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THE TRAINING OF PARAMEDICAL PERSONNEL
Br.jf. Anaesth. (1977), 49, 659
THE TRAINING OF PARAMEDICAL PERSONNEL R.
D.
STEWART
RONALD D.
STEWART, B.A., B.SC., M.D., Department of
Emergency Medicine, University of Southern California, School of Medicine, 1200 North State Street, Los Angeles, California 90033, U.S.A.
system to the arrival at a medical facility, and inhospital care—from reception at a medical facility to delivery of the patient to "definitive care" personnel. There are several questions which might be raised about such a concept, particularly in relation to the fact that all patients presenting to a casualty department are not true "life-threatening" emergencies. This would indicate that the care phase in hospital might be brief, and secondary care would be delegated, for example, to the patient's physician or clinic. Let us confine ourselves to the discussion of the pre-hospital care phase, with specific reference to resuscitation of the seriously injured and the personnel involved in their initial care. EMERGENCY MEDICAL SYSTEMS
Only within the last 10 years has much attention been given to care outside the hospital. It has been suggested that some 15% or more of accident victims die at the scene from injuries potentially reversible by properly trained medical personnel (Frey, Huelke and Gikas, 1969). Of the 670 000 deaths in the United States attributed to coronary artery disease, 50-60% occur suddenly outside the hospital setting (fig. 2). Such statistics are all the more alarming because no amount of improvement in staff or facilities within the confines of the hospital will improve these figures. It becomes logical, then, that the medical team extend its facilities and expertise beyond the limits of the hospital environment; that is, into the pre-hospital care setting. This idea of "extension" is not new; in the late 1950's the Soviet Union and the Scandinavians were organizing teams of trained physicians, nurses and technicians to deliver life-support care in the field (Moiseev, 1962). Belfast followed with Dr Frank Pantridge organizing the Mobile Coronary Care Unit from the Royal Victoria Infirmary (Pantridge and Geddes, 1969). Other communities, particularly in the United States, followed with pilot programmes designed to test the hypothesis that provision of proper emergency medical care would significantly improve the lot of the patient in the pre-hospital phase of their illness.
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The concept that the care of a sick or injured person can begin before the patient reaches a medical centre is not new. The history of organizations such as the St John Ambulance and the Red Cross testifies to this. The modern form of "pre-hospital care" began with Napoleon and his generals who developed means of transporting wounded soldiers from the battlefield to dressing stations. These "ambulances volantes"— flying carriages—were horse-drawn vehicles destined to persist as the forerunners of our modern motorized ambulance (McKenny, 1967). Thomas, the British surgeon, demonstrated during the Great War (1914-18) that proper care in the field could preserve life and limb (Rang, 1966). His invention of a wire splint to immobilize a fractured femur is well known to those of us involved in dayto-day emergency care. Within a relatively short period, much attention has been focused on what some have termed "a crisis in health care". Statistics and reports attest to the tragic incidence of accidents and sudden illness on motorways, in homes and at work. All too often, systems of emergency care are found wanting when close scrutiny reveals the quality of medical care delivered to the patient (Benson and Stewart, 1973). Emergency services in the community can be considered to consist of several phases of patient care (Taubenhaus, 1973): Pre-emergency (fig. 1). The phase during which the community is educated and prepared for emergencies which might arise. This would include education in basic first aid procedures, signs and symptoms of life-threatening illness, basic cardiopulmonary resuscitation, how to call up and use intelligently the emergency and rescue services. Emergency extends from the moment the patient is able to gain access to the medical care system to the time when definitive treatment is rendered by those involved in "secondary care". This would include two basic interrelated phases: pre-hospital care—that period of time covering the patient's access to the
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The evolution towards the concept of mobile intensive care units (MICU) has been, in our experience, one of the most significant developments in the field of emergency medical care in many years (fig. 3). In 1969 Los Angeles County, California, established an experimental ("pilot") programme of pre-hospital care delivered by trained technicians ("Paramedics") (Criley, Lewis and Ailshie, 1975). Since that time the County, with a population of about 7 000 000, has expanded its service so that all geographical areas are served by 130 paramedic units. More than 1300 technicians have been trained in the system. Twentysix hospitals throughout the County act as "base stations" within the system, directing the activities of these paramedics and the several hundred thousand calls for aid answered each year. Many different systems have evolved in recent years using various personnel to provide good "onscene" emergency care. Physicians, especially in
rural areas, have often become the "first-responders" (Morris, 1976) (fig. 4). A system using physicians may be appropriate in areas where a large system of technicians could not be economically or politically supported. The author has had the privilege of being part of such a system in a rather remote area of the province of Nova Scotia, Canada, for 2 years. There, first-response to serious illness or accident consisted of an ambulance driver (recruited from the community), the physician and a well-equipped ambulance. In most urban areas, however, the staffing of such units with nurses or physicians has proved largely uneconomical when compared with use of alreadyexisting facilities such as fire or ambulance personnel. In addition, medical personnel may find the practice of on-scene or "field" medicine to be a very different thing from the medicine practised within the secure walls of a hospital or medical clinic (Caroline, 1977).
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FIG. 1. Education of the public in the intelligent use of a pre-hospital care system is essential to its operation. Much of the burden of this responsibility falls on the shoulders of paramedical personnel. (Reproduced by kind permission of Los Angeles Fire Department.)
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FIG. 2. Prompt care delivered to the thousands injured in accidents or struck down with cardiovascular disease may make some impact on the high death rates in these illnesses. (Reproduced by kind permission of Rick McClure.)
One might consider it desirable to provide an emergency response system of which the overall goal is the provision of high quality pre-hospital care with personnel who are specifically trained to deliver such care. Such a philosophy has lead to the creation of mobile intensive care units and the development of a new breed of medical "para-professionals".
What is crucial to the concept of pre-hospital care is the question of the training of personnel. Yet to be agreed upon are very basic questions: the most appropriate personnel to train for such responsibilities, the training curricula and the roles and responsibilities of personnel. Much of what has been written to date represents the opinions and prejudices
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FIG. 3. Mobile Intensive Care Units extend the facilities of the hospital into the community, providing prompt advanced care to patients.
of each author, reflecting experience gained in the particular system with which he or she has been involved. There is a marked variation in the programmes of pre-hospital care offered in urban areas across the United States. Such programmes differ in respect to length of training, content and philosophy of curriculum, and types of personnel manning such
systems. The United States Department of Transportation has addressed the problem of standardization in its curriculum for pre-hospital care programmes developed by the University of Pittsburg and published only recently. The proposed standards suggest different levels of training, based on community need and objectives of the emergency care system.
