This Is a Test

      I hate taking tests. I'm using the word hate because dislike isn't strong enough. I dislike snow, cold soup, movies with subtitles, and teams who beat the Red Sox, but I don't hate them (well, maybe the Yankees a little bit). None of them aggravate me as much as EMS exams. Oral, practical, written--I dread them all. I'm afraid I'll forget the year Napoleon dispatched the first ambulance, or I won't verbalize donning a full body condom to treat a spider bite. My memory's not what it used to be. I still can't believe I learned New York City's protocols before I knew a platelet from a placenta. (Memo to NYC*EMS trivia buffs: Remember when Decadron was an option for treating EMD--I mean PEA?)

   I suppose we have it easier than some professions. Bar exams in most states last two days. London taxi drivers are tested on 300 routes covering 25,000 streets. That's roughly four times the combined number of bones, muscles, joints, ligaments and tendons in the human body. Next time I'm in London, I'm doing a ride-along with a cabbie instead of a medic.

   As a student in the early '70s, I had a casual attitude about exams. I was so apathetic, I came this close (picture Mike's thumb and forefinger spread the width of an EpiPen) to spending the last two years of college at the racetrack. I wasn't setting very challenging goals for myself. I'd decided any grade-point average that didn't rule out a cap and gown was acceptable. More than once my pre-med roommates were astonished at my cavalier acceptance of C's and D's. "I passed, didn't I?" was my mantra. I blamed the capitalist, imperialist, military/industrial complex for my indifference. Or maybe it was Woodstock.

   Then, as Dr. Seuss might say, something went bump. I started to take pride in scholarship. I wish I could tell you I awoke one morning with a hunger for knowledge, but I was driven more by competition, and maybe a milliequivalent of resentment. It felt good to do almost as well as those brainiacs with pocket protectors and arthritic personalities. By the end of my senior year, I had accumulated enough A's and B's to graduate cum mediocritas with a 2.8 GPA--sufficient to assure prospective employers I could use a slide rule, at least. I climbed the corporate hierarchy without having to recite scripted industrial scenarios like, "You arrive at the assembly line to find two employees seeking bathroom breaks at the same time..."

   I became exam-averse two decades and four careers later in medic school, on the Thursday before the Tuesday when we were beginning our ALS ambulance rotations in New York City. I had passed that week's written test, and was competing with classmates for slots at practical stations that would certify me as Less Ignorant Than Last Week or relegate me to another round of remediation. My final assignment was to start an IV and a dopamine drip on one of those vinyl arms with veins the size of water mains. I remember narrating my interventions as I'd been taught--confidently and methodically--to my preceptor, Scott, whom I would one day work with. I scarcely noticed the minutes passing. Scott did, perhaps because there were so many of them. At the end of the drill, during which the sun set in more than one time zone, Scott politely informed me that while I had been diligent in performing each step of the scenario, an actual patient would have long since succumbed--to old age, not shock. He did praise my enunciation, however.

   Until then I hadn't failed an EMS exam. I was angry and embarrassed. Scared, too, because I'd just blown the first of only two chances each of us had to pass that station. I wanted to do it again--now--but there would be no retests until the following week. It was a long four days until I demonstrated more timely delivery of emergent medication.

   That experience cemented my austere outlook on test-taking:

   We're only as good as our last performance. Each time we're evaluated is a fresh opportunity to screw up. There's no extra credit for prior achievement. Just because I can intubate a manikin from across the room doesn't mean I know what a pancreas is.

   Evaluating practical exams is a subjective exercise. I was relieved to pass my second IV infusion attempt, but I might not have with a different preceptor. What if the examiner administering my retest counted 40 drops per minute instead of 30, or decided my technique wasn't sufficiently sterile? At what point should instructors derail students' careers by dealing the "automatic failure" card?

   Passing is not enough. Even after overcoming my initial awkwardness at the IV station, I was still uneasy about doing drips in prime time. Written exams were hardly confidence builders, either. Scoring 80 when 75 earned you a card was no reason to celebrate; rather, it was motivation to master the remaining 20%.

   We test the science, not the art. I think most EMS providers would agree they've learned much more in the field than in the classroom. The challenge is how to quantify and evaluate intuition. Should EMS practical exams consist of monitored field exercises rather than contrived scripts?

   Two months after graduation I joined the faculty. It was strange to be on the other side of the desk. I tried to balance students' aspirations and the safety of their future patients. When candidates' failures triggered tears, excuses or pleas for second chances, I was reminded of how harsh the testing environment can be. It's a grueling process for examiners and examinees, with no video replay to validate close calls. I'm sure I didn't always get those right.

   Soon it will be time for me to reestablish my own competence. Let's see, 1973: federal funding of EMS. Or was that the debut of Emergency!?

   Mike Rubin, BS, NREMT-P, is a paramedic at Opryland in Nashville, TN, and a member of EMS Magazine's editorial advisory board. Contact him at mgr22@prodigy.net.