EMS Education in the Age of COVID-19

The COVID-19 pandemic has changed the delivery of education drastically and possibly forever. When schools began shutting down in March to curb the spread of the virus, educators had less than two weeks to convert in-person, interactive curricula into completely virtual, contactless classrooms. Accomplishing this seamlessly was challenging for medical and allied health profession schools, like EMS programs, where patient contact and practicing skills on classmates is an essential component of the training. Yet EMS professionals rose to the occasion. We profile a few of them here.

Rogue Community College, Grants Pass, Ore.

Gary Heigel, paramedic program director and chair of the Emergency Services Department at RCC, says his department is fairly progressive with how it delivers education, with moves in recent years to incorporate recorded lectures and reading assignments at home so class time could be dedicated to interactive activities like practicing psychomotor skills, scenarios, and small-group projects. Still, the switch to fully virtual training was not easy, requiring rethinking how to approach lessons no one in this industry likely ever thought would have to be taught online. It’s especially difficult when people enrolled in EMS programs often prefer hands-on learning methods, according to surveys of Heigel’s paramedic students. 

Rather than force students to work independently in asynchronous courses, classes were held via Zoom to minimize the feeling of disconnect. To ensure students avoided distractions, Heigel said it’s important to set ground rules, like requiring people have their videos on and microphones unmuted to allow for a more natural flow of conversation. Ask students to behave as if in a real classroom—look presentable, have good lighting, be awake, sit upright. Students who don’t have a good Internet connection at home are allowed to use the computer lab at the school. 

Instructors used creative methods to ensure students remained interested: breakout rooms within Zoom followed by debriefs with the whole classroom, videos, sharing screens, and Heigel even rotated through a stack of index cards of students’ names, calling on them to make sure everyone was actively engaged in dialogue. 

Heigel found presenting visuals of clinical scenarios online was quite successful—you can pull up images to simulate the environment, plus all students can clearly see the vitals of an ECG monitor instead of crowding around one device. He also recommends breaking up recorded lectures to 10–15-minute increments, as hourlong videos can be daunting. Pare down the lesson to 3–4 points you want to drive home—be strategic and make them obvious because studies show people typically walk away from lectures remembering only 10% of the content.

Since clinicals were postponed for a few months, Heigel and his colleagues delivered students kits containing stethoscopes, blood pressure cuffs, and bandaging and splinting materials to practice at home, whether on themselves or family members. “If you don’t give students the tools to practice, they’re not going to practice,” says Heigel. Students pay a lab fee the school uses to purchase equipment for the kits. On Zoom they’d practice using equipment to get accustomed to the motions—even if that meant applying a tourniquet to a chair leg. 

While RCC has provided kits for students for years, Heigel took it a step further this year. The school’s manufacturing department created 3D printed models of the trachea so paramedic students could practice cricothyrotomies. He provided a step-by-step video demonstration and then allowed students to practice the procedure as many times as they needed. Once they felt proficient enough, they recorded themselves performing the skill to send in for grading. Whereas previously students might pass a psychomotor skill marginally because they didn’t have any critical fails, this gives them the opportunity to truly develop competency in a skill before being tested on it. Even the grading process is easier for instructors—they just have to review videos rather than spend a whole day running skills stations, saving time and resources by limiting the frequency with which students request to come into the lab to practice with instructors. Heigel plans to develop more comprehensive kits covering about 20 skills.

Case numbers were relatively low in RCC’s area, so students were allowed back in June to complete condensed hands-on clinical labs outdoors at the RCC Fire Science training facility. Students wore masks and were screened each day before being assigned to small groups that rotated through skills stations. They were required to disinfect equipment and surfaces after use before continuing to the next station. Though they were about six weeks behind schedule, all students successfully completed the courses, and the EMT cohort actually had higher than average passing rates. “I’ve got phenomenal instructors who bent over backwards to make this work collegewide,” Heigel says. “We’ve just embraced this.”

Some components of EMS training aren’t as easily simulated outside of the classroom, like practicing patient interviews with family members. Though it’s not the ideal course structure, Heigel believes the EMS community will improve moving forward. “It’s inevitable. We are going to be way better in EMS education and as EMS providers. So many aspects of this are going to raise our game substantially.”

Heigel acknowledges that this rapid change in pace has been difficult even for people like him who like change.

