Exposed

The evening of the practical exam came suddenly for the student. The stakes were high: a career-enhancing certification or the shame of public failure. It was time to trust in preparation and the goodwill of the faculty.

Remnants of a summer sunset framed the evaluation site, a firehouse in New York City’s suburbs. The student entered through double glass doors, then climbed a broad staircase to a second-floor auditorium, where two examiners arranged skill-specific clusters of prehospital equipment and engaged in the banter of the already blessed.

Examiner 1 summoned the student to a testing station featuring half a manikin. The task was single-rescuer ventilation with a BVM. A green light on the polyurethane torso would illuminate to confirm adequate chest rise.

Even with the synthetic head tilted to the sniffing position, it was hard to inflate the make-believe lungs. You had to extend the plastic neck beyond what human physiology allowed, assure a seal by clamping the mask to the face with one hand, then squeeze the bag with the other.

The student had trouble getting a steady green light. Examiner 1 said he’d withhold judgment pending further evaluation. The student was grateful to still be in the game.

The next test was in a small room near the top of the stairs. The student entered ahead of Examiner 2, who closed the door and sat in the only chair. Supine on the linoleum floor of the well-lit space was Examiner 1, wearing a t-shirt, gym shorts and sneakers. His eyes were closed. Pretending to be unconscious was part of his job that evening.

The scenario introduced by Examiner 2 was relatively simple: An adult male had fallen off a ladder. The student’s task was to recite, more than demonstrate, how to assess and treat such a patient. Examiner 2 would provide feedback followed by a pass/fail grade.

The student knelt next to Examiner 1, who remained motionless, and parroted the sort of script-driven ABCDE assessment most EMTs knew by heart. Hands-on inspection and palpation were minimal: a pulse check plus discovery of a “painful” rib injury that had been tinted purple. The contrived routine was neither unusual nor terribly intrusive. Its purpose was to see if the student could narrate progressive care of a hypothetical trauma victim.

During dialog between Examiner 2 and the student, the patient’s simulated condition became clearer: responsive to pain, airway patent, breathing unlabored, a strong and regular pulse in the 70s, pain and paradoxical movement noted upon palpation of the left chest. The student announced he’d immobilize the spine, begin positive pressure ventilation, start transport, then expose the patient to check for other injuries. He felt good about his performance. Still on the floor beside Examiner 1, he looked up at Examiner 2 for some signal he’d managed the scenario correctly.

Examiner 2 paused as if waiting for the test to continue. “Well?”

“Well what?” the student asked, hoping whatever he’d forgotten was trivial.

“You said, ‘Expose.’”

The student was puzzled. Yes, he’d verbalized that step—the E in ABCDE. That should have been enough. It had always been enough.

There was an area left to expose. Never in a decade of rescue had the student been prompted to go there.

“You mean…you want me to pull his pants down?”

“That’s part of ‘Expose,’” Examiner 2 replied.

The student eyed Examiner 1, whose breathing had accelerated.

It’s still difficult for the student to process what happened; how easy it had been for a pair of well-known EMS educators to choreograph their gratification while ensuring secrecy and compliance. Their calculus was simple: Not many responders would risk failure by making unprovable accusations of misconduct. Any who did would be marginalized by a system that had already tolerated complaints about Examiner 1.

What if the student had objected to the scenario’s last step? What if he’d decided life could be just as fulfilling with one less patch? Would that have spared other trusting candidates a final exam they’d pass only by enabling predatory behavior?

The student lives with the guilt of the indecisive, the guilt of the submissive. It’s too late for him to do anything about that except offer this advice to other victims:

Tell someone. Face the offenders. Take the consequences now instead of later.

Nashville paramedic Mike Rubin is the author of Life Support, a collection of EMS-oriented essays, and a member of the EMS World Editorial Advisory Board. Contact Mike at mgr22@prodigy.net.