FORUM

The Training of Emergency Medical Technicians

Jack B. Peacock, MD, FACS El Paso, Texas

Peacock JB: The training of emergency medical technicians. Ann Emerg Med 10:379-380, July 1981. emergency medical technician, training

After hearing continued and often heated discussions among emergency medical technicians over what are relatively unimportant differences in field management techniques (such as whether to use wet or dry dressings on burn injuries), one wonders why some EMTs appear to be excessively concerned with trivial technical points. I offer for consideration several possible explanations.

As one listens to these debates, it becomes apparent that such discussions often stem from a lack of understanding of the pathophysiology of the disease process in question. As a result, excessive attention is paid to form in an effort to overcome or compensate for a poor understanding of function. There is no question that a standard of performance is necessary, that skills instruction must adhere to the standard, and that attention to technical detail is important to the satisfactory performance of skills in the field. However, this emphasis on form reflects an attitude acquired during training that has not been counter- balanced by an appropriate emphasis on clinical effectiveness. One seldom hears any discussion of or emphasis on correlating technical performance in the field with clinical effectiveness and patient outcome. While adherence to a standard of performance may be necessary, I observe that, in many instances and in many training programs, logic and understanding of what one is trying to accomplish are being sacrificed on the altar of technical perfection. For example, while a two-inch compression of the sternum may produce a "perfect strip" on Recording Annie ~, more or less effort may be required to restore effective circulation in an adult patient, depending on body habitus, chest wall compliance, and other fac- tors.

A second possible explanation for this concern with form and technique is that it may represent a healthy scientific curiosity on the part of the EMT about which method, under what circumstances, produces the best result for the indi- vidual patient. To be sure, there are many unanswered questions about the clin- ical effectiveness of a variety of treatment modalities that have been espoused in emergency medicine, and a dearth of scientific studies correlating treatment with outcome. However, I seldom hear in any of these discussions among EMTs any mention of patient outcome.

The most likely explanation, I think, lies in what has happened to EMT training in recent years. Initially, most EMT training programs were carried out under the auspices of hospitals, medical societies, or medical and nursing schools. Recently, however, there has been a proliferation of training programs operating outside traditional medical institutions, often with only token medical supervision or direction. Although the instructors in these programs may be well qualified, many have become full-time instructors and are no longer clini- cally active or involved on a regular basis with patient care on any level. With- out the benefit of the positive and negative reinforcement of continuing clinical

From the Department of Surgery, Texas Tech University School of Medicine, El Paso, Texas. Address for reprints: Jack B. Peacock, MD, Department of Surgery, Texas Tech University School of Medicine, 4800 Alberta Avenue, El Paso, Texas 79905.

10:7 (July) 1981 Ann Emerg Med 379/61

expe r i ence , and in the absence of effect ive med ica l l e ade r sh ip , some instructors begin to focus on process without the modera t ing influence of outcome data . As a resul t , ins t ruc- tors a re t e a c h i n g EMTs and o ther paramedica l personnel t ha t there is one, and only one, correct way to do th ings (the ins t ruc tor ' s way) under any and al l c ircumstances, in spite of the fact t h a t , for a g iven c l in i ca l s i tuat ion, a technique as t augh t may not be feasible, prac t ica l , c l in ica l ly e f fec t ive , or even in t h e b e s t in- terests of the pat ient .

W h a t e v e r t he e x p l a n a t i o n , as t e ache r s and c l in ic ians , we a re in some m e a s u r e r e spons ib l e . In our zeal to provide the most good for the most people th rough the t r a in ing of p rehosp i t a l providers , we have not

exercised appropr ia te leadership. We have failed to ins is t on real qua l i ty control in EMT t r a i n i n g programs; failed (in many instances) to demon- s t ra te more than a pass ing intel lec- tual in teres t in prehospi ta l care (by neglect ing to get out into the field or even into the classroom to see wha t is going on); and fai led to examine cr i t ical ly EMS methodology as i t re- la tes to p a t i e n t outcome. The good teachers in medic ine usua l ly main- t a i n su f f i c i en t c l i n i ca l p r ac t i ce to keep t h e i r t echn ica l and j u d g m e n t s k i l l s h o n e d a n d to m a i n t a i n an ongoing in te res t in eva lua t ing clini- cal methodolog ies in t e r m s of out- come. I th ink we should expect and insis t t ha t EMT ins t ructors demon- s t ra te s imi la r a t t i tudes and qualifi- cations.

If we are to m a i n t a i n excellence in the t r a in ing of emergency medical t e c h n i c i a n s and in the d e l i v e r y of p r e h o s p i t a l care , and i f we a re to d e v e l o p n e w a n d m o r e e f f e c t i v e m e t h o d s of p a t i e n t m a n a g e m e n t , EMT t ra in ing mus t r e m a i n a respon- s ib i l i ty of medical professionals . To quote McSwain, if we as profession- als " . . . do not assume this responsi- b i l i t y o u r s e l v e s , t h e vo id w i l l be r ap id ly f i l led by some sys t em tha t ne i ther unders tands qual i ty care nor has the f lexibi l i ty to ident i fy when dev ia t ions f rom s t a n d a r d protocols are important . ''1

REFERENCES

1. McSwain NE, Jr: Medical control - - what is it? J A C E P 7:116, 1978.

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