Students, what should we do with them?

[Veneficus]

The immortal question

How you handle students depends mostly on what you are trying to accomplish.

If you are trying to build great providers it takes time. In addition to the basic knowledge and capabilities, time must be spent discussing motivations, goals, and obstacles. Plans for overcoming shortcomings must be developed, not simply telling people they are not perfect and bouncing them out.

If you are trying to simply give somebody an evaluation as to whether they meet expectations, as Mycrofft said, objective expectations must be defined before hand. Otherwise a student or trainee has no idea what to expect or focus on from one day or preceptor to the next.

From my own perspective, I have seen people who I thought would never make it develop into outstanding providers. I have also seen people I thought would be outstanding providers bail out within weeks of starting work.

From the perspective of refusing calls or patients, I was trained in the era where it was absolutely unacceptable to refuse any call or patient for any reason. To ask for help or recognize it was somethig that would cause an individual stress, breakdown, or other was completely unheard of. You were either "man" enough, or you simply didn't belong.

It has taken sometime and effort to see past that mentality.

I have noticed that at all levels, working with people to become great is a lot more successful then simply telling them they are not.

Nobody starts out as the best. The lessons learned from failures are especially important. The idea that if you make a mistake even once you are gone has been tried by the US military. All that it has produced is incapable leaders whoo are trying to make it as far as possible before the law of averages catches up to them.

Just like not everyone is capable of standing in front of a class and teaching, not everyone is capable of being a clinical preceptor. The point of teaching is so that students learn, not to simply weed them out.

We didn't have FTOs until the later part of my EMS field experience. Many times a senior provider was "that guy who will show you the ropes." In my time as "that guy" if I failed everyone that didn't meet my standards, maybe 1 or 2 out of 100 would have made it.

But with some time and temperment, I realized that just like everyone cannot be a champion sports athlete, not everyone can be a pulitzer prize winning author, not everyone can be the healthcare provider who is the best of the best.

Without that rank and file, not only would the best people never stand out, but they would never get a day off either.

Not every student will one day be world class, probably 1:10,000 won't be. But patients who don't get a world class provider would get nothing if there wasn't a base level of less than perfect.

 

[Sasha]

I teach. I show her and tell her things ive learned that she will never see mentioned in the ems books. Doesnt make up for the fact even with coaching she refused to sit in the pt compartment.

 

[Ridryder911]

I am the Clinical Operations Manager, in which education is one of my duties as well as over seeing the FTO's. We have several programs in place to try to deal with such difficulties as discussed.

I believe that one way to prevent problems is to address the potential problems and try to have some guidelines such as assigned reviews and evaluations, addressing the problems (and good points) ensuring the employee/student fully understands their weakness, that proper documentation and identification of that problem exists and attempts to remodify per education, more clinical exposure, etc has been made to relive the problem. After such attempts have been exhausted; it should be clear to both parties that it is not in the best behalf for both of them and that they should be released. Emphasis may be made that EMS (depending on the situation) may not be the right career or this employeer is not right one.

R/r911

 

[steveshurtleff]

As a current student, I would say that it's probably better to fail during training than after. My AMR clinical was just 3 days ago, and while I did choke on a simple patient SAMPLE interview, I felt like I did well during a car vs. motorcycle trauma. I was on a dual-medic unit and, within reason in all cases, they stood back and let me go to work.

Anyway, if I am a bad fit, I'd much rather know sooner than later.

 

[YCALR]

It was not a trauma call.

It was what is actually a very routine transport. Patients scream. They scream because they're pissed, they scream because they're scared, they scream because they're hurt and they scream because they don't know any better. We don't get the option of going "Hey nope, not feeling this patient today. I'm gonna sit up front so I don't have to listen to them."

We had already had one lady with CP who let out blood curdling screams in the middle of the hallway taking her out. It is something you get used too. If you are not going to even try to get used to it, then you've got to get out.

If she had tried to sit in back and half way through go "You know what, I can't take it." Maybe I would have been easier on her, because she at least made the attempt to get acclimiated to the job. But no. She went directly to the front.

And this is NOT her first clinical.

