Remaking the Recert
I renew my paramedic certification every three years and my National Registry every two. In four out of every six years, I must complete some form of recertification process, and over a 35-year career, I will do that 23 times. The process and refresher course content have not substantially changed since the beginning.
How can my recertification/reregistration be more efficient, challenging and customized to what I need? How can it better prepare me to do my job and help raise my standard of care without simply increasing classroom hours? And why do I have to complete it away from home or work, on someone else's schedule? The computer may answer all these concerns, and perhaps allow educators to achieve greater levels of objective, competency-based education.
THE PROBLEM, THE SOLUTION
To ensure EMS providers are minimally competent, certification bodies like the NREMT and state EMS offices are forced into the current continuing education design. That design must be reasonable for attendees and cost-effective for course sponsors. Hour and curriculum requirements are based on the minimum time and content it takes to bring the poorest practitioners to competency. The rest of us are along for the ride. The resulting traditional recertification regimen condemns us to attend, en masse, regurgitations of the most basic material to simply assure we leave with minimum required knowledge and skills. This occurs regardless of our assessment, medical emergency, trauma and special-patient knowledge. Certification and registration bodies have lacked other ways to assure the public that refresher graduates have the knowledge they require-those minimum competencies.
A better solution may be found at your keyboard. The computer has tremendous energy to work for us, at our convenience. The power of computer-enhanced education was best described 25 years ago by educator B.F. Skinner when he predicted, "Classrooms seen to be filled with computers which would act as infinitely patient tutors, scrupulous examiners, and tireless schedulers of instruction." They go relentlessly about assigned tasks with unfailing patience and uncompromising adherence to defined standards. And they are available for individual use whenever and, for the most part, wherever they're needed.
COMPUTER-ENHANCED EDUCATION
Computer-enhanced education (CEE) uses computers' computer-enhanced educations to improve the educational experience. The most basic of these computer-enhanced educations are computer-based evaluation, enhanced electronic textbooks and computer-based patient care simulation. Integrated into learning systems, these components can change the face of recertification. An example of this computer-based recertification might measure your initial knowledge and identify your strengths and weaknesses. With this information, it constructs and presents an educational program to address your specific needs, both absolute (not meeting a competency) and relative (competent but weaker performance). CEE then rehearses your knowledge and judgment on simulated patients. Finally, it remeasures your competencies and, if indicated, remediates and retests you. In the time you'd spend before an instructor (with 20 other refresher students), you receive an individual educational experience that assures you acquire the knowledge necessary to provide good emergency care.
COMPUTER-BASED EVALUATION
You sit at your laptop, open your refresher program and begin with a test. The computer asks you questions regarding the essentials of emergency care. As you answer correctly, you advance to the finer points of prehospital practice. Your answers define where you demonstrate mastery, where you demonstrate competency but not strength, and where you just don't know all you should. After you move through the elements of EMS content-the EMS system, anatomy and physiology, assessment, medical emergencies, trauma emergencies, special patients and EMS operations-the computer analyzes your responses and formulates an educational experience for you. That program ensures you meet all the competencies of an EMS provider (and those established by your certification/registration body). It also provides information to address your weaknesses and may provide elective enhancements to help you grow professionally or investigate areas of interest.
The National Registry has already moved in this direction: It recently began computer-based testing for initial registration. What it's using is not the traditional 200-question exam it's given for the last 30 years. The Registry has engaged the computer's power to more efficiently evaluate students' knowledge base. If you initially answer questions correctly, the testing program increases question difficulty. If you continue to answer correctly, the exam process quickly recognizes you meet minimum competency, and the test ends. If you don't answer correctly, the questions become easier. If you still have difficulty, the test continues questioning only until it is clear you cannot demonstrate competency. If your knowledge is close to the competency level, the computer-based testing asks questions until it's sure you either meet the competency or don't. This type of evaluation, called computer adaptive testing, can use the fewest number of questions with great accuracy to ensure you have required knowledge.
ENHANCED ELECTRONIC TEXTBOOKS
Now with a template of your knowledge needs, the computer goes about presenting an educational program. The basis for this is simply an electronic page-turner with the contents of a complete textbook. You can move through the pages by turning them like the traditional text or scrolling continuously as if on one long page. You might also choose to have the computer read the chapter aloud. However, the electronic medium adjusts the content to meet your individual needs. Instead of being segregated into full chapters, the content is broken into smaller educational bites, generally objectives. Where you're weak, you get the content you need. Are you weak in airway anatomy, airway physiology, airway pathophysiology, airway assessment, airway adjuncts or airway care? You don't review the entire airway chapter, just areas that address your weaknesses. After reading the material, you answer questions, demonstrate competency and move on.
However, the computer resident "textbook" can present information much differently than the paper one you carried to class each week. It can provide material in many more ways. Instead of trying to find the right words to describe stridor, the computer plays audio examples of the respiratory sound. It can show you the aggressive pulsing of arterial bleeding on video rather than just by static drawing of a stream of very red blood rising from a sketch of a wound. The computer can show a video of traction splint application rather than a "scan sheet" with six images that "explain" the two-minute technique.
But the real teaching power comes from animations and simulations. Animations simply present a stream of events. You can slow or accelerate them to better demonstrate a process but do not otherwise provide input. An example might be the injury process involved in a frontal auto impact (in order, vehicle, body, organ and secondary impacts). You can show it in real time or various degrees of slow motion. Simulations are animations that let you adjust event elements to change the outcome. An example might be a pumping heart where you adjust the stroke volume and/or heart rate to alter cardiac output (then maybe add arteriole constriction to affect diastolic and systolic blood pressure).
