February 9, 2012

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Do as I say, not as I do

February 25, 2010 By 5 Comments

I was teaching a CPR class a couple days ago to a group of EMT students. While I was explaining the 30 compressions to 2 breaths ratio, a student raised her hand and asked me if I actually count or even follow the AHA guidelines when working in the field. Believe it or not, this is the first time any student ever asked me that. I was honest and told the group that I do not always follow compression ratios. As a matter of fact, I probably never do. As you can imagine, the class was full of comments and questions after that answer.

Of course, I explained the science behind the AHA guidelines and why they recommend fast and hard compressions. The hard part was explaining why me and most of my coworkers don’t follow them. Being a paramedic, It’s easy to explain that my focus is around ALS interventions. Being that I have plenty of BLS providers on scene with me, I don’t typically have to worry about doing CPR. However there isn’t really a good excuse as to the large number of EMS providers that just “pump and blow”. It kind of makes me wonder how much of the Heart Associations studies actually included pre-hospital cases. More importantly, it makes me wonder if it really makes a difference.

….which brings me to my next point.

It seems like every time I teach a class, whether it be CPR or an EMT class, I always find myself having the “when you get into the field” talk. There seems to be this big separation of what you learn in the classroom and what you learn on the streets. I get that there are many things that experience teaches you that a textbook just cant. But why can’t our education be more realistic? It almost seems that we do everything BUT prepare our EMT and Paramedic students for real life scenarios.

We don’t tell people in CPR classes that bagging patients for any period of time usually leads to abdominal distention and regurgitation. Sure if you “properly ventilate”, that shouldn’t happen. But throw in the “bouncing ambulance” factor and the “2 people trying to do five things” factor and you got yourself a gurney caked with used hot dogs.

We don’t seem to tell our paramedic students that Mr. Homeless on 4th street only calls 911 complaining of chest pain because he knows you will give him Morphine, a bed and a hot meal. Is it that the people writing the books are so far disconnected from pre-hospital medicine? Or do we just think it’s too “politically incorrect” to tell our students that our patients lie to us?

All I’m trying to say is that we as EMS educators and providers need to put more emphasis on teaching our students the reality of working in this field. I would like to see us try and close this gap between classroom and field learning.

Anyone beg to differ?


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  • http://twitter.com/Jeramedic Jeremiah Bush

    I don’t believe there is that big of a discontent between the education system and the field. At least not as the curriculum is concerned. We have what “on paper” is a standard of education, yet each school and instructor has their own way of teaching it (or not) and that is a disconnect.
    The issue is that life is not text book. To teach someone the basics of high level clinical medicine in a unpredictable way in order to model a real world patient presentation would be even more confusing then the current model. You still need to learn “crushing chest pain 9/10 radiating to left arm” before you can appreciate “grandpa doesn’t feel well today.” and understand they are both a potential MI. Also there needs to be a standard of testing. And teaching a student to do step A,then B, then C to pass a test in some ways makes sense. It’s easy to teach, remember, and test. But here is the disconnect, as much as we are taught A,B,C, I don’t believe (and perhaps I only speak for myself) think A,B,C. We ( I ) think Z. We are goal focused. “In the next 15min I want X,Y,and Z. I don’t really care how I get there, but I what Z.”

    Of course there are many things that must be done first and ” by the book” , like scene safety, airway, thorough assessments and so on. But as long as we treat appropriately and effectively, does it mater that you did 23:2 compressions? Or you did one intervention over another based on your clinical judgment and not the algorithm? That is what separates a “cook book medic” from a thinking medic. And perhaps that is how we should be teaching and testing.