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Proper pre-hospital care service must begin with decisions regarding the overall philosophy of care and outlining of objectives and responsibilities of the system. PHILOSOPHY
The philosophy of any pre-hospital care system begins with the recognition that this field of medical care is quite unique in many respects. Problems of the environment itself, for example weather, poor lighting, large or hostile crowds, may make even the simplest medical task impossible. In addition, limitations imposed by personnel training and responsibility make the development of clear objectives of prime importance. It has been suggested that the prime goal of any mobile intensive care programme is the stabilization of patients before transport to a medical facility. On close scrutiny, however, this philosophy has serious deficiencies which make it medically unsound. Patients presenting with serious lesions which cannot be reversed in a field setting are best presented promptly to the hospital environment where both equipment and training may afford a greater chance of survival for the patient. Proper pre-hospital care, therefore, depends upon the priorities set by the system and such priorities must be medically, not politically, determined (fig. 5).
The priorities with respect to role and responsibilities of paramedical personnel should include the following: (1) Assessment of a field situation—data collection. (2) Reporting such data by way of radio, telephone or written record. (3) Provision of appropriate medical care to a patient in the field. (4) Facilitating the entry of the patient into the medical care system. THE TRAINING PROGRAMME
A valid programme of training emergency medical personnel will have as its foundation the philosophy and goals discussed above. There are important factors to be considered in guiding such a programme towards the realization of its goals: Composition of the faculty—who teaches ? Length and organization of curriculum—how long to teach? Curriculum content—what to teach. Methods of training—how to teach. Evaluation. The Faculty—who trains ? In the discussion of philosophy and goals of the training programme it is evident that some of the most important responsibilities have been delegated
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FIG. 4. In isolated or rural areas, Physicians can be cast in the role of "first responders" in the event of illness or accident.
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to technicians operating remotely from medical personnel. In view of this, it is essential to ensure that such personnel are exposed as much as possible to practical aspects of patient care. It would seem appropriate, therefore, that such training programmes be designed and directed by physicians who are thoroughly familiar with the treatment of acute illness and injury and attuned to the philosophy of pre-hospital care. In our experience it has not been particularly fruitful to rely totally on physicians from specialties in which they would not be aware of the goals of the training programme. It must be agreed by those who do this training that this particular area is a unique field of endeavour and those who teach in the system must adhere to a common philosophy. If a multidisciplinary approach is applied to training, then each member of the team—nurses, respiratory therapists, etc.—must adhere to specific objectives which must be in tune with the philosophy and concepts of pre-hospital care. Most programmes have nurses as co-ordinators with a medical director who oversees the programme. Didactic classroom instruction is given by nurses and physicians. The ratio varies widely in different programmes. Ideally, physicians involved in the day-today management of emergencies should be the
cornerstone of the educational experience with nursing personnel acting as co-ordinators, and, on occasion, instructors. It is to be hoped that talented, well-trained paramedics who have a wealth of field experience might in the near future constitute the main source of non-physician instructors. Basic to the question of training is where to locate the educational programme: medical school, community hospital, junior college, etc. It is to be stressed that a training programme of this type must be clinically oriented. Theory must be relevant to clinical situations and there must be adequate exposure to bedside encounters with patients. In our experience, a relatively large teaching hospital offers great advantages, particularly if closely associated, geographically and otherwise, with a medical school. Length of curriculum There is much controversy and even greater variation in respect to the time required to train personnel in the management of emergencies outside the hospital environment. There are several reasons for this, including the fact that there is no real agreement on roles and responsibilities of such personnel. In the United States, basic first aid and life support required of ambulance personnel (EMT-I) are taught in a
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FIG. 5. The prime responsibility of the mobile intensive care paramedic is initial assessment and reporting, and prompt therapeutic intervention if appropriate to the field setting.
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relatively standard 80-hour curriculum. Clinical experience in hospital may be added to the didactic instruction. For those personnel with advanced lifesupport responsibilities such as defibrillation, drug administration and radio-telemetric communication, the length of training programmes varies from 150 to 1100 hours. It has been our feeling that a curriculum of at least 1000 hours extended over a period of 5-6 months is minimal when designed to train for the responsibilities delegated to the personnel in the Los Angeles County system.
specific. At this level of training a dogmatic approach to problems may be necessary at first, and accuracy may be sacrificed for simplicity. During phase I, the basic training portion, introduction to the curriculum must include an outline of the scope and philosophy of pre-hospital care. Throughout training the student must be made aware of the limitations imposed on the emergency technician by the level of training, equipment in the field and the environment itself outside the hospital. The philosophy of the programme must be instilled in the student and attitudes reflecting this philosophy should be an object of evaluation throughout the programme of training. Ethical matters and attitudes toward patients are introduced early and illustrated by word and example.
Curriculum content
Training programmes for paramedical personnel must be based on sound, relevant theory of emergency care reinforced with early and frequent clinical exposure. For reasons which are mostly logistic rather than anything else, the programme may be divided into several segments: Phase I—(Didactic) Classroom theory, 2 months. Phase II—Experience in hospital, 1 month. Phase III—Pre-hospital experience, 2 months. This is not to suggest that for 2 months the student sits in class "learning". Technicians learn best by seeing, hearing and doing. Therefore, the three phases must be integrated so that clinical exposure to patients' problems is experienced early in phase I and that during phase II basic principles are reinforced by "rounds" or classroom (didactic) sessions (fig. 6). The curriculum must be defined formally and in keeping with sound educational practice, objectives for students must be precise and the training goals
FIG. 6. Training programmes must emphasize clinical assessment early in the curriculum.
The curriculum may be built around those systems which will provide over 80% of life-threatening emergencies: Breathing—the respiratory system. Bleeding—the circulatory system. Brain—the nervous system. Bones—the musculoskeletal system. Teaching of resuscitation, particularly trauma resuscitation, can proceed in an orderly fashion by using an outline as illustrated in table I. It may be noted that for each system there is an initial basic science portion of anatomy (structure) and physiology (function). Details of these basics must be both relevant to understanding important concepts and clinically applicable. A rather simplistic approach which may lack total accuracy may be necessary here to achieve the prime objective of understanding basic concepts. A discussion of the evaluation (that is, the assessment) of each system and the reporting of such an assessment is crucial to the educational experience. As we have mentioned, significant to the role of paramedical personnel is the assessment and adequate description of signs and symptoms. Continual emphasis must be placed on verbal skills, observation and a systematic "problem-oriented" approach to field emergencies. Teaching of a field approach to emergencies by a paramedic must emphasize the importance of "data collection" rather than "diagnostic labelling" of the patient's problem. Intervention may or may not follow from the interpretation of these data by the physician. In the case where telemetric radio communication is not part of the pre-hospital care
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BRITISH JOURNAL OF ANAESTHESIA TABLE I. Portion of curriculum organization illustrating sequence of material presented to student. Similar approach with each system
FIG. 7. Early fluid administration and the use of the anti-shock garment have done much to make possible the survival to hospital of patients seriously ill from shock following trauma.