Oh, I was no longer referring to just your student. I was speaking in a general tone regarding this thread. I had read previously when you mentioned it was a dementia patient, I agree on that call. Dementia?? That should've been a 'no-breather'. But in regards to the thread, I don't think a student should be failed on their first 'nasty' call without some sort of guidance. But, I understand where you are coming from, there has not been one time that I have refused to take a call. I ak the front man(so to speak), always doing as much as possible.

 

[usafmedic45]

And sometimes they adjust to similar situations merely thru field experience. Brand new EMTs don't know what it is 'really' like during a trauma call, and to assume that their first, second or even third trauma determines their career outcome is ridiculous. As i have stated before, people in general need time to grasp the concepts and skills required during any call, hence the TRAINING period. Training is the time to explain situations and try and teach the student how to better themselves.

But you miss the point that the issue is generally not a person not being able to handle a situation but simply not having the right character, intelligence or even common sense to function adequately. Very few people wash out of EMS programs because they can't come to terms with bad trauma. Most who flunk out tend to do so because of their intellectual shortcomings or because of some manner of gross (as in, overt) flaw in their personality.

Perhaps there was a deeper reason for not being able to handle the situation, if that was the case, then an encouraging conversation would have sufficed.

....and in the comparatively few cases where people are washing out because of bad calls, that's a great strategy. However, that is not the primary etiology of EMT class washouts.

Simply giving them a failing mark defeats the whole purpose of the training.

Actually, no, it does not. The purpose of training is two-fold:
1. to give the skills necessary to do a job
2. to determine if that person has the criteria that we want in the field. It's a weeding out process. Ask a Navy SEAL or Army Ranger or PJ if flunking out students who don't measure up is defeating the purpose of training. It's an extreme example but one that does apply to this discussion.

Some people should be failed, but without giving the fair opportunity to have an educational conversation regarding performance, then what is the point of training??

As I said above, primarily to serve as a "gate-keeper" for the profession.

Now I am a 21 yr old, female working with AMR finishing up my Bachelors in both Biology and Psychology. Tell me again I 'can't' succeed!!!

Obviously you haven't taken (or had a very crappy instructor for) statistics and/or psychological research methods. Come back to this discussion when you can adequately discuss the problems with the above statement which are not limited to the following:
1. Anecdotal evidence ("n=1")
2. Egocentric bias ("self-serving bias")
3. Fundamental attribution error
4. Confirmation bias

 

[Veneficus]

answering out of order.

As I said above, primarily to serve as a "gate-keeper" for the profession.

I hate to be the one to point this out, but in the US EMS is not a profession. It meets none of the criteria.

Furthermore, when you look at most of the people who are self appointed "gate keepers" in US EMS, most of them are the skills focused, "we don't need this education, can you do the job, response times matter, we are not doctors," crowd.

Like attracts like.

In many areas whether yo can be an EMS provider isn't determined by your knowledge, ability, or dedication. It is determined by whether or not you can pass a physical test that has no realism or applicabilty to EMS or Fire Operations.

It's a weeding out process. Ask a Navy SEAL or Army Ranger or PJ if flunking out students who don't measure up is defeating the purpose of training. It's an extreme example but one that does apply to this discussion.

I am not surprised to see this argument raised, I am surprised to see you are the one who raised it.

I don't think this is an accurate comparison when talking about EMS. These types of myrmidons are already part of their respected branches. They are not entry level.

To use the comparison in medicine, medical students already have a base of knowledge to be selected to proceed to higher levels of knowledge and capability.

EMS providers are an entry level position. Similar to basic infantry or unrated sailors. The only thing required of them is to be able bodied, follow orders, and use the equipment they are issued.

While some EMS providers excel passed that level, it is not a requirement.

Lest we forget, a majority of agencies providing EMS see it as a merit badge or a collateral part of their real job. Just ask the people who represent the emergency services in the capital of the USA.

It is called "fire based EMS" not "EMS based fire."

 

[usafmedic45]

I hate to be the one to point this out, but in the US EMS is not a profession. It meets none of the criteria.

Point taken. I misspoke. I meant "trade".