The computer can also rehearse elements of prehospital practice that are hard to remember. These include things like the steps of scene size-up, primary assessment, secondary assessment and reassessment; elements of past medical history and the verbal chief complaint investigation; the Glasgow Coma Scale, revised trauma score and rule of nines. The computer can exercise your knowledge of prehospital medications (dose, route, rate of administration, indications, contraindications, side effects), dysrhythmia recognition and care protocols such as those for cardiac, trauma and medical patients. Again, it can test until you demonstrate a defined performance threshold.
Another benefit of the computer-powered textbook is its ability to branch. With a standard text, you move linearly (page by page) through the content. The computer-enhanced text permits you to jump around without stopping to change chapters (or even noticing the movement). Suppose you're a bit weak regarding the structure and function of the heart and blood vessels as you begin to study shock. The enhanced electronic text can automatically take you to the anatomy and physiology chapter to review the cardiovascular system. The enhanced text can also present the same material at different levels. If you're having trouble understanding a concept, it can present it in a very basic way. If you understand it well, it can provide a more intensive review, and if you wish to go beyond the basics, you can access enriched material.
The National EMS Education Standards, which are replacing the National Standard Curricula, are moving us toward alternative ways of prehospital education. Their preface says, "Although educational programs must adhere to the Standards, their format will allow for diverse implementation methods to meet local needs and evolving educational practices." Clearly the leaders in EMS education are opening the door for new approaches to education and recertification.
Some 20 years ago, original research published in the Annals of Emergency Medicine described a multisite study involving 111 paramedic continuing education students. It compared video, lecture and computer-based continuing education classes provided at 12 sites, randomly assigned. The computer presentation was a rudimentary page-turner with integrated questions. If the student answered incorrectly, they would return to the highlighted source content. This research demonstrated significantly better student performance from the computer-based educational method immediately after method completion and at 60 days.
COMPUTER-BASED PATIENT CARE SIMULATION
The real gem of computer-enhanced education is the computer-driven patient simulation. This presents simulated patients and requires you to assess, diagnose, manage and document as you would during a real response. At the simulation's conclusion it evaluates your performance, suggests ways to improve your care and may even direct you to remediation. This process can rehearse judgment skills as no classroom could. For example, you care for a hemorrhaging patient whose presentation (signs and symptoms) is driven by a physiologic shock model (the simulation responds to blood loss like a real patient). If you stop external hemorrhage and infuse fluids quickly, the patient's condition does not deteriorate as rapidly as if you delay your care. If you do not transport the patient quickly, his or her condition suffers. Other scenarios might include a developing tension pneumothorax that quickly compromises the patient, but selecting pleural decompression results in immediate improvement. The cardiac patient may display with chest pain and frequent PVCs. If oxygen and nitroglycerin are withheld, the patient goes into ventricular tachycardia, then fibrillation. These conditions are corrected with rapid defibrillation and medication interventions, if provided to ACLS standards. In other words, you can practice your clinical judgment on numerous simulated patients before you're presented with a real one.
RECERTIFICATION/REREGISTRATION
If, by the refresher program's conclusion, you demonstrate competency in all required areas, the program prints a certificate. You can send this to your state EMS office or the National Registry to verify your performance. If you do not demonstrate competency, you may retest until you achieve it. The outcome certificate may include such things as the time you spent, your performance on hundreds of objectives, and your scores in various categories. With wider acceptance of computer-enhanced education, this material may be sent electronically, easing the process of recertification/reregistration. You then simply provide confirmation of psychomotor skill competency and any other special continuing education requirements.
In addition to the facets of computer-enhanced education listed above, computers will perform such tasks as EMS call tracking and identifying times when our experience might merit less or more skills maintenance. For example, say your system uses a computer-based patient care report program with report analysis reviewing skills practiced in the field. It identifies that you've not intubated a patient in nine months, so you're called in to practice and demonstrate your airway skills. If, however, you've successfully placed three endotracheal tubes in the last 30 days, you get a bye.
CONCLUSION
Today there are no integrated recertification tools like what is described here. However, many EMS publishers and software companies have or are working on components needed to create such a tool. It is up to us, the consumers, to let them know the value of such recertification tools and our desire to use them.
With such tools, future recertifications can be more efficient, challenging and personalized. We can be better prepared to do our jobs and raise our standard of care without simply increasing our hours of attendance. And we can complete recertification at home or work, on our own schedules. With computer-enhanced education we can harness the computer's power to more easily become better EMS practitioners.
Virtual Encounters
Mosby has produced a CD-ROM-based patient care simulation called Virtual Patient Encounters. It presents audio and video clips describing 15 different medical and trauma patients from age five months to 65 years. For each it provides a scene overview and the initial information gained during primary assessment. You then have menu options to conduct further assessment and provide interventions. To assist your care, the program has intrinsic medication and protocol guides. All actions are recorded for review at the simulation's conclusion. Through this simulation, you can practice assessment and care on realistic patients at your keyboard and review the steps you took when you're done.
Robert S. Porter, MA, EMT-P, has been an EMS educator for 35 years and is currently the senior ALS educator for Madison County EMS in New York. He was the NAEMT's representative to the 1985 DOT EMT-Basic curriculum revision team and is a coauthor of the Paramedic Care line for Brady Publishing.