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II. "A"—THE AIRWAY—Respiratory system (A) Structure and function (B) Assessment and reporting (C) The patient airway (D) Ventilation and assisted breathing (E) Acute upper airway obstruction (F) Acute lower airway obstruction (G) Chronic obstruction—"C.O.P.D." asthma chronic bronchitis emphysema (H) Pulmonary oedema (I) Inhalation injuries and aspiration (J) Pulmonary embolus (K) Hyperventilation syndrome III. THE CIRCULATORY SYSTEM (A) Structure and function: the pump the pipes the fluid (B) Assessment and reporting (C) Bleeding (D) Shock (E) Fluids and fluid replacement
system, paramedic teams have operated using "protocols" or "algorithms". Such standing orders, however, must be based on observation of signs and symptoms rather than specific diagnoses. In either case the training approach must be similar. Hence, topics included in the curriculum might be dealt with as: "the dyspnoeic patient", "the patient with chest pain", and so on rather than "the patient with heart failure" or "the patient with myocardial infarction". It has been our experience that it is most difficult to train personnel to avoid diagnostic labelling in the field environment. It is only with careful planning of curriculum and constant reinforcement that proper priorities in pre-hospital care can be instilled in the student. Perhaps the most easily taught and most readily learned aspects of the paramedical training curriculum are manual skills. These would include many of the techniques used commonly in resuscitation of trauma patients: extrication, transport, cardiopulmonary resuscitation, fluid administration, use of antishock garment, etc. (fig. 7). Much emphasis must be placed on the skills of assessment and either verbal or written reporting. Radio communication is of vital importance, since
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verbal description of patients and emergency situations form the basis for therapeutic intervention in a mobile intensive care system. The ability of the student to exercise verbal skills must be constantly monitored and tutored. After assessment and reporting, therapeutic skills occupy the major portion of the curriculum. Resuscitation of the sick and injured requires prompt initial assessment and then application of life-support measures.
life support: bandaging, splinting, transport and the medical aspects of extrication, among others. It is to be emphasized that these techniques must be taught in a clinical situation. Introduction to patient care is mandatory in the early phases of the curriculum. A didactic programme which is integrated with early clinical exposure accomplishes several goals:
A—airway (1) Techniques of suction, suction equipment. (2) Oxygen and techniques of administration. (3) Maintenance of a patent airway: Artificial cough manoeuvres. Head and jaw positioning, patient positioning. Oropharyngeal, nasopharyngeal airways. Oesophageal obturator airway. Endotracheal intubation. Transtracheal ventilation. Cricothyrotomy. B—breathing (1) Positive pressure ventilation: Mouth-to-mouth. Mouth-to-mask. Bag and mask. Oxygen-powered ventilators. (2) Stabilizing flail chest. (3) Decompressing tension pneumothoraces. C—circulation (1) Cardiopulmonary resuscitation: Cardiac massage and advanced life support. Dysrhythmia recognition and treatment. Defibrillation, carotid sinus massage. (2) Techniques of fluid administration: i.m., i.e., s.c., i.v. (3) Fluid administration: i.v. line placement. Blood and blood pumps. (4) Anti-shock garment (MAST suit). (5) Pericardiocentesis. Additional skills must be introduced as adjuncts to the basic techniques necessary for resuscitation and
The relatively brief nature of any training programme would suggest the necessity of early, integrated bedside exposure of students to patients. Such exposure must be with adequate supervision and encouragement from faculty and staff. Methods Methods of training paramedical personnel in their role as first-responders and triage officers will depend upon the objectives of that training. Some of the most important skills required of paramedical personnel include the ability to assess patients, initiate therapy and verbally describe such assessment, and intervention. Paramedics should be introduced early in their training to actual patient care in a supervised environment and emphasis placed on historygathering and physical examination (data collection). The verbal description of emergency situations and patient assessment is most difficult. In our experience, it is an art which is not readily taught. Attempts must be made in the initial stages of training to instil in the student the importance of this art. Students should begin by being subjected to rigorous drill in medical jargon and terminology. "Street" terms and "dispatcher" language learned after many years with the fire or ambulance service must be forbidden. Only recognized medical terms should be used. Hence "stab wound" should replace "cutting"; "suction" rather than "aspirator", etc. Abbreviations,
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Training paramedical personnel in the therapeutic skills required for resuscitation could place emphasis on the following:
(1) It instils in the student at an early stage the relevance of his or her training. (2) It helps develop an empathetic, "caring" attitude towards patients. (3) It aids substantially in retention of important concepts. (4) It allows the faculty to judge better the performance of a student. (5) It permits the faculty to instil in students a confident, yet not arrogant attitude—the latter born of insecurity and anxiety with unfamiliar clinical situations.
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group representing the team at the hospital. All practices are recorded and reviewed, with particular attention paid to the verbal description and radio technique from the field unit. Such drills must be frequent and presented early in the training programme. The importance of clinical experience in the training of paramedics has been emphasized. The practical difficulties of providing patients who are acutely ill may be solved partially by the use of simulated emergency situations. Several hundred such simulations have been presented in the Los Angeles programme and have proved an invaluable teaching tool. "Patients" consist of graduate paramedics who are "programmed" to exhibit certain signs and symptoms in a given emergency situation. A team of two or three students is "dispatched" to the "scene" of the emergency. Field performance is monitored by transmitting the scenario by videotape camera to the classroom. Each simulation is reviewed visually and used to reinforce specific objectives (fig. 8). Realism is an important ingredient. Make-up and moulage are used to portray signs of injury or illness. "Blood" can be manufactured readily using a mixture of water, food colouring and starch. Fragments of bone or exposed muscle tissue can be had from a friendly local butcher. "Sweat" is best simulated by glycerin (water evaporates too quickly). Mortician's wax is useful in constructing wounds and holding impaled objects. Auscultatory findings can be simulated by a simply constructed "dummy" stethoscope the earpiece of which can be wired into a tape recording of the desired breath sounds. Arterial pressure cuffs may be adjusted to read high or low. Cardiac arrhythmias can be portrayed with any commercially available electronic arrhythmia simulator. Videotape systems, particularly colour, offer decided advantages in the training of paramedics. Not only can they be used in simulated patient sessions but they are useful in augmenting lectures with demonstrations of manual skills or field techniques. Traditional methods of medical and paramedical education cannot be relied upon totally to provide adequate education in this field. Part of the explanation for this rests in the fact that pre-hospital care is a relatively new field and experience is lacking. It is probably true to say that no experts yet exist in this particular area. Newer, even novel, approaches to paramedical education must be developed and tested.