“We as educators are constantly talking about lifelong learning. You have to be ready to do something new and different,” he says. “I would challenge instructors to push yourself to try new things, even if you don’t think they’re going to work very well. It’s OK to fail—that’s how you learn.”

In terms of the EMS mantra of adapting, improvising, and overcoming, he says, “This is a great time to really hammer down that lesson and remind people who forgot how to live that way. It’s a great challenge to a lot of educators to walk the talk. A lot of us were awfully stuck in routine ways of doing things. I hope people are open-minded about the benefits amid all the chaos,” Heigel says. 

Bergen Community College, Paramus, N.J.

Like all other EMS programs, Bergen Community College’s (BCC’s) paramedic science program had to move its didactic lectures to an online, synchronous delivery model while suspending labs and clinical hours. This method was to be continued for the next student cohort beginning in September, but the school is now allowing in-person testing for skills-based competencies. During labs BCC requires students to wear masks, maintain social distancing, and disinfect all materials used. 

In an effort to relieve the burden of the school’s affiliates to provide PPE, Program Director Joanne Piccininni, MBA, NRP, MICP, says students reporting to all clinicals in the hospital and field will use their own, including eye and respiratory protection as well as gowns. “We have integrated these PPE items into all simulation scenarios on campus to have the students ‘train as they fight’ and develop the mental model to be best prepared for the live patient environment,” Piccininni says. 

The program’s instructors, who are active paramedics, were eager to bring their experiences treating COVID-19 patients back to the classroom. “We are training them to operate in the current EMS environment,” says Piccininni. “We are most proud of the faculty’s willingness and ability to shift gears to an all-remote learning environment. The determination to give the students the best education, considering the challenging situation, was the main motivation of our clinical coordinator, Stephanie Niemiec, and myself.”

This shift was one of the toughest challenges at the start of the pandemic, says Piccininni, as it was difficult to keep students engaged and feeling connected despite communicating through screens. “We made the most of every online class meeting. We allowed the students to help drive the direction of the session by contributing to the focus. We also kept to our regularly scheduled meeting days and times for consistency.”

BCC incorporated gamification into its curriculum, such as virtual reality software for patient case scenario presentations, Piccininni says. “This led to an extremely motivated and determined cohort of students that had incredible focus when they were finally allowed to return to campus for lab skills competencies and medical simulation.”

UCLA Center for Prehospital Care, Los Angeles, Calif.

UCLA’s EMS program has implemented the same changes as others have—lectures are online while skills are practiced in person in small groups on the condition students are screened for COVID-19 and wear PPE. Michael Kaduce, NRP, MPS, EMT program director, says one of the innovations born was the encouragement each small group’s morale leader provided to students, particularly with reducing the stress of wearing masks by putting stickers on face shields when a member deserved recognition for accomplishments like earning a perfect score on a skills evaluation. 

Katie O’Connor, NRP, MPP, assistant program director of the center, says the online method shed light on educational opportunities not previously available. “We found moving some of the skills to online sessions allowed us to involve subject matter experts, educators, and simulated patients we wouldn’t have otherwise been able to include in our program,” she says. “I hope to expand on our distance simulation and improve our hybrid education methods.”

With less than one day to remodel its fully in-person training to a remote program, O’Connor says this was possible “through teamwork and sheer determination. We adopted a model of flexibility. Instead of focusing on what we typically do, we focused on what was possible.”

“I am really proud of our staff’s ability to come together, review as many ideas as possible, and develop best practices, asking ourselves, ‘Is that best for the student and their future patients?’,” says Kaduce. “Not only did our staff embrace the opportunity to go online, but our students really trusted us to move forward. We continue to hear from students their appreciation for our ability to make this work so they could get certified and serve their community.”

Kaduce says communication was one of the best methods of overcoming hurdles throughout the pandemic. “We have intentionally overcommunicated with all our students,” including past, present, and future students, regarding each group’s relevant needs. “We moved all our exams to an online proctoring service so we could continue with our high-stakes testing, which we felt was important to prepare students for the National Registry.” 

Instructors urged students and staff to stay home if they contracted COVID-19, assuring they’d work with them to keep them moving through the program. “We recognized students were going through an unprecedented level of stress with the pandemic, which meant we needed to be even more understanding and flexible of the challenges they were facing,” Kaduce says. 

