Educator Update - Summer 2019 by National Association of EMS Educators (NAEMSE)

The Hands On Approach to Gloves-Off Precepting by Alyssa Tarvin

A Matter of Degrees: The Case for Degreed Paramedics

by Leaugeay Barnes, MS, NRP, NCEE, FP-C

Foundations of Education: An EMS Approach 3rd Edition

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IN THIS ISSUE National Association of EMS Educators

SUMMER 2019

250 Mount Lebanon Boulevard Suite 209 Pittsburgh, PA 15234 Phone : 412-343-4775 Fax : 412-343-4770 www.naemse.org

2019 Board of Directors

Whatâ&#x20AC;&#x2122;s Inside

Bryan Ericson, M. Ed, RN, NRP, LP President

Page

2 New Executive Director!

Page

3 Symposium Letter

Page

4 Why Do We Need EMS Research?

Page

5 A Matter of Degrees: The Case for Degreed Paramedics - Leaugeay Barnes

Page

8 Treasurer Spotlight

Page

9 NAEMSE Member Benefits

Linda Abrahamson, MA, ECRN, EMT-P, NCEE Vice President Dr. Lindi Holt, PhD, NRP, NCEE Treasurer

Dan Carlascio, NREMT-P, I/C RATE HOTEL

Page 11 The Hands On Approach to Gloves-off Precepting - Alyssa Tarvin

Page 19 Save the Dates!

Rebecca Valentine, BS, NRP, NCEE, I/C Leaugeay Barnes, MS, NRP, NCEE, FP-C

Page 10 Hotel Information

Page 18 Foundations of Education: An EMS Approach - 3rd Edition

Dr. Nerina Stepanovsky, PhD, MSN, CTRN, PM Secretary

Grafft, MS, NREMT, EMSper Mgrnight (Rt) from Omni Joe Fort Worth $151 1300 Houston Street July 30BS to Aug 6, 2019. Christopher Metsgar, MBA, Fort Worth, TX 76102 To book your room, Jill Oblak, MA, MBA, NRP please visit the link to (P): 817-535-6664 Sahaj Khalsa, BS, NRP, NM, I/C below Discount Rate Dr. William Robertson, orPhD, visitDHSc, the NRP NAEMSE website.

National Office Staff Stephen Perdziola, BS Executive Director Erin Mihalsky, AS Membership Coordinator Laurie Davin, AS Education Manager

Inspiring Educational Excellence

Jared Kallmann, BA Education Coordinator Amy Brooks, BA Office Coordinator

Reprinting Information Interested in reprinting one of the articles you find in this publication? If so, please contact Stephen Perdziola via e-mail at stephen.perdziola@naemse.org or by phone at (412)343-4775 ext. 25

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NEW EXECUTIVE DIRECTOR!

National Association of EMS Educators Names New Executive Director! Bryan Ericson, NAEMSE President, is pleased to announce that Stephen Perdziola (right) has been appointed by the Board of Directors to the position of Executive Director, effective May 1, 2019. Stephen has been the NAEMSE business manager since 2007. His responsibilities over the past 12 years have covered areas of finance, operations, payroll, auditing, symposium planning and staff management. Bryan stated that Stephen was the logical individual to move into the Executive Director position. He continued, adding that Stephen has the experience, knowledge and personality needed to continue the mission of NAEMSE; which is to Inspire Educational Excellence. Prior to joining NAEMSE in 2007, Stephen worked as the Assistant Director of Business Affairs for the Community College of Allegheny County, the second largest community college system in Pennsylvania, for almost 10 years. “I could not be more honored to serve, not only the NAEMSE Board of Directors, but also its membership, in the role of Executive Director.” stated Stephen. “With a great board and staff to work with, exciting things are on the horizon.”

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NAEMSE Symposium 2019! by Stephen Perdziola - Executive Director of NAEMSE I hope you are as excited as we all are to be heading back to Fort Worth, Texas for the 2019 EMS Educators Symposium and Trade Show July 31 - August 5th. For the NAEMSE Board of Directors and staff this is the largest event we work on all year. Along with the NAEMSE Board, staff and its members, we hope you will be there to take part in it. Why? Because the NAEMSE EMS Educators Symposium and Trade Show is a one stop shop for educators. During the 5-day symposium you will be able to network with other EMS educators from around the country, attend pre-cons and sessions allowing you the opportunity to learn new techniques, and shared ideas in, EMS Education. You will be able to check out dozens of vendors and suppliers that will inform you of new and exciting products and services to keep your program competitive in today’s market. In addition you can look forward to having some fun and socialize at the welcome reception sponsored by NAEMSE, iSimulate and the Public Safety Group. This year’s symposium will again allow you to hear updates from NHTSA, NREMT and CoAEMSP. Make sure you check out the Trading Post event, sponsored by FISDAP, where you will leave with new resources that you can use in your classroom. The cost is only $35.00. Pizza and beverages will be provided for a one of a kind networking event. *For more Trading Post Information, please refer to the right column on page 17 titled “Special Events @ Symposium” Symposium overview: 1) Location - Omni Fort Worth Hotel, 1300 Houston Street, Fort Worth, Texas. 2) Discounted rooms - NAEMSE has contracted with the Omni for a discounted room rate of $151.00 per night plus tax. 3) Registration - NAEMSE has kept the 3-day main registration cost the same from last year - $495.00 for non-member and $395.00 for member - this includes all meals served in the exhibit hall during symposium. 4) Pre-Cons - There are several excellent pre-cons this year being held including the NAEMSE Level 1 and Level 2 courses. Visit the website for a listing of all the pre-cons available. 5) Travel - There are 2 airports that service Fort Worth area - Dallas Fort Worth Airport and Love Field. NAEMSE has partnered with SWA for discounted airfare so check out the link at: https://naemse.org/ page/FlightInfo to see if any flights would fit into your travel schedule. I look forward to seeing you in Fort Worth, Texas. I will save a seat for you!