  • http://twitter.com/Jeramedic Jeremiah Bush

    I don't believe there is that big of a discontent between the education system and the field. At least not as the curriculum is concerned. We have what “on paper” is a standard of education, yet each school and instructor has their own way of teaching it (or not) and that is a disconnect. The issue is that life is not text book. To teach someone the basics of high level clinical medicine in a unpredictable way in order to model a real world patient presentation would be even more confusing then the current model. You still need to learn “crushing chest pain 9/10 radiating to left arm” before you can appreciate “grandpa doesn't feel well today.” and understand they are both a potential MI. Also there needs to be a standard of testing. And teaching a student to do step A,then B, then C to pass a test in some ways makes sense. It's easy to teach, remember, and test. But here is the disconnect, as much as we are taught A,B,C, I don't believe (and perhaps I only speak for myself) think A,B,C. We ( I ) think Z. We are goal focused. “In the next 15min I want X,Y,and Z. I don't really care how I get there, but I what Z.” Of course there are many things that must be done first and ” by the book” , like scene safety, airway, thorough assessments and so on. But as long as we treat appropriately and effectively, does it mater that you did 23:2 compressions? Or you did one intervention over another based on your clinical judgment and not the algorithm? That is what separates a “cook book medic” from a thinking medic. And perhaps that is how we should be teaching and testing.

  • http://twitter.com/Jeramedic Jeremiah Bush

    I don't believe there is that big of a discontent between the education system and the field. At least not as the curriculum is concerned. We have what “on paper” is a standard of education, yet each school and instructor has their own way of teaching it (or not) and that is a disconnect. The issue is that life is not text book. To teach someone the basics of high level clinical medicine in a unpredictable way in order to model a real world patient presentation would be even more confusing then the current model. You still need to learn “crushing chest pain 9/10 radiating to left arm” before you can appreciate “grandpa doesn't feel well today.” and understand they are both a potential MI. Also there needs to be a standard of testing. And teaching a student to do step A,then B, then C to pass a test in some ways makes sense. It's easy to teach, remember, and test. But here is the disconnect, as much as we are taught A,B,C, I don't believe (and perhaps I only speak for myself) think A,B,C. We ( I ) think Z. We are goal focused. “In the next 15min I want X,Y,and Z. I don't really care how I get there, but I what Z.” Of course there are many things that must be done first and ” by the book” , like scene safety, airway, thorough assessments and so on. But as long as we treat appropriately and effectively, does it mater that you did 23:2 compressions? Or you did one intervention over another based on your clinical judgment and not the algorithm? That is what separates a “cook book medic” from a thinking medic. And perhaps that is how we should be teaching and testing.

  • Anonymous

    I strongly agree with your post, and the fact that the class room and the field are two different battle grounds. Teaching new providers the the AHA standard is more of a foundation. Once these people enter the field and relize how chaotic it gets on scene during a cardiac arrest they will relize what you mean. 98% of the time family is flipping out the new and inexperianced providers are fumbling with equipment and trying to provide the best care. And at times being the only paramedic on scene your last concerns and thoughts are if CPR is being provided at the right ratio and rate. I believe that time will teach these new provider the key concept is early perfusion (CPR). It is not the ratio that saves people but the perfusion to vital organs. Yes ventilations takes a role as well, however studies have showen it’s compressions that save lives. Long story short time will answer those questions for new providers, and they will relize all those instructions were just a foundation for a building block.

  • rescuejunky

    I strongly agree with your post, and the fact that the class room and the field are two different battle grounds. Teaching new providers the the AHA standard is more of a foundation. Once these people enter the field and relize how chaotic it gets on scene during a cardiac arrest they will relize what you mean. 98% of the time family is flipping out the new and inexperianced providers are fumbling with equipment and trying to provide the best care. And at times being the only paramedic on scene your last concerns and thoughts are if CPR is being provided at the right ratio and rate. I believe that time will teach these new provider the key concept is early perfusion (CPR). It is not the ratio that saves people but the perfusion to vital organs. Yes ventilations takes a role as well, however studies have showen it's compressions that save lives. Long story short time will answer those questions for new providers, and they will relize all those instructions were just a foundation for a building block.