Whatever will we do without the skill sheets?

Mix three parts primary survey and one part secondary survey in a pit-crew bowl. Slowly stir in a complete set of vital signs and some OPQRST as the history thickens. Add a dash of DCAP BTLS and My Baby Looks Hot Tonight, and transport for 5-15 minutes. Let cool in ICU for 3-6 days. Serves six.

If that sounds a bit ridiculous to you, it should. Yet, that is the way thousands of EMT students have learned psychomotor skills – and worse, the way instructors have taught it – for a couple of generations: as a recipe to be followed. Rote memorization of steps and parroting of arcane phraseology took precedence over actual skill or understanding. EMS instructors treated the NREMT psychomotor skill sheets as a recipe, and EMT students dutifully memorized those skill sheets, as if following the recipe to the letter made them skilled practitioners. [At the end of this article, download a guide to creating an EMT evaluation rubric].

It didn’t make for skilled practitioners or clinicians with critical thinking ability, it simply created a skills monkey. If evolution in EMS practice has taught us nothing else – remember when we gave high-flow oxygen for everyone, and collared and boarded every trauma patient? – it’s that there is nothing so pointless as being highly proficient at performing a procedure that harms patients.

So, after a great deal of input from EMS educators, thought leaders and system stakeholders over recent years, NREMT announced on August 24, 2021 that the ALS psychomotor exam would be discontinued in phases as part of its ALS Redesign Project, with full sunsetting of the ALS psychomotor exam completed by mid-2023:

“As we discontinue the psychomotor examination, we begin expanding the current cognitive examination to include new material related to communications, leadership and clinical judgment. The expanded examination will focus on soft skills and the EMS process.”

Bravo, NREMT. BRAVO.  

After being a vocal critic of NREMT in the past, the evolution of their CE process and now their initial certification standards has impressed me greatly. They are no longer the stodgy, hidebound organization I once considered them. They’re evolving, as EMS evolves. If only the few state EMS offices who still believe they adequately test EMS practitioners themselves could do the same.

And to add the cherry on the top of the good news sundae, NREMT announced in the same press release that it would be removing all EMR and EMT psychomotor exam materials from its website, prompting unoriginal and lazy EMS instructors and state bureaucrats everywhere to screech, “Whatever will we do without the skill sheets?”

Teach and evaluate EMTs, that’s what you’ll do. That’s what you should have been doing all along, as opposed to failing students who don’t meet an archaic and artificial standard of performance that had little clinical relevance 20 years ago, and has none now. For as long as I’ve been a paramedic, the advanced airway station gave you only 30 seconds per airway attempt, as if everything we’ve learned about pre-oxygenation and apneic oxygenation is moot. Generations of EMTs were taught the mnemonic “My baby looks hot tonight,” to remember the order of securing straps on a Kendrick Extrication Device – middle, bottom, legs, head, top.

Where did that come from? It certainly didn’t come from the inventor of the device; if you mention that mnemonic to Rick Kendrick, he’ll roll his eyes so hard he can see his own occipital lobe. It came from well-intentioned EMS evaluators in state EMS offices, who thought that some standard, even one they invented themselves from thin air, was necessary to protect the health and safety of the citizenry their EMTs were trusted to serve. It was a noble intention, but you know what they say the road to Hell is paved with …

I have been listening to EMS educators for years blaming NREMT for its unrealistic testing standards, when those unrealistic standards originated in their own state EMS offices. These are your people creating the hoops you must jump through, not some monolithic bureaucracy in Cincinnati. The NREMT’s official position has been for many years that the various state EMS offices who require psychomotor exam testing – and that’s still most of them – own the BLS exam. They administer it, they set the standards. NREMT has merely provided a set of testing rubrics to facilitate that, and has simply announced that it will no longer do so.

That’s a good thing, if you let it be. If you’re going to build a psychomotor skills competency portfolio in your EMS education program, or if your state still insists on a separate psychomotor exam, here’s your opportunity to evolve with the times. You still need an objective evaluation rubric, but it need not require a step-by-step recitation of phraseology or silly mnemonics. Many of the skills and clinical tracking apps available to EMS educators already have a full suite of such rubrics, or you can create your own.

I’ll list a few key points in developing your own evaluation rubrics:

• Understand that it is an evaluation tool, not a how-to guide. That’s how we’ve been treating it all along. Remember that the items on your rubric are typically ordered in the sequence that it is easiest to grade. The students should not necessarily be expected to perform the steps in that order.
• Don’t ever let your students see the skill sheets until late in their education. Teach them the proper techniques, sequences and behaviors; how to do the skill, not the skill sheet.
• Penalize only process errors that undermine proper care and outcomes. There is more than one way to skin a cat, and more than one way to assess and treat a patient. What matters is outcome.
• You’re the educator, but you are not the sole source of information. The students you have today have a wealth of resources to learn from. Vet them for accuracy, but embrace different approaches to education if they’re clinically valid.
• Abandon the “classroom vs. street” mindset. Skills are skills, and if they’re taught well in the classroom, they’ll hold up well on the street.
• Think in broad strokes. Avoid the temptation to make your evaluation rubrics – and most especially your “fail points” – too specific. You need to leave room for clinical judgment, both for yourself and your students.

If you do those things, you’ll be well on your way to evolving into a better EMS educator or evaluator.

In recent years, my state has revised its EMT psychomotor exam twice, and both times, my classes were pilot programs for the new psychomotor exam. First, they sunsetted old skill stations like Seated Spine Immobilization and Supine Spine Immobilization, and added a BLS Integrated Out Of Hospital Scenario (IOOSH) modeled after the one administered at NREMT ALS psychomotor exams. Next, they pared the EMT psychomotor exam down to only three stations: Medical IOOHS, Trauma IOOHS and Cardiac Arrest Management. One of the IOOHS stations will involve a special populations patient (pediatric, geriatric, abuse, special healthcare needs, etc.).

My students rocked the new exam both times, and I didn’t have to alter my teaching style a bit. You and your students can do it too.

Fill out the form below to download a guide to creating an EMT evaluation rubric.