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WHY DO WE NEED EMS RESEARCH?

Why do we need EMS research?

EMS research is critical to validating new and existing evidence-based clinical interventions that are used in the prehospital setting. Where does it start? In the classroom? How do you as an educator make that happen? Register today for the NAEMSE Symposium pre-con “Get Your Classroom into Research” and find out! This two-day pre-con will be offered at the annual NAEMSE EMS Educators Symposium and Trade Show August 1st and 2nd in Fort Worth, Texas. This pre-con will be taught by David Page, Dr. Heather Davis, Dr. Kim McKenna and Megan Cory. It is our responsibility as educators to teach our students how to answer the questions they encounter in their practice once they graduate from our programs. Participants in this workshop learn how to incorporate research into all facets of the classroom and to create a lifetime foundation of acquiring knowledge for critical thinking. Visit www.naemse.org to see more about this year’s NAEMSE EMS Educators Symposium and Trade Show.

The National Association of EMS Educators and the Boys and Girls Club of Tarrant County Texas Team Up to Save a Life. NAEMSE is proud to announce its first Community Outreach Day on Friday, August 2nd at the 24th Annual NAEMSE EMS Educators Symposium and Trade Show at the Omni Hotel in Fort Worth, Texas. Joe Grafft, Bryan Ericson, Steven Mountfort along with MedStar Mobile Healthcare of Fort Worth will be training 40 teenagers on the curriculum of “Until Help Arrives”.

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This program teaches various aspects of dealing with an emergency: how to call 911, stay safe and care for an injured person until help arrives, stop the bleed and position an injured person while providing comfort. They will also be taught hands-on CPR and AED training. NAEMSE is looking forward to this new event and hopes to continue this local outreach at future symposium locations.

A MATTER OF DEGREES: THE CASE FOR DEGREED PARAMEDICS

A Matter of Degrees: The Case for Degreed Paramedics By Leaugeay Barnes, MS, NRP, NCEE, FP-C We have all seen the national discussions regarding requiring an associate degree for future paramedics. The National Association of EMS Managers, The National Association of EMS Educators, and The International Associate of Flight and Critical Care Paramedics published a position paper advocating for degreed paramedics which provided a catalyst for the national discussion (Caffrey, Barnes, & Olvera, 2019).

Goode, Park, Vaughn, & Spetz, 2013; Kutney-Lee, Sloane, & Aiken, 2013). Unlike other occupations, EMS is uniquely positioned within the community to identify and address healthcare disparities. Education provides EMS with the knowledge, skills, and abilities to change the paradigm from reactive to proactive.

EMS has arrived at a juncture; professionalization, which includes the ability to self-regulate and develop evidence-based practices, require formal education standards (Boyleston & Collins, 2012) as advocated for by the newly formed American Paramedic Association (APA). This should not be confused with personal professionalism or the argument of whether an individual degreed paramedic outperforms or underperforms as In the last fifty years, EMS has evolved far beyond compared to an individual certificate paramedic. EMS the entity envisioned by the National Highway Traffic has the opportunity to align itself with all other healthSafety administration (NHTSA) under the Department care professions enhancing respect. EMS specific reof Transportation (DOT) in the 1960’s. The name Emersearch is an expectation of increasing education within gency Medical Technician clearly identifies the extent of the discipline. practice the DOT projected; leaving little doubt to the amount of education initially suggested. Paramedics Recruitment and retention are concerning in an already today interpret complex medical information, practice strained system (IOM, 2007). EMS loses many of its best advanced life-saving invasive procedures, and adminand brightest to other healthcare professions when ister a variety of potentially fatal medications often they become frustrated and move to pursue greater with limited diagnostic information in an unpredictable compensation and opportunity for advancement (Blau, setting (National Highway Traffic Safety Administration Chapman, Gibson, & Bentley, 2011; Blau & Chapman, [NHTSA], 2007). 2016; Patterson, Probst, Leith, Corwin, & Powell, 2005). One reason often cited for the lack of a required minimum education standard for paramedics is the nascency of the discipline however, EMS is in a position to learn from other healthcare professions as we move into a future which must be proficient in adapting to an ever-changing healthcare landscape. EMS’s education standards, with its multifaceted roles within the community and significant impact on the public (Institute of Medicine [IOM], 2007) should not be considered any differently than other healthcare professions. In fact, the autonomous nature of its clinical decision-making (IOM, 2007) supports a higher level of rigor than many other healthcare disciplines where help is a few steps away. The most compelling argument for education is improving patient outcomes. Ask any EMT or paramedic their reason for entering EMS and the most frequent response is likely, “to help people.” Despite a paucity of EMS specific literature, nursing provides evidence of a decrease in both mortality and morbidity (Blegen,

