Grading on the Curve
In college I never fully understood the "bell curve" grading system. I do know that no matter how poorly the best person did they still got an A and no matter how well the worst person did they still got an F. This seemed somehow unfair to me. I always thought and still feel there should be fixed standards. If everyone in the class got between 80 and 88 percent then everyone got a B. At least you knew the standard.
Then there was the topic of the retest. If you failed the first time you could always study some more and take the retest. I have on occasion been forced to use this option.
Lastly there was what I called the PE grading system. In the PE class everyone passed because it was assumed that everyone tried their hardest. I never understood why trying hard in Math didn't count the same as trying hard in PE. In math I tried my hardest and still got C's and D's and in PE I got A's. I tried to show my math teacher the light but he didn't bite. With my PE teacher I left well enough alone lest I should actually be graded on my skill level.
Then, after all my higher education, I got a real job and learned the truth about grading. Life gives you the test on an unannounced schedule and grades strictly on the results of your performance. There is no retest and on occasion the test comes before the subject matter has been presented or studied. There is no professor to appeal to and no certificate of achievement is passed out. The subject of cheating is seldom broached because life's tests are given on an individual basis with no one else around. The grading system is not always fair but it is always final. The paradox is that the outcome is not always relative to your performance.
Our profession in particular passes out unscheduled tests with no guaranteed previous training or learning opportunities. While this is unfair it is however a reality. What's to be done? The answer is training and evaluation. The buzz words are Continuous Quality Improvement, CQI for short. The CQI cycle goes like this. Train- Perform- Evaluate- Adjust/Retrain- Perform- Evaluate- Adjust/Retrain. Let's break this down and look at the individual aspects of CQI.
Training:
Training is the initial phase of any learning experience. It involves the didactic sessions which establish the cognitive framework of our tasks. In this phase we should become intimately familiar with the concepts, precepts and nuances of the subject matter. It also involves practical sessions where in we learn the motor skills which are required to manipulate the patient and equipment during the subject event. Included in this should be plenty of repeated practice sessions designed for true mental and physical mastery of the skill.
Performance:
Performance of the total skill set is the next step in the process. This occurs when a crew is assigned a task / skill set and required to complete it in a set time parameter and an acceptable proficiency level. The Traction splint is a good example of this concept.
Evaluation:
Once the task is completed the instructor evaluates the performance based on the time standard and performance parameters. Any deficiencies noted in the time standard or performance standard indicates a need for an immediate remediation session. In addition the instructor should take the initiative to improve the performance any way possible by giving tips which he has gleaned from his experiences.
Adjust and Retrain:
This is where we work the bugs out of our system and establish and fine tune our individual practices. We retrain until we have consistent high quality efficient operations across the board.
But how do we train for the unscheduled test which so often comes our way in the form of bizarre events or events which are considered low frequency / high risk events.
Let's start by discussing a few realities involved in these tests.
- The "test" almost always involves an entire crew and not an individual. Hence the preparation for these tests must involve training as a crew. (crew based training)
- The answer to the test always involves the full spectrum of our skills. This means we must perform a size up and an assessment, formulate a plan and physically carry out the plan on a real patient. Just talking through a solution won't cut it. The test must be taken as it given with all the intricacies and realities worked through to completion.
- The answers will vary based on the test.
- There is no make-up exam. Pass or fail we (and especially our patients) are stuck with the results.
With this in mind we now have the keys to training for and preparing for the unexpected test. Develop scenarios based events which are unusual or infrequent and which are in and of themselves difficult to resolve. Set the events up in a live format and spring the test on your crew. Require the crew to resolve the event in keeping with best safe practices and protocols. Resolution of the event must include all phases of the event from initial patient contact through transport. This includes performance of all skills to the extent to which they can be performed. For instance, if a traction splint is required for resolution of the event then the crew must apply the splint.
Let's look at an example of a high risk low frequency event. I will use the major motor vehicle accident where in we are tasked with protecting and securing the scene. How do we pull of this type of training?