I don't think this is an accurate comparison when talking about EMS. These types of myrmidons are already part of their respected branches. They are not entry level.

I used them as an example simply because the handful of real Rangers, Airborne, PJs and SEALs on this forum were a lot less likely to crow about being used as an example than say using Marine Corps boot camp as an example.

 

[dixie_flatline]

Going through fire school, we had a teacher who was Mr Negativity. "You're going to get eaten up by that nozzle reaction," "You'll never get up that ladder in time," "You don't have what it takes to fight fire" etc.

By and large students training under him DIDN'T do well. The same students responded (and performed) completely differently with a more supportive instructor. I can't stand the types who make snap-judgments based on some anecdotal evidence about who will and will not 'make it'.

Yes, I absolutely think we should be more willing to 86 someone who we wouldn't trust with our own lives, but it is certainly a fine line. Frankly, I'd be even more scared, I think, of a student who comes out swinging 100% on his/her first really bad call. The first patient contact I ever had was a super minor MVA on the side of the interstate - and it was even a refusal - just get some vitals, a signature, and be on our way. My hands shook like I was about to go into a diabetic coma (and I was a theater minor in college who doesn't usually mind talking to people).

 

[BandageBrigade]

It seems to me that two different things are being discussed here. The first is based off of being an FTO for a new employee. The second is being a preceptor for a student. My question would be what are your companies guidelines or policies for who can precept or be an FTO? Experiance? Time in with the company? Education? Instructor or evaluator specific courses?

 

[mycrofft]

I'm told Am Red Cross trainer's porcedures will reflect a new direction..

Instead of a slippery "test" with questions not addressed in the mandatory video, we will be using a checklistr to see of they know how to do CPR.



Downright f'in' revolutionary.

Next revision will reinstate the test, betcha.

 

[usafmedic45]

By and large students training under him DIDN'T do well. The same students responded (and performed) completely differently with a more supportive instructor. I can't stand the types who make snap-judgments based on some anecdotal evidence about who will and will not 'make it'.

Have you ever thought that the reason for the difference in "performance" were lowered standards or more of a willingness on the part of the instructor to let marginal performance slide? I am willing to bet there is more going on than a simple correlation like you are trying to paint it.

 

[dixie_flatline]

Have you ever thought that the reason for the difference in "performance" were lowered standards or more of a willingness on the part of the instructor to let marginal performance slide? I am willing to bet there is more going on than a simple correlation like you are trying to paint it.

Did the first (bad) teacher have higher standards for performance? Well, yes, perhaps. But in this case, I think the difference was mainly a bad instructor (who is no longer permitted to teach anyway). His approach was to throw them out there, let them make mistakes, and hope they learned from them without getting discouraged. It works for some, I'm sure, but by and large the overall effect was negative.

Example - advancing a charged hose line (class's first experience opening a nozzle near working pressure). He just had groups get on the line, and try to control it while walking and spraying. Too many new skills, too little preparation. Some people took big steps, some little, and few at the same time as their squad mates. His sole idea of constructive criticism was "You need more upper body strength to handle that line", including the 245lb collegiate wrestler. A different instructor spent time explaining what would happen as the line opened and moved, had groups practice advancing in unison, things like that. Those groups didn't get knocked on their keisters or send water in all directions. They put the wet stuff where it was supposed to go, and I'd call that a success.

Did the other groups learn from their trial by fire under the other guy? Sure, but it didn't build any kind of positive student-teacher relationship, and it actively discouraged quite a few people who started to think they didn't have what it takes, when really they just needed more planning and practice. I guess it sounds like I'm arguing for the carrot over the stick, but I don't think the second instructor really coddled the class. The first one just preferred to set more up for failure.

 

[Shishkabob]

It's one thing to be grossed out by a call. I, as well as everyone I know, wont fault someone for getting physically sick at a call.


However, there's a difference between getting sick, and refusing to do patient care. Refusing to do patient care is a no-no, student or licensed provider.

 

[usafmedic45]

Did the first (bad) teacher...

Then the issue was that he was a lousy instructor, not that he was hard on the students. Big difference.