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because of the possibility of garbled radio communication or bad writing, should be used sparingly. This is true particularly of slang or unusual terms which may well be foreign to medical personnel. (It was some weeks before the author had the courage to enquire as to the meaning of "D.F.O." often listed under "chief complaint" on paramedic report forms. The term happened to be an abbreviation for "done fell out"—a description of syncope or coma of sudden onset in a local ethnic dialect.) Care must be taken to adapt medical language to the pre-hospital care field where radio communications play such a vital role. Use of the term "arrest", for example, should be reserved for the medical term "cardiac arrest". The term "in custody" should be reserved for description of the legal difficulties of a patient. Such care avoids the confusion which might result from technical difficulties in radio communications. Cultivating the art of verbal description is difficult at best. Graduates of our training programme comment consistently on the insecurity and anxiety provoked during their internship by the responsibility of assessment and verbal reporting. To aid in developing such skills and to prepare the student for field performance, practice must begin early in the curriculum. Attempts are first made to develop the student's own ability to verbalize. This is done with the use of still photographs, not necessarily medical in nature. Students are asked to describe a given photograph to a small group. Discussion then follows as to the performance of each. A time limit is set for each exercise. From this beginning one can progress then to recorded descriptions of a medical nature, since by now the student should feel relatively comfortable with the initial exercises. Recorded descriptions are important for two reasons: first, they allow students an opportunity to review their performance and hear the sound of their own voices; second, they begin a process of "desensitization" to radio or recording equipment, particularly microphones. We have found that radio communications, especially those of a medical nature, produce significant anxiety in students, even those who have had extensive ambulance and rescue experience. The final phase in the assessment and verbal reporting programme consists of actual simulated radio communication. Two groups of students communicate by way of a two-way radio or telephone. One group presents a problem from "the field" to a
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Evaluation There is no system of evaluation which will please everyone or fulfil the ideals of consistency, reliability, fairness and relevance. Evaluation of the student must be done in such a way as to reflect the goals of training. It is therefore important that the student knows what is expected of him or herself; that is, the curriculum must be defined and objectives provided. It has been our experience that written examinations are not adequate in the evaluation process of paramedical training. Total reliance on written tests will result in a relatively poor correlation between performance of the student in the curriculum and performance of the paramedic in the streets. Oral and practical examinations, although much more timeconsuming and demanding of the instructor, are preferable. A difficulty exists in the use of oral and practical tests. Care must be taken to reduce the influence of the examiner's subjective feelings in the evaluation of practical performance and fund of knowledge. To 54
do this a policy of recording on tape all examination interviews is helpful. Should a student do poorly the examination can be reviewed by several others. A standard form which outlines acceptable responses or performance manoeuvres will help to reduce examiner error (table II). TEACHING THE "ART"
Those of us who feel the paramedic to be a new and valuable member of the medical team cannot help but be concerned about the problems of instilling in students something of the "art" of medicine. The nature of pre-hospital care makes it mandatory that the philosophy of training be founded on the basic elements of ethical and professional behaviour. One of the roles of the pre-hospital care team is to act as a "facilitator" of the patient's entry into the medical care system. Constant attention must be paid during the training programme to communicating attitudes of concern and compassion for the patient. At the same time, the student must not be given the idea
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FIG. 8. Realistic simulations of emergency situations can be used to provide students with valuable experience in on-scene care. Use of videotape is particularly desirable.
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TABLE II. Example of format for oral and practical examinations. Note instructions to examiners. All oral examinations are tape-recorded STATION : Thomas-Hare Traction Splint Score Acceptable response
Question
-1
-2
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Comments
NOTICE TO EXAMINERS: The candidate is to be judged solely on his ability to respond to the questions or situations presented. You are to accept only the responses as given in the right hand column. If you elect to accept another, merely note it in the space provided. The scoring system allows you to grade the candidate according to the appropriateness and speed of response. Candidates who answer or perform promptly, accurately and confidently are awarded " + 2"; those who answer hesitantly or require some prompting are given " + 1 " , etc. A grossly inappropriate answer or performance can score " — 2", " — 1", etc. ALL MINUS MARKS MUST BE EXPLAINED IN "COMMENTS" SECTION.
that he or she need only mount the white charger and thousands of lives will be saved. Problems of a field environment would oblige us to provide for the student a realistic picture of all aspects of prehospital care; its rewards, limitations and possible benefits to the community. CONCLUSION
emergency care. Important in the training of such personnel are the skills of patient assessment (history and physical), manual techniques and the development of verbal reporting using radio communications. Emphasis in the curriculum should include early and frequent encounters with patients in a clinical setting. Such training is best carried out in a large hospital, preferably affiliated with a medical school.
Mobile Intensive Care Units represent a growing force in emergency medical care in many areas of the world. The training of such paramedical personnel represents a relatively new field of medical education. Priorities within such programmes of pre-hospital care must be determined by competent physicians. The roles of such paraprofessionals might include: initial assessment, reporting of the assessment by radio, field intervention (that is, treatment) and facilitating the entry of the patient into the medical care system. The curriculum of paramedic training must be founded on proper medical priorities of
Benson, D., and Stewart, C. (1973). Inadequacy of prehospital care. Crit. Care Med., 1, 130. Caroline, N. (1977). Medical care in the streets. jf.A.M.A., 237, 43. Criley, J. M., Lewis, A. J., and Ailshie, G. E. (1975). Adv. Cardiol., 15, 9. Frey, C , Huelke, D. F., and Gikas, P. W. (1969). Resuscitation and survival in motor vehicle accidents. J. Trauma, 9, 292. McKenny, E. M. (1967). History of motorized ambulance transport. Milit. Med.,'132, 819.
REFERENCES
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Prepares splint properly for application Please apply the traction splint. Measures the lower limb before appliThis paramedic will assist you. cation Please instruct him as to what he Has helper hold steady traction must do. Removes shoe or checks for circulation to foot—or verbalizes same Places splint firmly under ischial area Places hip strap firmly Has adjusted cross-straps in correct position to support fracture site Applies foot-strap firmly to traction hook Telescope extension long enough to apply traction Applies firm (but does not force) traction OTHER: Score (page 1):
+2 + 1 0
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Moiseev, S. G. (1962). Experience in the administration of Rang, M. (1966). Anthology of Orthopaedics, 1st edn, p. 159. first aid to patients with myocardial infarction. Sov. Edinburgh: Livingstone. Med., 26, 30. Taubenhaus, L. (1973). The emergency service spectrum. Morris, M. C. (1976). On-the-scene emergency care by the J. Am. Coll. Emerg. Physicians, 2, 327. primary physician. J. Am. Coll. Emerg. Physicians, 5, 669. Pantridge, J. F., and Geddes, J. S. (1969). A mobile intensive care unit in the management of myocardial infarction. Am. J. Cardiol., 24, 666.
