A few months ago, I attended some refresher training on the video laryngoscope that had recently been added to our department’s protocols. Apparently a review of the PCR data showed that we weren’t using the VLs and that intubation rates had not improved. It was unclear whether or not that was because of an actual problem using the device or documentation errors, but the decision was made — correctly, in my opinion — to provide an in-service VL refresher to every ALS provider.
Unfortunately, this opportunity, like many, was another one wasted.
The paramedic who conducted the training did a good job. It was helpful to practice with the device, become comfortable with how it works, and use it on a manikin a few times. But the training could have been so much more.
After all, how often do we talk to and train every ALS provider in the agency? Besides the regular required continuing education sessions, and an occasional protocol change, it’s a rare occasion. And when we do, we often focus solely on a specific skill, like VL intubation. We don’t tie the motor skill to the cognitive decision-making process that might be necessary to perform it appropriately, nor did we even train on the other motor skills that often precede or follow intubation.
For example, part of using a video laryngoscope is deciding when to intubate, positioning the patient properly, choosing the right tube, suctioning, and ventilating the patient both before and after intubation. Yet, none of those skills was discussed during this training. Or practiced. We didn’t even have a mask, so BVM ventilation prior to intubation couldn’t be simulated, even though it’s a critical skill that we don’t practice enough, especially those of us who are ALS providers.
Contrast this with another training session that I got to teach, but can take none of the credit for, a few months earlier. Another protocol change enabled BLS providers to begin administering intramuscular epinephrine by drawing it into a syringe from a vial. The change was made to save money by no longer purchasing epinephrine auto-injectors.
The slides and other teaching materials, which were provided to me, covered more than the basics of how to draw up and administer the medication. Even though the indications for giving epinephrine had not changed, just the method of administration, we covered how to recognize the signs and symptoms of allergic reactions, what the side effects of epinephrine are, and what other medications and treatments should be considered for those patients. We put the skill into clinical context and took advantage of this opportunity to comprehensively review the topic.
Before implementing any training program, but especially those that are mandatory for every provider, such as the introduction of new equipment or protocols, consider these questions:
1. Am I focusing too much on the motor skill and not the cognitive thinking that should go before, during and after the procedure?
Any training that focuses solely on a single skill creates dangers. Perhaps new caregivers, recently given a new tool, will be in a rush to use it, even at the wrong time. Or maybe, as in the case of drawing up epinephrine, providers will be too hesitant to try something that’s new, different, and for years they’d been told they weren’t qualified to do.
Others have said more eloquently how focused we are on skills, rather than clinical decision-making, in EMS. Every single time we review a skill we need to also reinforce the thought-process that we use to determine whether or not to perform that procedure.
2. What other skills, tools or equipment should I have personnel use during training?
If a skill is always accompanied by other skills, do them together. This is especially critical in airway training. I remember in paramedic school when we had a long list of skills that were required. Intubation was one. Bag-valve mask ventilation was another. Suctioning was on the list also. But these aren’t just three isolated techniques. Each and every time you have a laryngoscope and a manikin, you should have a BVM and suction.
We’re really good at saying that “we practice like we fight,” but we’re not as good at actually doing it. Every time a paramedic starts to intubate and doesn’t have suction ready, it’s because we often have trained that way.
3. Does this training present a good chance to review a protocol or clinical condition?
Training on how to use a new CPAP machine? Seems like a perfect opportunity to review the pathophysiology and signs and symptoms of congestive heart failure or chronic respiratory ailments. Or perhaps to review the importance of and indications for also giving nitroglycerin to those CHF patients.
Interventions do not exist in a vacuum, but we often teach them like they do, setting up providers to fail and patients to receive potentially dangerous care.