Education can assist by creating opportunities and increasing compensation (Lemieux, 2014). The need to continually hire and train new employees adds further to the cost of operations which may be upwards of $10,000 each (Kirkwood, 2018). Interestingly, although most EMS programs are seeing lower enrollment and are actively recruiting, a majority of nursing and allied healthcare programs all requiring significant pre-requisites have waiting lists.

A quick search of the United States Department of Labor, 2018 website confirms the presumption that nursing and allied health occupations requiring a degree for entry-level providers are consistently compensated at a higher rate than those who do not. Colleagues in occupational therapy (OT) and physical therapy (PT) require an associate degree for their assistant programs and their compensation has significantly outpaced that of paramedics as has that of radiology and respiratory technicians. The causal effect between education and increased earnings is well-established across time,

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A MATTER OF DEGREES: THE CASE FOR DEGREED PARAMEDICS culture, and occupation (Lemieux, 2014). Paramedicine education hours and content continue to increase (National Highway Traffic Safety Administration [NHTSA], 2000) with most programs meeting or exceeding the contact hours required in an associate degree RN program. We are unfairly withholding credit from graduates of EMS programs that are anywhere from 1200 â&#x20AC;&#x201C; 2000 hours. Graduates who receive a degree have several long-term advantages over those who receive a certificate. A degree provides more opportunities in various venues and higher compensation (Lemieux, 2014). Personnel who become injured or burned out have a degree to fall back on rather than an expired state license and national certification. The decision to ignore issues associated with compensation and long work hours is a decision to continue the decline in the percentage of the population interested in becoming and staying involved in EMS as an occupation. It is time EMS evolve from the shifting-the-burden mentality (Senge, 1990) applying short-term fixes to ameliorate symptoms rather than resolving the fundamental problem (Jacobs, DiMattio, Bishop, & Fields, 1998). Currently, several national EMS documents and philosophies are being reviewed and revised which will guide EMS into the next decade. This offers a rare opportunity to inspire transformational and visionary change and take courageous steps towards confronting the market failures EMS is experiencing (National EMS Advisory Council [NEMSAC], 2012).

References

Blau, G., & Chapman, S. (2016). Why do emergency medical services (EMS) professionals leave EMS? Prehospital and Disaster, 31(Suppl.1), s105-s111. https://doi.org/doi:10.1017/ S1049023X16001114 Blau, G., Chapman, S., Gibson, G., & Bentley, M. (2011). Exploring the importance of different items as reasons for leaving Emergency Medical Services between fully compensated, partially compensated, and non-compensated/volunteer samples. Journal of Allied Health, 40(3), 33-37. Blegen, M. A., Goode, C. J., Park, S. H., Vaughn, T., & Spetz, J. (2013). Baccalaureate education in nursing and patient outcomes. The Journal of Nursing Administration, 43(2), 89-94. http://dx.doi.org/10.1097/NNA.0b013e31827f2028

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Boyleston, E. S., & Collins, M. A. (2012). Advancing our profession: Are higher educational standards the answer? The Journal of Dental Hygiene, 86(3), 168-178. Caffrey, S. M., Barnes, L. C., & Olvera, D. J. (2019). Joint position statement on degree requirements for paramedics. Prehospital Emergency Care, 23, 434-437. https://doi.org/10. 1080/10903127.2018.1519006 Institute of Medicine. (2007). Future of emergency care: Emergency medical services at the crossroads. Retrieved from The National Academies Press: https://www.nap.edu/ download/11629 Jacobs, L. A., DiMattio, M. K., Bishop, T. L., & Fields, S. D. (1998). The baccaluareate degree in nursing as an entry level requirement for professional nursing practice. Journal of Professional Nursing, 14(4), 225-233. http://dx.doi.org/10.1016/ S8755-7223(98)80063-X Kirkwood, S. (2018, January 29). 3 ways EMS leaders make or break paramedic training programs. EMS1. Retrieved from https://www.ems1.com/paramedic-chief/articles/374184048-3-ways-EMS-leaders-make-or-break-paramedic-training-programs/ Kutney-Lee, A., Sloane, D. M., & Aiken, L. H. (2013). An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Affairs, 32(3), 579-586. http://dx.doi.org/10.1377/hlthaff.2012.0504 Lemieux, T. (2014). Occupations, fields of study and returns to education. Canadian Journal of Economics, 47(4), 10471077. National EMS Advisory Council. (2012). EMS system performance-based funding and reimbursement model [Final Advisory]. Retrieved from https://www.ems.gov/nemsac/ FinanceCommitteeAdvisoryPerformance-BasedReimbursement-May2012.pdf National Highway Traffic Safety Administration. (2000). EMS education agenda for the future: A systems approach. Washington D.C.: Department of Transportation. National Highway Traffic Safety Administration. (2007). National EMS scope of practice model (DOT HS 810 657). Retrieved from https://www.ems.gov/education/EMSScope.pdf Senge, P. M. (1990). The fifth discipline: The art & practice of the learning organization. New York, NY: Doubleday Business.

