The tension in the air was palpable. The sweat pouring off the participants in this air-conditioned venue revealed the high stakes that surrounded this event. My own anxiety rivaled that of the practitioners around me—so much pressure to judge this right! The mission was to be fair and impartial, to separate and identify the superior-performing teams from this pool of vast experience and talent. This was not my first rodeo: As a 35-year paramedic and now a command physician, I had mentored and tested more than my share of Registry exams, competitions, and general skills verifications. But this was different.
There are many ways to assess medical knowledge and skills. Book knowledge can easily be gauged based on the percentage of correct answers on a written test. This represents a critical part of the evaluation process but has its limitations in the clear reality that we are not all good test takers. Moreover, we have all seen that student with the amazing didactic grade point average who lacks the necessary skill set to translate that book knowledge to success in the street. The best paramedics and practitioners may not score the highest on a multiple-choice exam.
Practical evaluation provides the ability for the evaluator to determine how the provider will function in a dynamic clinical scenario. The complexity of evaluating someone’s practical skills ranges from simple paper-based oral testing to staged events or simulations, which can provide not only variations in clinical parameters but also a sense of realism and urgency as one assesses and treats simulated patients. If done effectively, this sense of realism fully engages providers and allows more accurate evaluation of their clinical skills and scene management, a psychological state known as the suspension of disbelief.
When I achieved paramedic certification, the best we could hope for was a CPR manikin and perhaps an intubation head. Today’s simulation manikins provide a level of complexity that allows the practitioner to perform advanced procedures ranging from intubation and defibrillation to needle decompression. As a medical director for several paramedic schools and an instructor who in the past had access to sophisticated simulation labs, I had become convinced this was the gold standard. It was my time at the EMS World Expo Clinical Challenge last year in Las Vegas that opened my eyes to what might be a better way to train and evaluate medical practitioners.
A Newfound Respect
My first experience utilizing live patients was with the ski patrol. We typically conducted training and testing in the snow. It never seemed practical to haul a manikin up the chair lift. We would often use patrol candidates with simulated injuries to practice immobilization and extrication techniques so as to better prepare for the actual injured skiing public.
What iSimulate brought to Las Vegas at the EMS World Expo Clinical Challenge was an absolute game changer. It’s certainly altered my view on the art of simulation and testing. Our team of evaluators consisted of seasoned educators with a common focus on clinical excellence and, hopefully, the vision to push the edges of the boxes traditionally identified as prehospital care. One could not ask for superior equipment or better support. The centerpiece of each station was the ALSi simulated cardiac monitor. This device provided real-time vital signs and rhythms, with the capability to allow participants to intervene with electrical therapy as needed. It served as a fully functioning monitor/defibrillator and alternatively as an AED.
The flow of the scenarios was dynamic, consistent, and seamless as the evaluator was effortlessly able to transition through the deterioration and improvement of the patient’s condition. The intuitive iPad-based facilitator made this simple, even to a non-tech-savvy physician such as myself. Our mock patients were paramedic students from the local training academy and acted through their assigned roles with Academy Award-level excellence, fully committed to the suspension of disbelief. After the event several students shared that working in this venue provided them not only a unique educational experience but also a newfound respect for the patient-provider relationship. Beyond just the moulage of our simulated patients, the environment was filled with props that provided not only realism to the scenarios but also replicated the real-life obstacles so prevalent in prehospital care. No detail was overlooked, from the blood-splattered walls and pumping wounds to the high-tech IV arm simulators that allowed participants to establish intravenous access.
The stakes were high: First prize was an all-expense-paid trip to the EMS2018 conference in Copenhagen for the team winning each track. To keep the playing field level, we ran both ALS and BLS competitions. Second prize was top-of-the-line iPads. The teams ranged from high-volume, big-city metropolitan services to rural crews whose average day includes 90-minute transport times. Both coasts were in attendance, as well as crews from multiple countries. The unifying thread was that each team operated with the obvious synchronization of a well-oiled machine. These team members knew each other and communicated with a precision that could only be born from a thousand shared patient encounters. It was to be a three-day event, single elimination, with the top teams advancing to the finals on the last day.
Our opening scenario for the BLS providers was an unresponsive overdose. The patient had not been seen in 14 hours. They were found in a mock bathroom on a cold concrete floor. Our role-player was moulaged to be extremely pale and near-apneic. Their pupils were pinpoint and they were unstable, with a GCS of 3, and hypotensive, with a heart rate in the 40s. To add to the complexity, the patient had managed to place a fentanyl patch in an inconspicuous place. The task was to provide appropriate BLS care with recognition of impending circulatory collapse. The patient needed aggressive respiratory support, naloxone, and treatment for hypothermia.