“We also put up an educator resources page on our UCLA website, recognizing there were many programs forced to go online overnight that may not have the resources necessary to do so,” says Kaduce. “We thought it was our part to help, as we’ve been doing online education for years and have many resources. Even before the pandemic our motto has been ‘EMS education is a team sport,’ and the pandemic has demonstrated how we are all on the same team.” 

O’Connor says sharing the load with other EMS educators around the world helped immensely with planning. “By reaching outside our institution, we were able to find creative solutions and actually improve our program. We saw scores on exams increase, students reported increased engagement in scenarios, and they felt their assessment skills increased with the change in platform for patient interviews.”

CAPCE

EMS educators aren’t the only ones who have had to make sweeping changes to their operations—the accrediting body CAPCE (the Commission on Accreditation for Pre-Hospital Continuing Education) had to accommodate for the new way of life too. With site visits for evaluating and renewing agreements with accredited providers no longer an option, these were completed virtually while the site visit deadline was extended by 18 months to allow personnel to return to the office and make necessary arrangements. And because some providers lacked the manpower to meet the June 30 reapplication deadline, CAPCE extended it to the end of 2020. Those who applied by the deadline and met paperwork standards were given provisional accreditation with the condition a site visit be completed within one year. 

“I’m really impressed with the entire EMS community in how we’ve managed to do some really innovative things to continue EMS education programs,” says Jay Scott, executive director of CAPCE. “We’ve always been adaptable. Those innovative approaches should not be put aside when all this is done—we should continue to be as innovative as we can into the future,” which he believes will improve retention and recruitment. “After you’ve made a change like this, I don’t think you can go back to the standards we had before. We’re going to have even more reliance on this virtual world we’ve had to set up because of COVID-19.”

This acclimation supports the trend CAPCE has observed in the gradual move away from self-paced study to online learning, says Scott. He sees the marketplace leaning toward virtual classrooms with live instructors with whom students can interact in real time from their homes. This could be a game-changer for providers in rural areas who need to travel long distances to attend CE courses, which is part of the reason Scott believes this can boost retention rates. 

“I think that’s the way EMS education is going to go. I don’t see it devolving back to where we were even a year ago,” he says. “We’re seeing a growth of people who have been able to recertify—in part that’s due to the altruistic, intrinsic motivation to help that all EMS providers share but also because we’ve made the recertification process easier, and it’s more exciting.” 

That process was developed in partnership with NREMT, and allows providers to instantly import CAPCE courses directly into their NREMT profile, saving time from manual input.

“EMS practitioners are amazingly gifted caregivers, and they give of themselves all the time,” says Scott. “It’s really difficult to ask an individual to stay longer past their shift to do continuing education, so the ability to do that coursework while I’m on my shift on a mobile platform greatly enhances my motivation. It keeps me more engaged in the process if I can learn while I’m working and not have to take time away from my family. That’s what the future should look like.”

Scott says we also must reevaluate the definition of CE: “It shouldn’t be a rehash of what we already know. There should be new information and new material.” For example, Scott’s EMS agency receives multiple chest pain calls per day, so he and his fellow providers have become proficient in treating STEMIs—but he hasn’t delivered a baby in years. Instead of asking these providers to take a class on STEMI treatment, they should focus on skills in which they are less proficient. Says Scott, “Is it really continuing education, or is it continuing competency?

“Unfortunately, COVID-19 has driven change forward for us, but now is the time to take advantage of that. What is the gold standard we’re going to reach for?” says Scott. “My board of directors is very forward-thinking, and they see this evolution as an improvement in the continuing education process. They want to make sure EMS providers have access to excellent education programs that provide innovative learning strategies and keep them working in the field. We desperately appreciate the ability to help and be a part of the larger positive change.”

NREMT

The COVID-19 pandemic was in full swing by March of this year—the same month National Registry providers were due for recertification. With school and testing centers closing, NREMT had to make some unprecedented decisions.

“The coronavirus pandemic hit fast and hard, impacting not only our EMS professionals’ livelihood but also their families and daily lives,” says Bill Seifarth, executive director of NREMT. “The National Registry had to be empathetic and understanding, while at the same time ensuring we could continue to protect the public by keeping a steady stream of certified EMS professionals available.

“The board of directors immediately recognized the importance of ensuring providers could obtain classes for continued competency. That meant waiving distributive education limits—a decision that was made after thoughtful discussion and deliberation,” Seifarth says. This waiver allows NREMT members to fulfill their requirements through any online state-accepted or CAPCE-accredited program for both the 2020 and 2021 recertification cycles. In-person CE is still encouraged if possible.