A MATTER OF DEGREES: THE CASE FOR DEGREED PARAMEDICS Patterson, D. P., Probst, J. C., Leith, K. H., Corwin, S. J., & Powell, P. M. (2005). Recruitment and retention of emergency medical technicians: A qualitative study. Journal of Allied Health, 34(3), 153-162. Retrieved from http://www.ingentaconnect.com/content/asahp/jah/2005/00000034/00000003/ art00006 United States Department of Labor. (2018). https://www.bls. gov/

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TREASURER SPOTLIGHT

Lindi Holt PhD, NRP, NCEE NAEMSE Board Treasurer Hometown - Speedway, IN Current Employer - Hendricks Regional Health Job Title - Lead Paramedic, Community Paramedicine Program Job Scope - Lead clinician for the team. EMS Educator for the team. Assisting with program development and community resource involvement. Hardest Job Aspect - Not being able to help patients who need our help, but do not want our help. Most Rewarding Job Aspect - Being able to assist patients with navigating the healthcare system and linking them to resources to improve their quality of life. Why did you join NAEMSE - Charter member. I feel that EMS Instructors need mentoring and networking opportunities. Additionally, we should be our own advocates for job security and practice succession planning for the future of EMS. NAEMSE Activities/Participation - Regular presenter at symposium. Served on Education, Executive and Communications Committees. Have assisted with the development of the NCEE examination (NEMSEC Board member). Personal Hobbies - gardening & canning; rescuing special needs animals; running lights and sound for local rock bands. Who Would Play you in a movie - one of the munchkins in the Wizard of Oz. What is your refrigerator never without? REAL butter & Coke Classic.

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WHY YOU SHOULD JOIN You Belong

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Through the National Association of EMS Educatorsâ&#x20AC;&#x2122; expansive community of members, you will be consistently rewarded with one-of-a-kind interactions courtesy of our highly influential Instructor Courses and Annual Symposium & Trade Show. Coupled with access to our expansive Trading Post (a shared library containing thousands of documents, videos and presentations), joining NAEMSE affords you a vast web of professional and personal connections.

A NAEMSE membership means that you will be able to utilize the many discounts that are available, which include: SuperShuttle/ExecuCar, Hertz Rent-A-Car, and 50% off a subscription to Prehospital Emergency Care Journal; just to name a few. You will also recieve special discounted prices on all Instructor Courses, significant fee reductions on Symposium Registration, and much more!

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THE HANDS ON APPROACH TO GLOVES-OFF PRECEPTING

The Hands on Approach to Gloves-Off Precepting By Alyssa A. Tarvin, NRP Excellent. Not just good. Not just great but excellent. Isn’t that the level of care everyone in our community deserves? In many departments, everyone is a preceptor. To think that we are sticking our paramedic students with any paramedic assigned to the ambulance for the day, doesn’t make much sense- especially if that paramedic is not trained to teach or doesn’t want to teach. I personally don’t believe this has anything to do with the skills and level of care these paramedics provide; some just don’t like teaching or are not comfortable in that setting. Any paramedic can be an excellent preceptor, but it takes willingness, time, and commitment – and likely a step outside a comfort zone. Many departments have also intern programs. My employer, Burlington Fire Protection District pays up to $5,000 a semester for the student’s education, and the student is at the station for a minimum of 24 hours a week. Most of our students are voluntarily on duty every third day, going above and beyond their required time commitment, to gain as much experience as possible. The launch of our scholarship intern program coincided nicely with my interest in teaching, as our shift gained a few paramedic interns. Over several years I honed this preceptor system, which is systematic enough to produce consistent successful results, yet flexible enough for every level student. This program continues to be a work-in-progress, but I am confident this system will continue to produce great leaders and care providers. This system allows the preceptor to adapt to different learning needs of the student, pushes the student to the highest standard of learning and care, and creates a method that adds consistency among preceptors. The System: A Hands-On Approach to Gloves-Off Precepting Day One is the first day the paramedic student and preceptor are together. This usually works out to be one full day, or a couple short days, depending on their ride time schedule. “Day One” includes observation and an overview of ground rules, departmental policies, and