The ALS providers were faced with a similar scenario with a significant added twist: Their patient had their legs folded beneath them for 14 hours due to the overdose and loss of consciousness. With administration of the naloxone, it was found that, upon release from the presenting position, the patient had bilateral lower leg compartment syndrome with resulting hyperkalemia. This included signs of shock and EKG findings consistent with hyperkalemia: peaked T-waves and widening QRS complexes. The successful competitors resuscitated the patient and provided lifesaving treatment for the hyperkalemia that consisted of calcium and sodium bicarbonate.
Our paramedic students really fell into their roles. Superb actors to the end, they responded to the appropriate therapies and displayed the right level of discomfort in the case of the ALS scenarios. No manikin can simulate the realism a medical-savvy role-player can provide. Consistency between testing stations was maintained by a physician/paramedic educator team that randomly rotated from one identically staged room to the next. A standardized medical case, oxygen equipment, and ALSi monitor were made available to each crew, with time to explore the bags to gain familiarity.
The teams performed very well in the opening round. They were obviously all experienced and moved rapidly to treat the overdose and resuscitate the patient. Finding the fentanyl patch, treating the hypothermia, and recognizing the hyperkalemia from the compartment syndrome, however, proved to be challenging. The teams that successfully conquered all these challenges were invited to the finals.
On to the Finals
The quality of the competitors made it clear that the final round needed to create an extreme challenge to identify the winning teams. We accomplished this by doubling down on the patient load. It’s important to note the teams were limited to two participants; we entered the final day with the intention of taxing this resource to the maximum.
Both ALS and BLS teams faced multiple patients with little to no bystander support. Our BLS providers entered a classroom complete with traditional student and teacher desks. One student had stabbed a classmate in the groin. The assailant was in police custody, handcuffed on the other side of the room. The arresting officer, played by one of the evaluators, was less than helpful, declining to assist the competitors in any way. The victim had an obvious arterial puncture with simulated pulsating blood and unstable vital signs. The team had less than four minutes to control the hemorrhage, or the patient would rapidly deteriorate and become unresponsive. This was a high-extremity penetrating wound, and the injury pattern was designed to ensure direct pressure or tourniquet application would be ineffective, meaning each team member would have to manage a patient on their own. Competitors needed to emergently pack the simulated wound to achieve adequate patient stabilization. In addition, a second patient, the assailant, was actually a diabetic with a rapidly plunging glucose level. He was, strategically, too altered to provide any useful medical history. The scenario was designed so he would rapidly deteriorate from confused to unresponsive with snoring respirations if a blood glucose check was not performed and oral glucose administered.
Our ALS teams were given an equally challenging task: Their assault took place in a courtroom complete with a judge’s bench and prosecutor/defense desks. The bleeding victim had the same issues and need for aggressive bleeding control utilizing appropriate wound packing. The assailant, however, was being restrained by court officers in a clear state of excited delirium that rapidly deteriorated into a ventricular tachycardia with pulses. As a group we decided this arrhythmia would prove refractory to cardioversion (as is common in excited delirium) and instead would require pharmacologic intervention consisting of lidocaine or amiodarone administration. If treatment were delayed, the patient would deteriorate into full arrest and not respond to resuscitation efforts. As with the BLS scenario, court officers were not able to assist the team, fully stretching the capabilities of the two providers.
Ultimately our winning teams identified, addressed, and managed all issues with the limited resources provided—a truly commendable feat that showed their superior clinical knowledge, critical thinking skills, and communication ability. The winners were the University of Missouri Staff for Life Helicopter Service (ALS), with team members Kristopher Thompson and Jordan Horner, and New York’s West Valley Hose Company (BLS), with team members Heather Lafferty and Shawn Lafferty.
I left Las Vegas exhausted from three long days of competition but filled with a new vigor and interest in EMS education. I had learned as much as I’d taught. I had always considered myself a progressive medical director and prehospital instructor, but now I was faced with the challenge of implementing all I’d learned.
In my view, the ALSi monitor, coupled with an experienced user and the ability to address dynamic clinical scenarios, is the next generation of medical education. Use of a motivated, medically aware victim allowed a level of realism that would be virtually impossible to duplicate with a manikin. Although it is probably not likely that my teaching venues could provide mock courtrooms, it became clear to me that recreating a simulated environment, including all the challenges that exist in the austere arenas of prehospital medicine, is the optimal way to train and evaluate prehospital providers.
In subsequent months I have been able to incorporate the ALSi monitor into simulated training and testing with many paramedic students. It has proven to be a great education and evaluation tool. I look forward to continuing training initiatives in the coming years and would be privileged to work again with the educational team that came together in Las Vegas.
Ben Usatch, MD, FAAEM, NREMT-P, is a graduate of Jefferson Medical College. He completed a residency in the Drexel/MCP emergency medicine program and currently serves as an attending physician and deputy department director, working as a part of the Main Line Health System in the Lankenau Hospital emergency department, Wynnewood, Pa. He has worked in EMS for 35 years and currently serves as the Montgomery County regional medical director as well as the medical director for Narberth Ambulance, AMR Ambulance, Boothwyn Fire Company, the Montgomery County Training Institute, and the AllState Paramedic Training Institute.