COMPETITION
RESCUE/EMS
These two organizations have found that skill contests are an excellent way to motivate higher levels of training. And the positive results are certain to show up in the field.
C.A.E
EMS
The quality of emergency medical care delivered to a patient is directly related to the training and skill of those persons who administer it, and not solely upon the equipment and technology available.
When a paramedic graduates from training he brings certain attitudes, skills and knowledge to the job. But current field performance has shown that basic skills performance deteriorates rapidly. A Texas study of the performance of EMTs and paramedics published in 1980 showed that while the average instructional knowledge loss for both EMTs and paramedics did not exceed over 10 percent over a two-year period, the basic skill loss was staggering-EMTs lost 50 percent of their basic skills and paramedics lost 61 percent of their basic skills over the study period.
The Texas study concludes that the retention of skills and knowledge appeared to be directly related to the frequency of use. And participants in continuing education programs experienced an 11 percent greater retention average for skills than those who did not participate in the continuing education program.
If instructors are able to link real events to continuing education then the bridge between training and field performance will have been made.
It is a common error among EMS managers to think that the more cases that an EMT or paramedic sees the greater the experience and knowledge. Frequently, the large number of cases may be basically the same case repeated over and over. In other words, does the person have five years of experience or one year repeated five times?
(See EMS opposite page)
In an attempt to use continuing education to improve field performance, the Florida Chapter of the American College of Emergency Physicians developed the annual Clinical Conference on Pre-Hospital Emergency Medical Care held each July in Orlando, Fla. Over 1000 fire fighters, emergency medical technicians, paramedics and others interested in pre-hospital emergency care have attended last year’s meeting. These attendees are career and volunteer, urban and rural, from all over the United States and Canada and several foreign countries (Venezuela, Bahamas, Jamaica, United Kingdom). The size of the conference mandates that many of the presentations be cognitive (classroom) in format. However, at each of the preceding conferences, the program planning committee took into account the need for practical instruction by providing opportunities for registrants to do hands-on activities such as water rescue courses, automobile extrication courses, trench and ditch collapse courses.
In addition, the afternoon sessions of the conference were divided into smaller sessions to provide the registrants with a smaller instructor/student ratio. These afternoon minilectures and technique sessions also attempt to provide hands-on practical sessions for the attendees.
Continuing education is, for the most part, directed toward the “knowledge” side of the triumverate (knowledge, skills, attitude). Continuing education also tends to be classroom activity, primarily. Ironically, deficiencies in paramedic and EMT performance have only been infrequently shown to be the result of knowledge deficiencies.
Training effective methods have been ranked according to their effectiveness at altering field performance:
- Direct experience
- Contrived experience (programmed patient scenario)
- Audiovisual experience
- Audio presentation
- Visual presentation
- Written presentation
Altering field behavior
The basic problem in both initial training and continuing education is not the simple transmission of information, but in the alteration of field behavior and the achievement of optimal field performance by personnel. Another goal for the training effort is not only education but motivation.
Continued on page 18
In 1978, the National Advanced Life Support Contest was added to the conference in another attempt to link training (in this case a programmed patient scenario) to real events in the field. Observation of field operations graphically demonstrated that single individual competency could often be overshadowed by poor team coordination and team performance. While certification is based on individual skill and knowledge, field operations always involve multiple individuals, with all the problems, and advantages, of team operations.
The problem scenarios for the advanced life support contest are developed by a working group of six paramedics. The problems are then reviewed by another group of emergency physicians and selected field paramedics for completeness and appropriateness to field operations.
Judging criteria
The judging criteria are also developed by the paramedic working group and detail the specific flow of each of the situations in a patient care format. Each of the individual items in the judging criteria are assigned possible points for the importance of the item, along with the difficulty of accomplishment. For example, properly evaluating the unresponsiveness of the patient gets a maximum 20 points, placement of an esophageal airway has a maxium 50 points, EKG interpretation has 100 points, and administering sodium bicarb every 10 minutes in arrest situations has 100 points.
The judges may assign all available points for correct action, or parts of the points for partially correct actions, or none of the points for incorrect action or if the team did not even do the judged task.
Each of the entered teams (there were 22 in the 1982 contest) are judged by teams of three judges: two field paramedics (AHA/ACLS certified) and one emergency physician (usually the medical director of a prehospital ALS system). Each of the judging teams in the past two contests have included out-of-state judges who were paramedic instructors interested in establishing similar contests in their own states.
Since these competitive situations are based upon actual operations in the field, they are representative work samples (job skills tests) and should be adequate evaluators of team performance. Team performance under competitive stress situations demonstrates if the team has cognitive mastery of the essential skills necessary for the management of prehospital advanced life support.
The problems involve all phases of advanced life support: trauma and cardiac, adult and pediatric, and single and multiple patients that could be faced by the EMS team. Each team is instructed to bring all the equipment that they would normally use to manage ALS situations in the field, and the contest furnishes a Lifepac 5 for each of the teams to use. The teams must furnish a fully stocked drug box, IV solutions and administration sets, airway management equipment, MAST counterpressure suits and any other equipment that they normally use in ALS situations.