EMS protocols. Observation will quickly progress to assisting with basic skills and patient communication. This will rapidly allow the preceptor to determine the student’s comfort level in the back of an ambulance and interacting with people. My ground rules are fairly simple. But one thing I have learned, is to not assume anything is common sense. Everything should be explained in detail. Ground Rule #1: I explain upfront that we see some pretty crappy stuff in this job, and that the student has the option to “tap out” if something is too traumatic, too uncomfortable, too stinky, or too chaotic. We will discuss and process when we get back to the station. Ground Rule #2: The patient’s life comes first. I tell the student that they may get “pushed into a corner” if the run turns bad and the patient’s life is on the line. I remind them not to take this personally, and that I’ll review the circumstances when the run is completed. Ground Rule # 3: We will respect our patients and their families at all times, no matter what. Ground Rule #4: Accept criticism. For this system to work, the student must accept constructive criticism. I explain that I am going to be picky. I am going to be annoying. But I am going to make them excellent. Not just good, not just great, but we are striving for excellence. Ground Rule #5: My final, but very important ground rule is: DO NOT EVER LIE ABOUT A BLOOD PRESSURE. The reason this conversation is SO important to have is not about the accuracy of the numbers, it is about the sense of responsibility it should instill in our students. The student should recognize that they could potentially be holding the patient’s life (and my license) in their hands. I explain that many times, we base our medications and treatment modalities on vital signs and I am relying on them to help me gather accurate pieces to the puzzle to treat this patient appropriately. This conversation lets my student know that I mean business and that I am relying on them to be a strong part of my team- even if their only job is recording a blood pressure.

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THE HANDS ON APPROACH TO GLOVES-OFF PRECEPTING We spend the rest of Day One reviewing departmental policies and guidelines such as uniform policy, expectations around the station, truck checks, safety vest policy, and review of the patient care reporting software. I also discuss with the student the types of runs we will go to, the types of patients we will encounter, and how these runs can impact us mentally. During initial orientation, I have often seen new students sent to the ambulance to “learn where everything is.” While I understand the paramedic has other duties to complete before giving full attention to the student, it is generally not an effective way of learning the rig and equipment. I don’t care if my student remembers where the bedpan and mass casualty bag are on their first day. Now the emesis bag? Pediatric bag? Oxygen? These are essential and I go over this personally with the student. It is so important to establish the right tone for the relationship with your student. It’s essential that they know your expectations and that you are consistent with them. You aren’t their drill instructor, but you also aren’t their best buddy. Your sole purpose at this point in their career is to make them an excellent paramedic. PHASE ONE: SHOW ME YOU’RE A GOOD EMT In this phase, the student begins performing as an EMT and will eventually act as the primary EMT. I focus on teaching assessment in detail, while they are perfecting their EMT-B skills. The student eventually begins operating as the primary EMT. Upon completion of Phase One, the student will be aggressive with assessment, regardless of run type. On any BLS patient, the student will be comfortable as the primary care provider. On critical runs, the student is reliable as an integral part of the crew. We train our EMTs to spike IV bags, place ECG electrodes (both 3 and 12 lead) and prepare drugs for administration when assisting a paramedic. Our EMTs complete this “ALS-assist” course annually as part of our continuing education. I review this course with my student so they know what’s expected of them, and what they can expect from our other crew members. Students must be successful at Phase One before moving to Phase Two. There is no set timeline here because our EMTs all start with a different foundation. This system is performance-based, not time specific, so that at the end of Phase One, each student is in the same position.

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PHASE TWO: ASSESS, ASSESS, ASSESS Regardless of where the student is in paramedic class, this is where I begin teaching Paramedic-level assessment. Assessment is one of the most important and challenging tasks to master in the field, so I focus on teaching it very early. The newest beginner can learn assessment techniques that will serve as a great foundation for their paramedic-level care. I want my student thinking like a Paramedic before they have the responsibility of doing skills and managing the scene. Assessment within this system is split into two levels to allow for gradual learning. Level One teaches the student all about focused assessment. I perform my patient assessment as normal, including a physical assessment. Once we formulate a primary impression, the student performs the focused assessment. For example, if a patient presents with chest pain, I will obtain a history and determine that the patient is having chest pain (obvious softball). My student will then ask the patient to describe their pain, onset, and very importantly, pertinent negatives. As the primary care provider, I proceed with my treatment, explaining my treatment choices to the student while we transport. I always introduce myself and my student to the patient and let them know that I will be teaching while we are taking care of him/her. I have never once encountered a problem with this conversation. Most patients actually chime in and ask questions themselves. Although it really should go without saying, the teaching comes after patient care. I can ‘do’ and ‘teach’ well, but if a run is more critical, then patient care obviously supersedes, and we will discuss the run later. In order for a preceptor to be successful, he/she must be comfortable talking while doing. It may take some practice, but it is a skill worth developing. Level Two focuses on full assessment. As the student advances in class, they usually start becoming more involved in assessment in a very natural transition. You may have to coach your student to start speaking up to begin the initial assessment. For some reason, speaking the first word upon encountering a patient and leading the patient encounter can be very intimidating. During this phase, the student begins writing the

