"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.

My colleague's experience made me, as an educator, sit back and revisit the issue of using students as patients. In my program, we frequently have students perform skills and assessments on each other (none, however, as personal as a breast exam). They do EKGs (but only on male students), IVs, spinal immobilization and vital signs, just to name a few. Using students as patients is cost-effective and can be a useful learning experience, but must be done with sensitivity and limitations.

Actors

Another option is to hire outside people to act as patients. We tried this in our program with students from the Performing Arts department. The actors were briefed about what to expect. We always made sure nothing was done to invade their privacy or offend their modesty. So far, this has worked well for us. The Performing Arts students are great at acting out patient scenarios, and our EMS students have the benefit of practicing assessments and skills on real "patients." Another benefit is that since these are not medical people, they grow suspicious of strange equipment they have never seen before, just like real patients in the field. This forces students to take the time to explain exactly what they are doing, like they will need to in the field. Actors may be most useful when students have become competent with skills and need a more realistic learning experience. This realism is especially useful late in the program to challenge students with scenario-based learning.

As actors usually have no medical training, they must be extensively briefed as to how to portray a patient with an illness or injury. They also must be educated about how to react to different treatments. This time-consuming preparation has been our biggest limitation to using actors as patients. However, overall it has been a great educational tool and well worth the time and cost.

Real Patients

Another common practice is to have students practice on real patients, either in the field or in the hospital setting.

I remember my first cardiac arrest as a paramedic student. It was at a wedding reception; one of the family members collapsed. I remember running the arrest with a circle of bystanders that included the bride and groom and the entire family watching. As nervous as I was, the call went smoothly. The pressure I felt simply could not be simulated in a classroom with my classmates and instructor watching.

In my program, our paramedic students do about 900 hours of clinical time in which they're exposed to actual patients. They spend time intubating patients in an operating room. They are in the labor and delivery unit, assisting with delivering newborns. They are on the ambulance, taking care of patients in the field. They participate in group therapy during their psychiatric rotations. They work in the emergency department alongside physicians and nurses. The benefits are enormous: Students get to practice in a realistic environment where they encounter a variety of patients and perform assessments and skills under the watchful eye of their preceptors.

However, there are drawbacks. Patients are subject to having skills performed by an inexperienced provider. How many times have we sat and watched a student fish for the IV we could easily do? How many awkward assessments have we watched from students who are not yet comfortable talking to patients? And for the field or clinical preceptor, this certainly is a strain. In medicine there's a saying: "Show me a student who only triples my work, and I'll kiss their feet." Having a student slows us down and makes more work. However, the benefits to the student's education, and the future of our profession, make this a worthwhile endeavor.

Conclusion

A sound educational program uses a variety of methods to teach students. Ideally, a program should integrate all the different modalities of teaching skills: using manikins, students and actors as patients. EMS education also needs to include real patients in the field and hospital environments under the oversight of a preceptor. By integrating these methods, we can provide a good educational experience for our students as they develop into prehospital care providers.