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THE TRAINING OF PARAMEDICAL PERSONNEL R.
D.
STEWART
RONALD D.
STEWART, B.A., B.SC., M.D., Department of
Emergency Medicine, University of Southern California, School of Medicine, 1200 North State Street, Los Angeles, California 90033, U.S.A.
system to the arrival at a medical facility, and inhospital care—from reception at a medical facility to delivery of the patient to "definitive care" personnel. There are several questions which might be raised about such a concept, particularly in relation to the fact that all patients presenting to a casualty department are not true "life-threatening" emergencies. This would indicate that the care phase in hospital might be brief, and secondary care would be delegated, for example, to the patient's physician or clinic. Let us confine ourselves to the discussion of the pre-hospital care phase, with specific reference to resuscitation of the seriously injured and the personnel involved in their initial care. EMERGENCY MEDICAL SYSTEMS
Only within the last 10 years has much attention been given to care outside the hospital. It has been suggested that some 15% or more of accident victims die at the scene from injuries potentially reversible by properly trained medical personnel (Frey, Huelke and Gikas, 1969). Of the 670 000 deaths in the United States attributed to coronary artery disease, 50-60% occur suddenly outside the hospital setting (fig. 2). Such statistics are all the more alarming because no amount of improvement in staff or facilities within the confines of the hospital will improve these figures. It becomes logical, then, that the medical team extend its facilities and expertise beyond the limits of the hospital environment; that is, into the pre-hospital care setting. This idea of "extension" is not new; in the late 1950's the Soviet Union and the Scandinavians were organizing teams of trained physicians, nurses and technicians to deliver life-support care in the field (Moiseev, 1962). Belfast followed with Dr Frank Pantridge organizing the Mobile Coronary Care Unit from the Royal Victoria Infirmary (Pantridge and Geddes, 1969). Other communities, particularly in the United States, followed with pilot programmes designed to test the hypothesis that provision of proper emergency medical care would significantly improve the lot of the patient in the pre-hospital phase of their illness.
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The concept that the care of a sick or injured person can begin before the patient reaches a medical centre is not new. The history of organizations such as the St John Ambulance and the Red Cross testifies to this. The modern form of "pre-hospital care" began with Napoleon and his generals who developed means of transporting wounded soldiers from the battlefield to dressing stations. These "ambulances volantes"— flying carriages—were horse-drawn vehicles destined to persist as the forerunners of our modern motorized ambulance (McKenny, 1967). Thomas, the British surgeon, demonstrated during the Great War (1914-18) that proper care in the field could preserve life and limb (Rang, 1966). His invention of a wire splint to immobilize a fractured femur is well known to those of us involved in dayto-day emergency care. Within a relatively short period, much attention has been focused on what some have termed "a crisis in health care". Statistics and reports attest to the tragic incidence of accidents and sudden illness on motorways, in homes and at work. All too often, systems of emergency care are found wanting when close scrutiny reveals the quality of medical care delivered to the patient (Benson and Stewart, 1973). Emergency services in the community can be considered to consist of several phases of patient care (Taubenhaus, 1973): Pre-emergency (fig. 1). The phase during which the community is educated and prepared for emergencies which might arise. This would include education in basic first aid procedures, signs and symptoms of life-threatening illness, basic cardiopulmonary resuscitation, how to call up and use intelligently the emergency and rescue services. Emergency extends from the moment the patient is able to gain access to the medical care system to the time when definitive treatment is rendered by those involved in "secondary care". This would include two basic interrelated phases: pre-hospital care—that period of time covering the patient's access to the
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The evolution towards the concept of mobile intensive care units (MICU) has been, in our experience, one of the most significant developments in the field of emergency medical care in many years (fig. 3). In 1969 Los Angeles County, California, established an experimental ("pilot") programme of pre-hospital care delivered by trained technicians ("Paramedics") (Criley, Lewis and Ailshie, 1975). Since that time the County, with a population of about 7 000 000, has expanded its service so that all geographical areas are served by 130 paramedic units. More than 1300 technicians have been trained in the system. Twentysix hospitals throughout the County act as "base stations" within the system, directing the activities of these paramedics and the several hundred thousand calls for aid answered each year. Many different systems have evolved in recent years using various personnel to provide good "onscene" emergency care. Physicians, especially in
rural areas, have often become the "first-responders" (Morris, 1976) (fig. 4). A system using physicians may be appropriate in areas where a large system of technicians could not be economically or politically supported. The author has had the privilege of being part of such a system in a rather remote area of the province of Nova Scotia, Canada, for 2 years. There, first-response to serious illness or accident consisted of an ambulance driver (recruited from the community), the physician and a well-equipped ambulance. In most urban areas, however, the staffing of such units with nurses or physicians has proved largely uneconomical when compared with use of alreadyexisting facilities such as fire or ambulance personnel. In addition, medical personnel may find the practice of on-scene or "field" medicine to be a very different thing from the medicine practised within the secure walls of a hospital or medical clinic (Caroline, 1977).
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FIG. 1. Education of the public in the intelligent use of a pre-hospital care system is essential to its operation. Much of the burden of this responsibility falls on the shoulders of paramedical personnel. (Reproduced by kind permission of Los Angeles Fire Department.)
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FIG. 2. Prompt care delivered to the thousands injured in accidents or struck down with cardiovascular disease may make some impact on the high death rates in these illnesses. (Reproduced by kind permission of Rick McClure.)
One might consider it desirable to provide an emergency response system of which the overall goal is the provision of high quality pre-hospital care with personnel who are specifically trained to deliver such care. Such a philosophy has lead to the creation of mobile intensive care units and the development of a new breed of medical "para-professionals".
What is crucial to the concept of pre-hospital care is the question of the training of personnel. Yet to be agreed upon are very basic questions: the most appropriate personnel to train for such responsibilities, the training curricula and the roles and responsibilities of personnel. Much of what has been written to date represents the opinions and prejudices
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FIG. 3. Mobile Intensive Care Units extend the facilities of the hospital into the community, providing prompt advanced care to patients.
of each author, reflecting experience gained in the particular system with which he or she has been involved. There is a marked variation in the programmes of pre-hospital care offered in urban areas across the United States. Such programmes differ in respect to length of training, content and philosophy of curriculum, and types of personnel manning such
systems. The United States Department of Transportation has addressed the problem of standardization in its curriculum for pre-hospital care programmes developed by the University of Pittsburg and published only recently. The proposed standards suggest different levels of training, based on community need and objectives of the emergency care system.