THE HANDS ON APPROACH TO GLOVES-OFF PRECEPTING narrative after every run. I will not write the narrative portion for them. I will, however, provide suggestions as they learn to write the narrative. I have thought extensively about this- should I make the students write these reports knowing they have to write a report of the encounter for school as well? The answer is yes because, although it can be a pain to write two narratives, the student is far more prepared to start working right away after graduation because they are so good at documentation and understand what’s expected. While they are learning how to write narratives, I will be very picky about language and grammar choices, and demand a detailed narrative. Essentially, I play the lawyer. If a third party read this narrative, knowing nothing about what happened, would they understand that we treated the patient correctly? Would the narrative paint an accurate and thorough picture of the patient encounter? I try to prompt them by asking questions regarding information they have omitted from their narrative instead of just correcting it. I often give my student suggestions and provide examples of how I write my narratives, but ultimately, how they formulate their narrative is their choice. During this phase, I continue to write the rest of the patient care report, so the student’s focus can remain on improving their assessment skills. Completion of Phase Two will not end with a perfect assessment. It takes time to master that skill. This is why I focus on assessment so early in the system. I believe this method is so successful in large part because we begin assessment well before traditional ride-time would have started. Completion of this phase often takes the student right up to the point of being “cleared for skills” in their class. If, however, the student has mastered assessment prior to being cleared to do skills, I will eventually become his/her skills assistant. This will give them a feel for being the lead provider while I perform skills for them until they are cleared. I will begin to focus on discussing treatment modalities and most importantly, the why behind them. PHASE THREE: SKILLS- PRACTICE MAKES PERFECT During Phase Three, I allow the student to focus on their skills. I show them a little grace and allow them to back off of doing the full assessment. It can be pretty difficult to juggle both right away, and I want them to become proficient at their skills. They will begin per-

forming all ALS skills and will start utilizing our crew EMT or me for BLS skills. The student learns how to assertively but respectfully assign tasks to other crew members. When we do our regular check-ins (to be reviewed later), I always ask which skills the student has performed least, or which ones they still need to perform for class; e.g., intubation, IO access. I will do my very best to assign them a skill they need when the opportunity arises. This requires communication to the rest of my crew en route to the scene and with the engine crew when we are on scene. My students know that if I assign them a skill, they must complete it. Patient care always trumps any skills checklist. We have a window behind the captain’s chair in our ambulance which I utilize on the way to a call to have a quick conversation with my student and my EMT. On any critical call, we establish a quick game-plan while en route. This gives the student the opportunity to remind me that they need an intubation and gives our crew a chance to prepare mentally for the call. We also discuss who is bringing what equipment from the ambulance. I give updates based on the notes from dispatch. On any call, I will drill them on their differential diagnosis based on the notes of the dispatch to prep for assessment on scene. These interactions may seem simple, and like common sense, but they make a huge difference in your student’s comfort level once on scene - especially on very critical calls. These continue throughout the duration of the student’s program. Regarding specific skills, I follow some guidelines, but it is situation-dependent. Generally speaking, I allow the student two IV attempts before I try to gain access myself. When performing an ECG, the student places the 12-lead electrodes and I place the limb leads. I review their 12-lead electrode placement every single time until I trust that they have it mastered. I am very particular about electrode placement, as you and your student should be. If a patient is extremely critical and needs something quicker than my student can perform, I will step in and perform the skill (see ground rules). This is a rare occurrence, and usually only happens with very critical pediatric runs. Most students understand and are almost thankful for the “step-in” in those instances. During this phase, I don’t expect my student to be

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THE HANDS ON APPROACH TO GLOVES-OFF PRECEPTING perfect at their skills. In fact, I don’t really even expect them to be good. I work with them on every single skill, until I believe they have gained enough proficiency that they only need practice. A few of my students have been extremely hard on themselves when they miss an IV. If there’s something I’ve noticed that they can improve on, or any tricks and tips I can offer, I will. But oftentimes, this frustration comes when the student has already been starting IVs for a while, and it’s just a bad streak. I have had students get visibly and vocally frustrated, use profanity in front of the patient or family members, or be completely distracted for the rest of the transport. I usually shoot them a “look” to let them know that their behavior is unacceptable, and then we discuss the incident after we transfer care. During this conversation, I don’t yell at them or speak to them like a child. I give them some advice on how to let it roll off their back so they can focus on the rest of the transport. I don’t badger them, and like any conversation we have, after it’s over, it’s completely over- unless my student wants to discuss it more. This issue alone is a big reason for letting the student just focus on their skills for this phase. Once the student shows proficiency in their ALS skills, and the ability to control their emotions if they don’t succeed at a skill, we begin Phase Four. PHASE FOUR: INTEGRATION This is by far the toughest phase for any student. Most students find the transition to “doing and talking” at the same time very difficult. This phase is led by your student’s comfort level and simply guided by you. At the beginning of this phase, you should take a look at how much time your student has left in class before they begin national testing and assess how much progress needs to be made to meet that deadline. The majority of my students arrive at this phase at around the halfway point in class (around month 6). Phase Four is when our students become paramedics. The student combines what they learned in Phase Two regarding assessments with their skills from Phase Three. Because they are expected to do both at this point, I will act as a second paramedic for ALS skills only if necessary. Otherwise, I will act as a basic provider. This is the first phase that you’ll really back off and start handing the reins to your student- or at least let them hold the reins too. But, I do not ‘throw my student to the wolves’ during this phase.

