For the fire/EMS officer who realizes, accepts, and embraces that EMS training must be at regular intervals, the question then becomes, “How do you accomplish this?”
WHERE DO WE START?
EMS drill planning essentially requires the same procedure for firefighting drills, with some subtle but distinct differences. The first decision is what to train on.
Evaluate the patient types you regularly encounter, such as cardiac complaints, respiratory emergencies, diabetes patients, general illness, syncope, and motor vehicle crash patients. Develop a list of important skills used on a routine basis. These are your bread and butter responses.
Think about some of your more unique responsespatient contacts where you had to think just a little bit outside of the box. Did the patient have an unusual chief complaint? Was a rarely used skill or piece of equipment called for?
Once you identify target areas or subjects to train on, create a lesson plan. Firefighting drill planning for many officers has become very familiar. There are numerous premade templates and even full drills available online. One of the best resources for firefighters is provided by the Maryland Fire and Rescue Institute Web site. I prefer to use the fire service-based model resource, since this is the format with which personnel in combined fire/EMS agencies are most familiar.
Take your topic list and write a brief topic description and what you hope to accomplish. Because we talk about in-service training with our members, we know our target audience and the level of instruction required. Here, there are distinctions between writing an EMS drill and planning a firefighting evolution.
Establish a spreadsheet and a topic schedule. The first column lists the individual lesson topic. Then have several consecutive columns that include the following: the type of drill (lecture vs. hands-on or a combination of the two), a detailed description of the drill’s main focus and intention, the lead instructor and assisting facilitators, and any special notes (material resources, training locations, and any other pertinent information).
RESOURCES AND REFERENCES
Standard EMT and paramedic textbooks are your technical reference material. Your state, regional, and local policies and protocols are your detailed information sources. Another great resource is your standard patient care sequencefrom your scene survey to transport. Your patient care report is a great format for identifying different areas on which to focus.
Obtaining available equipment resources for EMS training can be more difficult than for fire suppression training. For fire training, securing a facility or other training location is often the greatest challenge. All the tools you need are on the rig. For EMS training, there are a few more intricacies; training materials tend to be the greatest challenge.
What materials do you need? Are they easily obtainable? For your training to be effective, you require patients and some patient care aids. Budget constraints generally dictate what you can and can’t obtain. A moulage kit costing several hundred dollars may be too much of an investment, but $20 worth of make-up from the local pharmacy or big box store can be effective. An advanced life support (ALS) “mega-code” mannequin is ideal, but the $5,000 needed may not be readily available. You can convert the beat-up rapid intervention team training mannequin into an unconscious, unresponsive patient with simulated traumatic injuries with simple things such as various colored children’s clay, broken pieces of chalk, and some old spare clothes.
Disposable supplies also present a stumbling block. To bandage a wound or stabilize a shoulder or limb, you must use gauze, triangular bandages, and tape. They cost money and must be restocked. Set aside a 20- or 30-gallon plastic container to keep “disposable” items in for reuse during training exercises.
Human patients are generally easy to find. You can preprogram partners, crew, and other station members as patients using index cards with their chief complaint, history of the present illness or injury, medications, medical history, and other pertinent information. Conduct full interviews, deliver oxygen to your patient via nonrebreathing mask, conduct nebulizer treatments using water instead of medications (always use local policy and procedures as a guide), take vital signs, and perform hands-on assessment.
For ALS scenarios, you can adapt and overcome. If ALS arms and mannequins are not available, you might consider reverting to the real thing. Anyone taught to establish an intravenous line practiced on themselves and their classmates. Again, follow local policy and procedures.
You can place EKG machines on patients and take and interpret three-lead and 12-lead evaluations. For dysrhythmias that need attention, hand a Web site printout to the student instead of a rhythm strip. Use small sharps containers with IV tubing that has the injection port facing out as your patient’s arm, and administer medications. Place a small (50 ml) spiked saline bag under the patient and tape the tubing to the arm to represent an established IV line.
MOTIVATION AND EXECUTION
When writing your lesson plans, come up with a motivational statementa brief paragraph that explains to the students the importance of mastering the skills they are about to learn. The motivational statement is generally interchangeable with the detailed description you plugged into your spreadsheet next to the topic.
The firehouse is a good general place to perform your drills. The parking lot for your personal vehicles, the apparatus bay, lounges, offices, and inside or outside the location will suffice. After all, you routinely encounter patients in all of these locations.
Choose a location for a particular evolution, and place your crew in that remote area with the equipment they would normally remove from the apparatus while you program and place the patient. Brief the crew on the situation they will respond to, and allow them to grab any additional equipment they feel they may require based on the dispatch information you give them. Give the crew a time limit (generally 10 minutes from initial patient contact). The crew responds to the patient location and begins care.
The scenarios must be straightforward to start. You can throw every possible situation at your providers. It’s never a straightforward sick job with stable vital signs where a thorough evaluation and interview lead to an informed diagnosis and treatable situation. Instead, offer an acute pulmonary embolism patient frothing at the mouth and gasping for air or a motor vehicle collision victim who was thrown from the car and now has an open head wound, unequal pupils, a hemopneumothorax, and unstable vitals.
EXPECTED OUTCOME
To determine if any training initiative is effective, you must have quantifiable, expected results. Run crews through several similar evolutions to establish whether they are consistently achieving a minimum standard. Evaluate the students using standard objective patient care criteria. An excellent resource is the practical testing sheets from the National Registry of EMTs or your local regional certification agency. In addition, I prefer to have the crews that are not involved in a particular evolution watch the current scenario. This allows them to observe the performance of the crew in action, critique their peers, and think about what they might have done differently.
I find peer review more valuable than corrections coming solely from the instructor/evaluator. The majority of critique points are typically verbalized by the students’ peers. This leaves the instructor/evaluator room to add additional points or summarize the main learning points of the evolution.
After several varied training sessions, look for patterns and see where improvement is needed. Are you bringing the right equipment in to every call? Are your crews working as a team, interacting with and feeding off each other, or are they islands unto themselves? Are your basic life support providers solid with assisted medication protocols? Are your ALS providers able to properly perform and interpret a 12-lead EKG?
These regularly scheduled drill periods, combined with your formal quality assurance/quality improvement, should paint an accurate picture of the consistency and quality of patient care. When you have achieved this as your standard, it is time to set the bar higher and challenge providers to continue to advance their studies and skills. For agencies that require continuing education credits, the medical community always has some type of continuing education session in progress at regular intervals at various healthcare facilities. Your medical director can serve as a bridge to access this type of valuable training.
Success in the field is a direct result of classroom training and preparation. Basic, regularly scheduled field fire/EMS service training will consistently improve your skills and have a greater positive effect on patient outcomes.
BARRY S. DASKAL is a police officer/aircraft rescue firefighter with the Port Authority of New York and New Jersey Police Department at John F. Kennedy International Airport in New York City. He is also a certified EMT-critical care and clinical lab instructor at the Nassau County (NY) EMS Academy and a member of the Wantagh (NY) Fire Department. He previously served as a police officer with the New York City Police Department and as a supervising fire alarm dispatcher with the Fire Department of New York. He has been a volunteer firefighter since 1990 and has served as a captain and training officer. He is the creator and host of “The Average Joe Firefighter Podcast” on FireEngineering.com.