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Proper pre-hospital care service must begin with decisions regarding the overall philosophy of care and outlining of objectives and responsibilities of the system. PHILOSOPHY
The philosophy of any pre-hospital care system begins with the recognition that this field of medical care is quite unique in many respects. Problems of the environment itself, for example weather, poor lighting, large or hostile crowds, may make even the simplest medical task impossible. In addition, limitations imposed by personnel training and responsibility make the development of clear objectives of prime importance. It has been suggested that the prime goal of any mobile intensive care programme is the stabilization of patients before transport to a medical facility. On close scrutiny, however, this philosophy has serious deficiencies which make it medically unsound. Patients presenting with serious lesions which cannot be reversed in a field setting are best presented promptly to the hospital environment where both equipment and training may afford a greater chance of survival for the patient. Proper pre-hospital care, therefore, depends upon the priorities set by the system and such priorities must be medically, not politically, determined (fig. 5).
The priorities with respect to role and responsibilities of paramedical personnel should include the following: (1) Assessment of a field situation—data collection. (2) Reporting such data by way of radio, telephone or written record. (3) Provision of appropriate medical care to a patient in the field. (4) Facilitating the entry of the patient into the medical care system. THE TRAINING PROGRAMME
A valid programme of training emergency medical personnel will have as its foundation the philosophy and goals discussed above. There are important factors to be considered in guiding such a programme towards the realization of its goals: Composition of the faculty—who teaches ? Length and organization of curriculum—how long to teach? Curriculum content—what to teach. Methods of training—how to teach. Evaluation. The Faculty—who trains ? In the discussion of philosophy and goals of the training programme it is evident that some of the most important responsibilities have been delegated
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FIG. 4. In isolated or rural areas, Physicians can be cast in the role of "first responders" in the event of illness or accident.
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to technicians operating remotely from medical personnel. In view of this, it is essential to ensure that such personnel are exposed as much as possible to practical aspects of patient care. It would seem appropriate, therefore, that such training programmes be designed and directed by physicians who are thoroughly familiar with the treatment of acute illness and injury and attuned to the philosophy of pre-hospital care. In our experience it has not been particularly fruitful to rely totally on physicians from specialties in which they would not be aware of the goals of the training programme. It must be agreed by those who do this training that this particular area is a unique field of endeavour and those who teach in the system must adhere to a common philosophy. If a multidisciplinary approach is applied to training, then each member of the team—nurses, respiratory therapists, etc.—must adhere to specific objectives which must be in tune with the philosophy and concepts of pre-hospital care. Most programmes have nurses as co-ordinators with a medical director who oversees the programme. Didactic classroom instruction is given by nurses and physicians. The ratio varies widely in different programmes. Ideally, physicians involved in the day-today management of emergencies should be the
cornerstone of the educational experience with nursing personnel acting as co-ordinators, and, on occasion, instructors. It is to be hoped that talented, well-trained paramedics who have a wealth of field experience might in the near future constitute the main source of non-physician instructors. Basic to the question of training is where to locate the educational programme: medical school, community hospital, junior college, etc. It is to be stressed that a training programme of this type must be clinically oriented. Theory must be relevant to clinical situations and there must be adequate exposure to bedside encounters with patients. In our experience, a relatively large teaching hospital offers great advantages, particularly if closely associated, geographically and otherwise, with a medical school. Length of curriculum There is much controversy and even greater variation in respect to the time required to train personnel in the management of emergencies outside the hospital environment. There are several reasons for this, including the fact that there is no real agreement on roles and responsibilities of such personnel. In the United States, basic first aid and life support required of ambulance personnel (EMT-I) are taught in a
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FIG. 5. The prime responsibility of the mobile intensive care paramedic is initial assessment and reporting, and prompt therapeutic intervention if appropriate to the field setting.
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relatively standard 80-hour curriculum. Clinical experience in hospital may be added to the didactic instruction. For those personnel with advanced lifesupport responsibilities such as defibrillation, drug administration and radio-telemetric communication, the length of training programmes varies from 150 to 1100 hours. It has been our feeling that a curriculum of at least 1000 hours extended over a period of 5-6 months is minimal when designed to train for the responsibilities delegated to the personnel in the Los Angeles County system.
specific. At this level of training a dogmatic approach to problems may be necessary at first, and accuracy may be sacrificed for simplicity. During phase I, the basic training portion, introduction to the curriculum must include an outline of the scope and philosophy of pre-hospital care. Throughout training the student must be made aware of the limitations imposed on the emergency technician by the level of training, equipment in the field and the environment itself outside the hospital. The philosophy of the programme must be instilled in the student and attitudes reflecting this philosophy should be an object of evaluation throughout the programme of training. Ethical matters and attitudes toward patients are introduced early and illustrated by word and example.
Curriculum content
Training programmes for paramedical personnel must be based on sound, relevant theory of emergency care reinforced with early and frequent clinical exposure. For reasons which are mostly logistic rather than anything else, the programme may be divided into several segments: Phase I—(Didactic) Classroom theory, 2 months. Phase II—Experience in hospital, 1 month. Phase III—Pre-hospital experience, 2 months. This is not to suggest that for 2 months the student sits in class "learning". Technicians learn best by seeing, hearing and doing. Therefore, the three phases must be integrated so that clinical exposure to patients' problems is experienced early in phase I and that during phase II basic principles are reinforced by "rounds" or classroom (didactic) sessions (fig. 6). The curriculum must be defined formally and in keeping with sound educational practice, objectives for students must be precise and the training goals
FIG. 6. Training programmes must emphasize clinical assessment early in the curriculum.
The curriculum may be built around those systems which will provide over 80% of life-threatening emergencies: Breathing—the respiratory system. Bleeding—the circulatory system. Brain—the nervous system. Bones—the musculoskeletal system. Teaching of resuscitation, particularly trauma resuscitation, can proceed in an orderly fashion by using an outline as illustrated in table I. It may be noted that for each system there is an initial basic science portion of anatomy (structure) and physiology (function). Details of these basics must be both relevant to understanding important concepts and clinically applicable. A rather simplistic approach which may lack total accuracy may be necessary here to achieve the prime objective of understanding basic concepts. A discussion of the evaluation (that is, the assessment) of each system and the reporting of such an assessment is crucial to the educational experience. As we have mentioned, significant to the role of paramedical personnel is the assessment and adequate description of signs and symptoms. Continual emphasis must be placed on verbal skills, observation and a systematic "problem-oriented" approach to field emergencies. Teaching of a field approach to emergencies by a paramedic must emphasize the importance of "data collection" rather than "diagnostic labelling" of the patient's problem. Intervention may or may not follow from the interpretation of these data by the physician. In the case where telemetric radio communication is not part of the pre-hospital care
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BRITISH JOURNAL OF ANAESTHESIA TABLE I. Portion of curriculum organization illustrating sequence of material presented to student. Similar approach with each system
FIG. 7. Early fluid administration and the use of the anti-shock garment have done much to make possible the survival to hospital of patients seriously ill from shock following trauma.