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During the initial assessment and gathering a history at the scene, I allow the student to do the majority of the assessment. I will insert my own questions if I feel they need to be asked. By continuing to engage, my student can learn from those questions and assessment techniques, which are often learned best by watching other providers. As we load the patient into the ambulance, I always have a quick 10-second conversation with my student. “What’s going on with this patient?” and “What is your plan?” I offer my coaching at that time if they need it, maybe a couple of quiz-style questions, and then I proceed with their acceptable treatment plan. I’m still reviewing, quizzing, and teaching during the run when appropriate. I still obtain patient information, document vitals and procedures as the student is performing them. I encourage the student to formulate and document their own primary impression, chief complaint, and of course, the narrative. The patient care report gradually becomes their responsibility, based on how they are advancing. I will call report if the student is tied up with the patient, because patient care is the student priority. I try hard to make it possible for the student to call report, when appropriate. Talking and doing is a skill the student must be developing at this point. As we approach the hospital, I ask the student what they are going to say when transferring care to the ER staff. After transferring care, I always ask the student if they have any questions, and my students should always ask if there is anything they could do better. Have the conversation about what to do better if you need to, but do so in an atmosphere of constructive criticism and encouragement. Always talk about the positives if you have negatives to critique. This phase requires an encouraging preceptor, but one who is not afraid to perfect this student. Our goal is excellence. The only way to obtain excellence is to constantly critique and improve, but keep a balance with positive feedback. Phase Four ends with a competent and mostly confident student who comfortably initiates aggressive assessment and treatment. This student does not miss things on “cookie-cutter” runs. Your student accepts criticism well and asks for ways to improve. A student who is ready to move on from Phase Four connects the why to the what; they understand the physiology

THE HANDS ON APPROACH TO HANDS-OFF PRECEPTING behind our treatment. Your student will be motivated to learn more and continue training. Your student will think almost as fast as you on complex runs. The student is able to write the majority of the patient care report, but prioritizes it correctly. A student who has successfully completed Phase Four manages time well in the back of the ambulance, balancing on-scene treatment and assessment with en route modalities. The student is starting to grasp scene management- which can be a very difficult development for those with little experience as an EMT, but we will continue to master this during the final phase. PHASE FIVE: YOU ARE THE PARAMEDIC- THE BIG PICTURE Phase Five is the hardest phase for preceptors. This is when we hang out in the background, and let the student take the reins. You must be extremely particular during the previous four phases- so you are comfortable letting go when it’s time. During Phase Five, I make a very conscious effort to not assist on assessment (unless the student is missing something HUGE- i.e.: time last seen normal for a stroke patient), and to allow the student to process through their treatment plan without coaching. Our job at this point should be perfecting our student, chiseling a great product, and making sure they don’t harm themselves or the patient. The student will utilize the crew EMT as their EMT. I am merely an observer, occasionally helping out logistically when it makes sense. (e.g.: carrying equipment, placing a blood pressure cuff, performing as directed by my student if the patient’s condition deteriorates during transport, providing advice on destination choices if absolutely necessary, and being available for consult on out of the ordinary runs). During the beginning of phase five, I still wear gloves. The student is writing the entire patient care report at this point. The student is calling for additional resources should they deem it necessary. They are choosing the transport destination, and unless I find it wildly inappropriate, that is their choice to make. This phase goes very well for most students who have followed this system and is extremely rewarding for you as the preceptor to see your student develop into a paramedic based on your precepting.

By the end Phase Five, I have removed my gloves and I sit in the captain’s chair belted in. I am literally there only to ensure that the student does not neglect care in a way that would harm the patient or the patient outcome. Despite the amount of experience and training you have given your student, they are still going to run into unfamiliar situations. You are there during Phase Five if they need to “phone a friend.” During Phase Five, I do not take over patient care reports. I’m here for questions and am more than happy to help, but it is their responsibility. I do not prompt unless it is something that will directly impact patient care or anyone’s safety on scene. I do not stop teaching after the run and I do not stop quizzing the student. I do not give report or add to the report unless student has missed something that is detrimental to transfer of care. Upon completion of Phase Five, you should have a Paramedic on your hands. You should have a partner that you feel comfortable working with. You should trust your partner enough to say, “get access,” or “you got the airway?” and know your patient is in the best hands possible. It is our responsibility to our patients to create outstanding, well-rounded, excellent care providers. ADDITIONAL COMPONENTS OF THE SYSTEM Equipment Checks: Each ambulance should be checked daily- we know that. I encourage our preceptors to use this time as a “drill and learn” scenario. You should touch almost every piece of equipment and use this as an opportunity to review with and teach your student. At first this will be a conversation; then it will become a quiz type interaction. Push your student to memorize, learn more, and think outside the box. Work through scenarios in which you would use the equipment and allow the student to ask questions and formulate their treatment plan. By Phase Five, you should have created a student that you can trust to complete this check the right way, every single time. Check-ins: Check-ins are sit-down conversations with your student. Go to the office or a small conference room, where you can have a confidential, frank conversation. By making these feel “official,” the student will take them more seriously, and I think we get better