“Early in the pandemic, we recognized the need for a swift and bold action by way of the provisional certification,” says Seifarth. “It was impossible to know how many people—including frontline EMS professionals—might become ill or would be unavailable for service, and it was paramount we were able to get qualified and competent EMS personnel into our communities.” These provisional certifications were granted to any candidates who had completed an EMR, EMT, AEMT, or paramedic program and passed the computer-based National Registry cognitive examination. 

Within seven weeks NREMT fast-tracked online proctoring for the EMT and AEMT cognitive exams, though this wasn’t slated to begin until 2021–2022, since testing centers had limited appointment availability. “The program has some challenges, but overall it has been highly successful, with about 13,000 examinations given through the end of August 2020,” says Greg Applegate, MD, chief science officer of NREMT. “At the same time, the National Registry worked with government officials and Pearson VUE to keep test centers available for essential medical personnel.”

Though these emergency actions are temporary, the National Registry is considering maintaining online proctoring and other innovative evaluation methods for EMS candidates. “The past few months showed us we can move swiftly in response to the needs of the EMS community without compromising our mission of protecting the public,” Seifarth says.

Valerie Amato, NREMT, holds a B.A. in English and Pre-Law and is currently pursuing a Master of Public Health degree at Temple University. She is a volunteer EMT with the Philadelphia Medical Reserve Corps and Temple University EMS. 

Sidebar: How to Keep the Learning Going 

With COVID-19 causing increases in call volumes, longer call times due to PPE use and decontamination, greater social distancing between crews, and a general avoidance of large indoor groups, agencies have had to think differently about the way training is provided to their teams.

With large face-to-face classes on hold, organizations have shifted a great deal of training online or to hybrid instruction. Online training can be synchronous or asynchronous. Synchronous is when the course is taken in “real time,” with a live instructor, typically on a videoconferencing platform or learning management system. The instructor usually presents live or with the help of a slide deck. Asynchronous is when a course is laid out, typically in a learning management system or learning module, and the student goes through at their own pace, typically reading articles or viewing videos. Both systems have the advantage of convenience—if you have a computer and an Internet connection, you can access the course. The disadvantage is that the student only gains knowledge points and is unable to get hands-on practice. 

Hybrid courses are gaining in popularity. Here, rather than be in a face-to-face class for the entire course, the student gains their knowledge by viewing videos (typically asynchronous) and then having occasional live classes to gain skill practice. These live classes, while representing less time together than a full class, still pose a possible risk, and students should be socially distanced in class and wear appropriate PPE including masks. 

Self-Study

Some agencies are establishing training by setting up self-study modules. These modules can be asynchronous courses, or agencies can make their own. With the latter option learning activities are planned that can include viewing a video, reading an article, and having a piece of sample equipment available the student can hold and practice with. For accountability purposes, students can take videos of themselves practicing the skill and submit it to their training officer or the individual responsible for keeping records. There are many places to get research-based articles or videos for use, including EMS World. 

Limited or Adapted Drills

Some organizations are used to training nights or multiunit drills. With COVID forcing agencies to separate crews or limit contact, drills might be limited to a set of partners or an engine crew. In these cases a supervisor or company officer can lead a drill, preferably outdoors, where the risk of droplet transmission is lower. Participants should still wear masks and PPE, but small-unit drills can be run for skill recurrency, reviewing decontamination procedures, or learning new equipment.

Hot Wash After Calls

The National Center for Homeland Security and Preparedness in upstate New York uses a training practice called “hot wash” in its scenario-based training. In these situations students go through a simulation while being observed by instructors. After the evolution is completed, students are briefly brought together to “hot wash,” or reflect on what went well and what didn’t. Then the instructors review various teaching points related to the scenario. Hot washes are short, no more than 5–10 minutes, and the main purpose is to have students reflect and analyze their actions. Even without a training evolution, partners or a company can use the “hot wash” idea after calls. Sometimes simply thinking about calls and questioning yourself can be as valuable a learning experience as a class.

Final Thoughts

Whether we are paid or volunteer, EMS providers are expected to be professional and should never stop learning. While COVID-19 may have slowed or stopped our traditional way of learning, it is an opportunity to adapt, overcome, and modify the way you train to keep the learning going.

Barry Bachenheimer, EdD, FF/EMT, is a career educator with more than 34 years in EMS and fire suppression.