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II. "A"—THE AIRWAY—Respiratory system (A) Structure and function (B) Assessment and reporting (C) The patient airway (D) Ventilation and assisted breathing (E) Acute upper airway obstruction (F) Acute lower airway obstruction (G) Chronic obstruction—"C.O.P.D." asthma chronic bronchitis emphysema (H) Pulmonary oedema (I) Inhalation injuries and aspiration (J) Pulmonary embolus (K) Hyperventilation syndrome III. THE CIRCULATORY SYSTEM (A) Structure and function: the pump the pipes the fluid (B) Assessment and reporting (C) Bleeding (D) Shock (E) Fluids and fluid replacement
system, paramedic teams have operated using "protocols" or "algorithms". Such standing orders, however, must be based on observation of signs and symptoms rather than specific diagnoses. In either case the training approach must be similar. Hence, topics included in the curriculum might be dealt with as: "the dyspnoeic patient", "the patient with chest pain", and so on rather than "the patient with heart failure" or "the patient with myocardial infarction". It has been our experience that it is most difficult to train personnel to avoid diagnostic labelling in the field environment. It is only with careful planning of curriculum and constant reinforcement that proper priorities in pre-hospital care can be instilled in the student. Perhaps the most easily taught and most readily learned aspects of the paramedical training curriculum are manual skills. These would include many of the techniques used commonly in resuscitation of trauma patients: extrication, transport, cardiopulmonary resuscitation, fluid administration, use of antishock garment, etc. (fig. 7). Much emphasis must be placed on the skills of assessment and either verbal or written reporting. Radio communication is of vital importance, since
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verbal description of patients and emergency situations form the basis for therapeutic intervention in a mobile intensive care system. The ability of the student to exercise verbal skills must be constantly monitored and tutored. After assessment and reporting, therapeutic skills occupy the major portion of the curriculum. Resuscitation of the sick and injured requires prompt initial assessment and then application of life-support measures.
life support: bandaging, splinting, transport and the medical aspects of extrication, among others. It is to be emphasized that these techniques must be taught in a clinical situation. Introduction to patient care is mandatory in the early phases of the curriculum. A didactic programme which is integrated with early clinical exposure accomplishes several goals:
A—airway (1) Techniques of suction, suction equipment. (2) Oxygen and techniques of administration. (3) Maintenance of a patent airway: Artificial cough manoeuvres. Head and jaw positioning, patient positioning. Oropharyngeal, nasopharyngeal airways. Oesophageal obturator airway. Endotracheal intubation. Transtracheal ventilation. Cricothyrotomy. B—breathing (1) Positive pressure ventilation: Mouth-to-mouth. Mouth-to-mask. Bag and mask. Oxygen-powered ventilators. (2) Stabilizing flail chest. (3) Decompressing tension pneumothoraces. C—circulation (1) Cardiopulmonary resuscitation: Cardiac massage and advanced life support. Dysrhythmia recognition and treatment. Defibrillation, carotid sinus massage. (2) Techniques of fluid administration: i.m., i.e., s.c., i.v. (3) Fluid administration: i.v. line placement. Blood and blood pumps. (4) Anti-shock garment (MAST suit). (5) Pericardiocentesis. Additional skills must be introduced as adjuncts to the basic techniques necessary for resuscitation and
The relatively brief nature of any training programme would suggest the necessity of early, integrated bedside exposure of students to patients. Such exposure must be with adequate supervision and encouragement from faculty and staff. Methods Methods of training paramedical personnel in their role as first-responders and triage officers will depend upon the objectives of that training. Some of the most important skills required of paramedical personnel include the ability to assess patients, initiate therapy and verbally describe such assessment, and intervention. Paramedics should be introduced early in their training to actual patient care in a supervised environment and emphasis placed on historygathering and physical examination (data collection). The verbal description of emergency situations and patient assessment is most difficult. In our experience, it is an art which is not readily taught. Attempts must be made in the initial stages of training to instil in the student the importance of this art. Students should begin by being subjected to rigorous drill in medical jargon and terminology. "Street" terms and "dispatcher" language learned after many years with the fire or ambulance service must be forbidden. Only recognized medical terms should be used. Hence "stab wound" should replace "cutting"; "suction" rather than "aspirator", etc. Abbreviations,
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Training paramedical personnel in the therapeutic skills required for resuscitation could place emphasis on the following:
(1) It instils in the student at an early stage the relevance of his or her training. (2) It helps develop an empathetic, "caring" attitude towards patients. (3) It aids substantially in retention of important concepts. (4) It allows the faculty to judge better the performance of a student. (5) It permits the faculty to instil in students a confident, yet not arrogant attitude—the latter born of insecurity and anxiety with unfamiliar clinical situations.
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group representing the team at the hospital. All practices are recorded and reviewed, with particular attention paid to the verbal description and radio technique from the field unit. Such drills must be frequent and presented early in the training programme. The importance of clinical experience in the training of paramedics has been emphasized. The practical difficulties of providing patients who are acutely ill may be solved partially by the use of simulated emergency situations. Several hundred such simulations have been presented in the Los Angeles programme and have proved an invaluable teaching tool. "Patients" consist of graduate paramedics who are "programmed" to exhibit certain signs and symptoms in a given emergency situation. A team of two or three students is "dispatched" to the "scene" of the emergency. Field performance is monitored by transmitting the scenario by videotape camera to the classroom. Each simulation is reviewed visually and used to reinforce specific objectives (fig. 8). Realism is an important ingredient. Make-up and moulage are used to portray signs of injury or illness. "Blood" can be manufactured readily using a mixture of water, food colouring and starch. Fragments of bone or exposed muscle tissue can be had from a friendly local butcher. "Sweat" is best simulated by glycerin (water evaporates too quickly). Mortician's wax is useful in constructing wounds and holding impaled objects. Auscultatory findings can be simulated by a simply constructed "dummy" stethoscope the earpiece of which can be wired into a tape recording of the desired breath sounds. Arterial pressure cuffs may be adjusted to read high or low. Cardiac arrhythmias can be portrayed with any commercially available electronic arrhythmia simulator. Videotape systems, particularly colour, offer decided advantages in the training of paramedics. Not only can they be used in simulated patient sessions but they are useful in augmenting lectures with demonstrations of manual skills or field techniques. Traditional methods of medical and paramedical education cannot be relied upon totally to provide adequate education in this field. Part of the explanation for this rests in the fact that pre-hospital care is a relatively new field and experience is lacking. It is probably true to say that no experts yet exist in this particular area. Newer, even novel, approaches to paramedical education must be developed and tested.