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THE HANDS ON APPROACH TO HANDS-OFF PRECEPTING information to use to build or adjust our teaching style. This private conversation reinforces to the student that we are being critical to make them better, not to criticize them in front of the crew. In the beginning, these can be monthly. By the end of their program, you will be meeting weekly. During these meetings, I point out the things they are doing well, and I address anything they need to improve. These meetings are good for addressing things that they are consistently doing incorrectly, or less than par. If they are moving too slow in the system, we talk about what we can each do to speed up their progress. We discuss particular skills they need to complete for class, runs they want to see, and runs they still feel uncomfortable with. These are usually relatively relaxed and positive sit-downs but don’t be afraid to be blunt and upfront with your student and their progress. Your responsibility as a preceptor: Homework is your student’s responsibility. But I have found it very beneficial for me as a preceptor to sit down with my student occasionally and review some of their material with them. Mostly because the information is ever changing. Also, because it helps them to see that excellence in this career means constantly learning and seeking to improve yourself and the care you provide for your community. Depending on the opportunity in your area, another good idea is to attend some of their classes. The instructors always appreciate the assistance and it helps to go back to the skill sheets for some skills that we don’t perform often, or even the ones we can perform in our sleep. My recommendations on ride time: Most of my students have been scholarship interns at my department. These students are assigned to my shift 24 hours a week from the moment they start classes. They are typically utilized in whatever capacity is needed that day staffing wise, but we try to put them on the ambulance more often if they are pursuing a Paramedic degree or certification. I have had profound success with this method as opposed to having students pop in and out during their ride time as they hop from department to department. My recommendation is to take the hundreds of hours the students are required to ride (500 for our local programs) and allow them to start chipping away at them from the beginning of class. The skills requirements would be the same, and they wouldn’t start

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until they have been properly trained on those skills. They would, however, start learning assessment right out the gate. Finding a good preceptor at a department that has any decent run volume is key. Our department makes around 1,800 EMS runs a year, where neighboring departments are making as low as 100 and as high as 9,000. Students should have an allotment of hours (maybe 50 or 75), which they use to ride in very busy departments. The experience at these departments is absolutely necessary, but should not consume their ride time. This experience at very busy departments helps their time management, as most busy departments are inner city and close to the hospital. This allows the student to really feel what busy feels like and figure out how to manage that. Oftentimes, the students go to busy departments and their preceptor is different every time. It’s just whoever happens to be on the ambulance that day. Having the same preceptor who truly enjoys teaching Paramedic students at a slower department is more beneficial in my opinion than hopping around to 15 different busy departments. Disclaimer: if there is an incredible preceptor at a busy department, then proceed with the system. I can acknowledge and appreciate the desire to learn a little something different from a variety of preceptors, and exposing students to busy departments is a great way to get this exposure and experience. They can get a feel for how other paramedics do things and take bits and pieces from each, just as we all did. You will also take vacation days and rotate off the ambulance every once in a while, to meet staffing needs, so your student will be exposed to other paramedic preceptors. But as a general statement, having the same preceptor for at least 70% of their schooling and starting a consistent rotation on the ambulance as soon as possible has proven most effective in my experience. Why I precept: I look at precepting as an opportunity to impact someone’s view on this career, as my preceptors impacted mine. I can influence (somewhat) how my student will treat the grandma that hasn’t bathed in two weeks and calls at 3am because she is lonely. I can hopefully influence how my student will process his or her first pediatric cardiac arrest. I will impact the essential information my student passes along to the hospital when transferring care and I will make them a provider that always thinks one step ahead. I will teach them

THE HANDS ON APPROACH TO HANDS-OFF PRECEPTING tips and tricks and knee jerk reactions that have saved my patients’ lives. I will help them avoid some of the mistakes I have made and teach them to learn from the ones they inevitably will also make. I am hopeful that by precepting, I can create more paramedics that go the extra mile and maintain their education and love for the job. I am hopeful that I can create more paramedics that want to teach their own students to do the same. At the end of the day, I have saved lives based on researched algorithms and protocols and because of what my preceptors, educators, and instructors taught me; that one tip, that one little trick, that one little red flag to always watch for, and that ability to distinguish between sick and not sick. My preceptors and educators have saved the lives of my patients through my hands, and that is a beautiful gift and opportunity we have in this career.

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References

Paris PM, Roth RN: EMT-Paramedic: National Standard Curriculum. Available at http://healthandwelfare.idaho.gov/ portals/0/Medical/MoreInformation/Paramedic%201998%20 National%20Standard%20Curriculum.pdf