 

[Veneficus]

Refusing to do patient care is a no-no, student or licensed provider.

I wish it were that simple.

But there are several assumptions that must be met.

There must be a patient provider relationship, or at the very least a duty to act.

A provider does not always have to provide care. A great example of this is abortion.

Personal safety, abusive patients, etc, may negate the requirement to provide care.

Now EMS doesn't always fit into these categories, IFT is more likely to, but I think EMS exercises the exceptions more than they realize.

Obviously lack of safety absolves from care.

BLS providers are more than used to turfing patients they are "uncomfortable" with.

I see and hear of male EMS providers quite regularly turf female patients they feel uncomfortable caring for. A provider who does have an established relationship to care for a patient is obligated only to see the patient receives equal and appropriate care. They do not have to be the one who provides it.

LIke I said earlier, I am old school, male, female, menance to society or upstanding civic leader, I make no exceptions and personally care for all.

I don't think providers should refuse calls. But I also realize that my personal convictions on the matter are not the law.

In the original example that spawned this thread, the provider (student who has no obligation and moreover cannot have an obligation) felt uncomfortable providing care. A higher level provider (aka paramedic) was readily available and did provide care. At no point was care compromised.

Whether or not any of us find that unacceptable is moot. She was within her rights.

 

[Shishkabob]

I had an EMT refuse to ride with a patient once during a hospital discharge because the patient had a history of seizures... though hadn't had a witnessed one in a long time, and was being controlled by meds, but he felt "uncomfortable"



"Not feeling comfortable" is the biggest piece of crap excuse I hear all the time and it gets on my nerves. Right, because I have a P in my name, I'm instantly comfortable with any and every call, my short experience be damned. I truly don't give a darn WHAT someone is comfortable with, as that shouldn't factor in to the equation to the point of outright refusing to do something based off just that. I'm not comfortable with MUCH of what I do on a daily basis, but I do it. The only way to get comfortable is to do it and be exposed to it.




I had a patient much like Sasha's when I did transfers. I hated the call. It changed my view, to an extent, on abortion / euphanasia, yet I still worked the call.




You're looking at it legally. I'm looking at it as I don't want you as my partner if you refused to do something because it's not comfortable. Not dangerous, just uncomfortable.

 

[katgrl2003]

"Not feeling comfortable" is the biggest piece of crap excuse I hear all the time and it gets on my nerves.

I hate that excuse! I had an basic partner pull it on me, and I'm the same level. :wacko:

 

[Veneficus]

You're looking at it legally. I'm looking at it as I don't want you as my partner if you refused to do something because it's not comfortable. Not dangerous, just uncomfortable.

Linuss, not trying to single you out or direct these comments towards you, but you happen to give the most thought provoking replies.

If I may?

Sometimes discretion is the better part of valor.

In some cases not only is it acceptable to defer when you are not comfortable, but actually benefits the patient.

In surgery, only the most skilled surgeons attempt to reoperate on most cases, much less the more complex ones.

That doesn't apply to EMS do you say?

Sure it does.

What if you were riding with another medic as your permanant partner? You come upon a patient who needs intubated. Your partner assesses the airway, determines it to be a difficult intubation, relates that he hasn't intubated in a while, that he does not think he can intubate this patient and asks you to.

He is defering to you because of his lack of comfort.

Would you not do the same if the situation was reversed?

How many male providers have turfed female patients with OB/GYN issues on their female partners?

How many of those do you think were doing for their comfort as well as or more so than that of the patient?

Is that wrong? (incidentally I think it is. A healthcare provider should be not just capable, but proficent, of taking care of all people.)

What if the motivation is fear of litigation? Is that any less of not being comfortable?

 

[Shishkabob]

A healthcare provider should be not just capable, but proficent, of taking care of all people.

And how do you become capable and/or proficient if you never step up to that which you are initially uncomfortable with?



I had a patient almost give birth in my ambulance a couple of shifts back. We called for a second unit and we had the female EMT ride in with me.


Was I uncomfortable? You betcha. Did I leave the patients side or refuse to do the call? Nope.