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because of the possibility of garbled radio communication or bad writing, should be used sparingly. This is true particularly of slang or unusual terms which may well be foreign to medical personnel. (It was some weeks before the author had the courage to enquire as to the meaning of "D.F.O." often listed under "chief complaint" on paramedic report forms. The term happened to be an abbreviation for "done fell out"—a description of syncope or coma of sudden onset in a local ethnic dialect.) Care must be taken to adapt medical language to the pre-hospital care field where radio communications play such a vital role. Use of the term "arrest", for example, should be reserved for the medical term "cardiac arrest". The term "in custody" should be reserved for description of the legal difficulties of a patient. Such care avoids the confusion which might result from technical difficulties in radio communications. Cultivating the art of verbal description is difficult at best. Graduates of our training programme comment consistently on the insecurity and anxiety provoked during their internship by the responsibility of assessment and verbal reporting. To aid in developing such skills and to prepare the student for field performance, practice must begin early in the curriculum. Attempts are first made to develop the student's own ability to verbalize. This is done with the use of still photographs, not necessarily medical in nature. Students are asked to describe a given photograph to a small group. Discussion then follows as to the performance of each. A time limit is set for each exercise. From this beginning one can progress then to recorded descriptions of a medical nature, since by now the student should feel relatively comfortable with the initial exercises. Recorded descriptions are important for two reasons: first, they allow students an opportunity to review their performance and hear the sound of their own voices; second, they begin a process of "desensitization" to radio or recording equipment, particularly microphones. We have found that radio communications, especially those of a medical nature, produce significant anxiety in students, even those who have had extensive ambulance and rescue experience. The final phase in the assessment and verbal reporting programme consists of actual simulated radio communication. Two groups of students communicate by way of a two-way radio or telephone. One group presents a problem from "the field" to a
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Evaluation There is no system of evaluation which will please everyone or fulfil the ideals of consistency, reliability, fairness and relevance. Evaluation of the student must be done in such a way as to reflect the goals of training. It is therefore important that the student knows what is expected of him or herself; that is, the curriculum must be defined and objectives provided. It has been our experience that written examinations are not adequate in the evaluation process of paramedical training. Total reliance on written tests will result in a relatively poor correlation between performance of the student in the curriculum and performance of the paramedic in the streets. Oral and practical examinations, although much more timeconsuming and demanding of the instructor, are preferable. A difficulty exists in the use of oral and practical tests. Care must be taken to reduce the influence of the examiner's subjective feelings in the evaluation of practical performance and fund of knowledge. To 54
do this a policy of recording on tape all examination interviews is helpful. Should a student do poorly the examination can be reviewed by several others. A standard form which outlines acceptable responses or performance manoeuvres will help to reduce examiner error (table II). TEACHING THE "ART"
Those of us who feel the paramedic to be a new and valuable member of the medical team cannot help but be concerned about the problems of instilling in students something of the "art" of medicine. The nature of pre-hospital care makes it mandatory that the philosophy of training be founded on the basic elements of ethical and professional behaviour. One of the roles of the pre-hospital care team is to act as a "facilitator" of the patient's entry into the medical care system. Constant attention must be paid during the training programme to communicating attitudes of concern and compassion for the patient. At the same time, the student must not be given the idea
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FIG. 8. Realistic simulations of emergency situations can be used to provide students with valuable experience in on-scene care. Use of videotape is particularly desirable.
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TABLE II. Example of format for oral and practical examinations. Note instructions to examiners. All oral examinations are tape-recorded STATION : Thomas-Hare Traction Splint Score Acceptable response
Question
-1
-2
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Comments
NOTICE TO EXAMINERS: The candidate is to be judged solely on his ability to respond to the questions or situations presented. You are to accept only the responses as given in the right hand column. If you elect to accept another, merely note it in the space provided. The scoring system allows you to grade the candidate according to the appropriateness and speed of response. Candidates who answer or perform promptly, accurately and confidently are awarded " + 2"; those who answer hesitantly or require some prompting are given " + 1 " , etc. A grossly inappropriate answer or performance can score " — 2", " — 1", etc. ALL MINUS MARKS MUST BE EXPLAINED IN "COMMENTS" SECTION.
that he or she need only mount the white charger and thousands of lives will be saved. Problems of a field environment would oblige us to provide for the student a realistic picture of all aspects of prehospital care; its rewards, limitations and possible benefits to the community. CONCLUSION
emergency care. Important in the training of such personnel are the skills of patient assessment (history and physical), manual techniques and the development of verbal reporting using radio communications. Emphasis in the curriculum should include early and frequent encounters with patients in a clinical setting. Such training is best carried out in a large hospital, preferably affiliated with a medical school.
Mobile Intensive Care Units represent a growing force in emergency medical care in many areas of the world. The training of such paramedical personnel represents a relatively new field of medical education. Priorities within such programmes of pre-hospital care must be determined by competent physicians. The roles of such paraprofessionals might include: initial assessment, reporting of the assessment by radio, field intervention (that is, treatment) and facilitating the entry of the patient into the medical care system. The curriculum of paramedic training must be founded on proper medical priorities of
Benson, D., and Stewart, C. (1973). Inadequacy of prehospital care. Crit. Care Med., 1, 130. Caroline, N. (1977). Medical care in the streets. jf.A.M.A., 237, 43. Criley, J. M., Lewis, A. J., and Ailshie, G. E. (1975). Adv. Cardiol., 15, 9. Frey, C , Huelke, D. F., and Gikas, P. W. (1969). Resuscitation and survival in motor vehicle accidents. J. Trauma, 9, 292. McKenny, E. M. (1967). History of motorized ambulance transport. Milit. Med.,'132, 819.
REFERENCES
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Prepares splint properly for application Please apply the traction splint. Measures the lower limb before appliThis paramedic will assist you. cation Please instruct him as to what he Has helper hold steady traction must do. Removes shoe or checks for circulation to foot—or verbalizes same Places splint firmly under ischial area Places hip strap firmly Has adjusted cross-straps in correct position to support fracture site Applies foot-strap firmly to traction hook Telescope extension long enough to apply traction Applies firm (but does not force) traction OTHER: Score (page 1):
+2 + 1 0
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Moiseev, S. G. (1962). Experience in the administration of Rang, M. (1966). Anthology of Orthopaedics, 1st edn, p. 159. first aid to patients with myocardial infarction. Sov. Edinburgh: Livingstone. Med., 26, 30. Taubenhaus, L. (1973). The emergency service spectrum. Morris, M. C. (1976). On-the-scene emergency care by the J. Am. Coll. Emerg. Physicians, 2, 327. primary physician. J. Am. Coll. Emerg. Physicians, 5, 669. Pantridge, J. F., and Geddes, J. S. (1969). A mobile intensive care unit in the management of myocardial infarction. Am. J. Cardiol., 24, 666.
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