Start with the setup of the event. Find a location where you can safely set up the event and leave it in place for a while. The back of the station or the city yard are often good locations. Have your local tow company bring in some wrecks and set up the props for your event. Mark out your "intersections" or "traffic lanes" with barrier tape or paint.
Next write up the scenario and what you expect from the crew. In this case I would include the following tasks as bench marks for this event:
- Position the apparatus to establish a physical barrier to protect the scene from the most imminent threat.
- Assure all appropriate traffic safety PPE is worn.
- Have the crew leader size up the event end develop the action plan.
- Have the crew secure the area for the incident. This would include the deployment of barrier tape, traffic cones or strobes to direct traffic around the event.
- Have the crew define the treatment area by locating a safe area for the patients and marking the safe transit route.
Once you have done your preparations it is time to spring this on the crew. Nothing in this scenario goes beyond the basic elements of our individual training. But how often do we actually perform this task as a crew in a realistic fashion. I believe what you will find is initial poor performance not because of poor training but because we have not taken the time to work through the details of the events as we would actually have to perform them. Communications will be weak because we have not actually practiced talking to each other in this setting. Crew members will have trouble finding equipment because they have not actually handled it recently. Crew resource management will be a challenge because we are required to prioritize the tasks and perform them "real time" instead of talking through them as we so often do.
Performance will dramatically improve the second time simply because we have learned from the process of actually taking a "real time test". You can have them take the test until they are proficient. Then change the scenario by remarking the lanes or having them approach from a different direction. Be creative and improvise so you can challenge your crews.
This same prop set up can then be used as a triage / patient movement drill using CPR mannequins or large cones for patients. I once used 28" tall traffic cones as patients. I placed patient information inside the cones for the triage team to access. I painted the tips of some of the cones white to represent ambulatory patients. I required that all 30 of the patients be triaged and transported and that each patient move through each of the designated sectors. I also required that each sector be set up physically using our disaster equipment. "Ambulatory patients" (cones) could be moved by one crew member in groups of five at a time. This simulated the initial phases of the START process. Some of these ambulatory patients were seriously injured and still required triage.
We learned from this the importance of an early command structure which provides an immediate treatment area and at least two members to man it. The non-ambulatory patients had to be moved on back boards with a minimum of two rescuers from the incident scene to treatment and on through the system. This challenged command and caused him to realize what the true manpower requirements would be at a scene like this.
The end result was a very effective mass casualty patient movement drill that did not require the gathering of a large group of patients. It was easily set up and reset as needed. The crews learned how to evaluate the scene and where and how to set up their respective sectors. They learned more effective communications because they were forced to actually go through the organizational process and not just talk about it. Crew organization was challenged by the physical requirement of having to actually move the patients. The transportation sector was challenged because they had to shuffle squads and actually record patient numbers and dispositions. All this learning occurred because we did the drill in real time as a crew.
Another twist in this type of training is to withhold the presence of an ALS provider in the initial phases of the incident. This will force your BLS providers to deal with the initial phases of the incident unassisted. From this they will learn to take initiative when performing their assessment and treatment. When you allow the ALS provider to arrive on the scene have the lead EMT-B give a progress report and hence practice transfer of patient care.
The end result of this realistic and maybe off-the-wall training approach is two- fold: 1. We experience an increase in our ability to think our way through the really tough situations and 2. We have prepared as a crew to react to and overcome these real life tests. Your imagination and commitment to training are really the only limits to how well you prepare your people for the "pop quizzes" which will surely come their way.
Be safe.
Jim
Jim Baird is the Fire Chief for the City of Brunswick Fire Department in Ohio. He is a Certified EMS instructor and also serves as a Certified Fire Instructor for Cuyahoga Community College Fire Training Academy. He is retired from the Mesa Fire Department in Arizona where he served as Firefighter Paramedic/Captain Paramedic for 20 years. He has 29 years of experience in the emergency services. You can contact him via E-mail at JBaird@brunswick.oh.us or Bairds2468@sbcglobal.net.