"Patients" in EMS Education

Early in the semester, my EMT-Basic students participated in a relay race for bonus points on their next exam. Each team was instructed to perform specific skills on a patient before progressing to the next station. First the teams had to perform obstructed-airway techniques, then CPR, airway maneuvers and oxygen administration. In between each station, each team had to move its patient from room to room, sometimes floor to floor. I watched in horror as members of one group became so caught up in placing first that they brutally dropped the patient on his head, then proceeded to carry him roughly up a flight of stairs, almost separating his arm from his torso in the process. Luckily, the "patient" was one of our manikins, not a real person.

The next time my class did this race, we used real people as patients. The students still worked quickly to place first, but this time no patients were dropped. After this experience, we reviewed the use of manikins, students and outside personnel for skill labs.

The Educational Process

EMS education is an intricate process of leading students through classroom training, skill labs and clinical rotations to assist them in becoming certified and delivering patient care in the field. Students may have limited patient-care experience before entering an EMS class. The quality of training will determine the provider's ability to care for patients after graduation. Training should enable students to demonstrate knowledge and skills within a challenging learning environment. To enhance learning, education should be as realistic as possible.

EMS educators are faced with the dilemma of providing the best possible learning opportunities for the varying levels of students in a class. When providing skill training, there are several modalities available. Choices include manikins, using students as patients, hiring outside people to act as patients and using actual patients in the clinical setting. Which of these provides students the best education while remaining legally and ethically sound? Let's take a look at each of these modalities.

Manikins

Manikins are an excellent educational tool because they enable students to practice numerous skills, including intubation, chest decompression, IVs and cricothyrotomy. Manikins can simulate a difficult airway, a choking patient, or let you start intraosseous therapy. They come in various sizes, from neonates through large adults, and allow students to become comfortable performing skills in a non-threatening environment. Manikins are valuable for teaching skills that cannot be practiced on real patients.

However, there are limitations to using manikins for education. Their ability to simulate realistic patient care is limited. Manikins do not simulate provider-patient interaction. There are no consequences for handling manikins roughly. Manikins are excellent for skill practice, especially early in training; however, we need to remember these limitations.

Students

Another common choice is to use students as patients and have them take turns performing skills on each other. This allows students to become used to touching people, while also providing students the opportunity to feel empathy toward patients by teaching what it feels like to be a patient. Think of the look of absolute terror on new EMT students' faces as their classmates carry them down a flight of stairs on a stair chair. The student who has experienced that terror will be more empathetic toward the patients they carry down stairs.

With the use of students, there are ethical and legal issues to consider. Recently, one of my female colleagues, who is in her first year of nursing school, found herself in a predicament. In her nursing class, the students were expected to perform breast exams on each other. Understandably, she was uncomfortable having such a personal exam performed during class by a classmate. She refused, and her nursing school later revisited this practice. The legal ramifications of using students to practice breast exams are huge-in fact, it meets my college's definition of sexual harassment. The ethical ramifications are just as serious; students do not learn if they do not feel safe in the classroom environment. This certainly was an invasion of privacy, and definitely not a sound educational practice.