In order to hold costs down, the teams are encouraged to use drug containers that are out of date or that have been used in training. The drug containers are frequently filled with colored water and placed into the original boxes and taped shut. For the drugs in vial containers, the contest allows small bottles of sterile water to be substituted, since the judges are interested in the dosages used and not if the team can break the drug vials. Each bottle must be labeled as to the drug that it is supposed to contain, and the same vial cannot be used for all drugs. However, most of the competing teams bring outof-date drugs that they have obtained from their drug supply or from one of their local hospitals.
Only peripheral IV techniques have been used in the past since an adequate manikin for central line simulations does not exist. In the past, intracardiac medications/injections have not been allowed by the contest rules, but a review of the rules is currently underway for the 1983 contest.
Airway management
Both esophageal (EOA or EGTA) and endotracheal intubations must be used in the airway management sequence since the judges are interested in evaluating the ability of the team to place both of these essential airway devices. Failure to utilize both of the tubes results in the subtraction of points from the team’s score.
The judges are interested in how well the team functions independently. Therefore, there are no simulated radio or telemetry transmissions used in the contest. Judges are allowed to ask questions of the team before, during and after the management of the situation. In addition, the judges supply the appropriate vital sign information to the teams at appropriate times throughout the situation.
After each of the 22 teams have passed through one of four judging stations (using the same problem and same judging criteria) the top five teams (selected by total accumulated points) are announced and placed through another round of judging with a more complex situation.
In this second round of judging, each team is judged by four paramedics and two emergency physicians. The second problem has had such complicating factors as two patients (one adult and one pediatric), a pediatric cardiac arrest, a trauma arrest, darkness (the room lights are turned out), or an electrocution with wires present.
The results of the second round determine the placement of the top five teams. The first, second and third places receive trophies. These awards are presented during the full session on the second day of the conference in order to provide maximum exposure for the winners and contestant teams.
The winning team is asked to return to the clinical conference the following year to teach an afternoon minilecture entitled How to Efficiently Manage a Cardiac Arrest. This session has proven to be one of the most popular sessions among the afternoon lectures. The advice that the winning team is able to provide can be divided into several categories: teamwork, equipment, scene organization, and clinical competency of the team members.
Practice makes winners
Teamwork can only be accomplished through practice sessions focusing on the specific job activities that must be accomplished and an understanding of the roles of each of the team members. For example. one team member is assigned to manage the airway and monitor the EKG, another team member is assigned to start the IVs and push medications and defibrillate, and the third team member is responsible for setup and supply for the other two members. If the roles are well defined, then the scene organization and teamwork develop rapidly, while equipment organization and clinical competency of the individuals is rehearsed and refined with the practice sessions.
The finalist teams all practiced their scene operations at least one time per week for a minimum of six weeks before the contest. Teams usually arrive the night before the contest and run through several dry-run practice drills the evening before the sessions. The adage that practice makes perfect has been very evident in the winning teams over the length of the contest. A well-coordinated, smoothly operating ALS team is a joy to watch operate. There is little conversation, smooth transitions from phase to phase throughout the situation, quiet consultation between team members for problem solutions, and constant checking on the activities of each other — in other words, a team that is providing the patient with the optimal prospect for survival.
Learning from mistakes
The mistakes that the teams make are not usually major mistakes. For example, the esophageal airway is placed in the airway but poor technique is used and the ventilation rate is missed for too long a period. Or teams placed the paddles of the defibrillator onto the dirt floor, gathering sand and grit into the electrode jelly. Or needles are contaminated and IV lines took too long to tape into place, disrupting the organization and flow of the scene. Other mistakes may be improper hand placement for CPR and failure to call the warning “clear” before defibrillating the patient (resulting in the shocking of one of the team members and his removal from the operation). Sometimes there was no suction done on the airway, little team coordination, hyperextension of the patient’s neck, interruption of CPR for 15+ seconds to watch EKG strip and so on.
These relatively minor operational problems (and many others) can be easily overcome with team practice sessions. None of the teams gave totally incorrect drug dosages, nor defibrillated an alive patient. “Patients” certainly did not survive the efforts of some of the teams, but in those cases the overall team performance was generally at the lower end of the scale. Some teams had outstanding individual team members that were restricted in their function by other less qualified team members. These types of problems are very evident to the judges while they are observing the teams in operation.
It takes teamwork
One strong team member cannot carry the entire team. Recent moves by some fire departments to reduce the manning on ALS units from two paramedics to one paramedic will show up in a lower survival rate of cardiac arrest patients. In a study conducted by the Philadelphia Public Health Department of over 200 cardiac arrest patients, it was shown that when two paramedics were working on the patient, 16 percent of the patients were ultimately discharged from the hospital alive. With only one paramedic and one EMT, none of the patients survived.
The actual judging sessions are just a small part of the real purpose of the contest: to motivate people to increase their personal and team competency through preparation for the contest, and to increase overall system performance through competition between teams and agencies.
We believe that this goal has been partly met in that some teams have reported to the judges that they were not allowed to perform endotracheal intubation until they needed the skill to enter the contest; in that another team that did not do so well in the first contest returned home and used the contest as justification for further in-service education (and returned the next year and placed within the top five finalists); in that observers from one community took the contest idea back and are using it as a goal for the completion of their first paramedic training course (to enter in next year’s contest); and in that another team raised community funds to send them to the contest, which provided their paramedic program with excellent community visibility.
Our goals have been met and we feel certain that competition is a valid method for increasing team performance and improving the prehospital emergency medical care provided to the patient.
