Eighty Percent…


That’s what my pass rate was for my students’ EMT-Basic exam yesterday.

On the face of it, that doesn’t seem so bad, but when you’re used to a pass rate of 96%, it’s cause for disappointment.

80% marks the lowest pass rate I have ever had. Failing an exam station, even just one, is an anomaly.

My students just don’t fail.

If they fail, it means I have failed. I invest a lot of emotional capital in my students. To me, that’s the difference between teaching and instruction.

A few years back, I wrote a little article for an EMS e-zine outlining my personal philosophy on teaching EMT students that works better than anything I’d scribble here. Give it a read, and then we’ll come back:

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On an EMS discussion list recently, I happened to mention that I had once trained retrievers professionally. Given what I currently do, I took a lot of ribbing about the similarities between training retrievers and teaching EMT students. Gary Saffer was particularly droll, inquiring if I had ever had to whack an EMT student on the nose with a rolled-up copy of JEMS.

Although I’ve been tempted, I’ve never had to go that far, nor have I ever had to rub an EMT student’s nose in the puddle of biohazardous waste they left on the floor of the rig. I was however, struck by the similarities between my former career and my current one. Many training principles are universal, whether applied in the classroom or the training field, and I thought I’d write down some of the truisms I’ve discovered along the way.

1. “You can’t polish a turd.”

I’ve only been training EMT students for about ten years, but I started training retrievers professionally at age fourteen. In the ensuing twenty years, that much has become obvious, distilled down into one line borrowed from Greg Margolis.

Natural instinct cannot be taught.

A wise old dog trainer told me once about teaching a dog to do multiple retrieves, “Son, as long as the dog can mark and remember a fall, I can teach him to count.” The trainer realized that the dog has to have some innate ability to excel at his job.

This concept holds equally true for EMT students. You can’t teach a student to think laterally rather than linearly. Students either have the ability to think on their feet or they don’t. In class, we develop those traits, but we can’t teach it to them if it’s not already there. Sure, you may teach a student enough to earn a patch, but they’re not going to excel as a street medic without those traits. And sadly, traditional EMS education often actually suppresses those traits.

You can force a retriever to do a lot learned tasks, but they’re not much fun to hunt with. Also, the student, either canine or human, has to have the smarts to make it all the way through the training program. A great many simply don’t have what it takes. The trainer has to identify those that don’t have what it takes very early in the game and screen them out. It’s the only fair way to do things – further polishing of the turd only serves to smear feces on the entire class.

2. Fundamentals are learned in the classroom.

You know, they call it a classroom because the students go there to well, you know, learn things. The street, your job, is where you put what you’ve learned to good use. Real life is not a kind teacher. It can be especially brutal to those EMTs who lack the critical skills necessary for learning those lessons the street provides. Those skills are called fundamentals, and they’re learned in the classroom.

I take issue with the types who tell the rookie medics when they hit the streets, “Here’s where the real learning begins, kid.”

Not so.

The street amounts to an extensive postgraduate education in EMS, but if the rookie didn’t have a sound undergraduate education, they are going to fail.

I like to call the EMS instructors who subscribe to this philosophy “The STREET Society.” They teach their classes with endless war stories that begin with the refrain, “When y’all get to THE STREET…”

Retriever trainers have a similar nemesis in the “by gosh, by gum” club of dog owners. They introduce their retrievers to water by throwing them in, or introduce to gunfire by dragging the puppy out to the gun range. “By gosh, it seemed like a good idear, so I figgered, by gum, I’ll give ‘er a whirl!”

The sink or swim instruction method is not a character builder, folks – it’s an esteem destroyer. While I made of great deal of money fixing the mistakes of idiots like these in the retriever training business, in the EMS profession it drives good people out of our ranks.

3. Even an EMT can get collar wise.

A “collar wise” dog is one who knows when the electronic collar is on and when it’s off. In competition, they realize they can screw up with impunity. The problem occurred because the trainer screwed up – used a training instrument as a punishment tool. Sounds a lot like a poorly set up QA program doesn’t it?

Before long, the medics resent the FTO, and rebel in a million little ways. Often they don’t take him seriously in situations where he can’t punish them. The relationship between the FTO and medic is damaged, often irreparably. Inadequate supervision often encourages the EMT to screw up when the FTO isn’t looking.

A collar wise retriever is extremely difficult to fix. A collar wise EMT may not find peace with the current FTO or company – all because a tool that should have been used for improving the EMT’s performance was used to punish instead.

4. Don’t neglect the positive reinforcement.

In any one EMT class or retriever training string, a certain percentage will excel no matter how pathetic a teacher you are, a certain percentage will lie around licking their testicles (or flirting with their classmates, or sleeping), and the rest will lie on the bubble of passing or failing, depending upon your skill as an instructor.

This last group needs to hear the words GOOD JOB as often as we can find a reason to say it.

The unmotivated or talent-deprived fall into that category of unpolished turds, and our best choice is to separate them from the rest of the class as expeditiously as possible.

The top people in your class are largely self-motivated, and could pass an EMT by correspondence course with flying colors. The best you can do is harness their energy and enlist them in your goal of helping those on the bubble. Negative reinforcement (punishment) usually doesn’t work on the majority of them, and may wind up creating a collar wise dog or EMT. Judicious negative reinforcement of your top achievers is sometimes effective in harnessing their energies, but is very delicate ground to tread.

5. Create a positive learning environment.

Retriever training, as simply as I can put it, is all about contriving a situation where it is easier for the dog to do the correct thing, and then offering positive reinforcement when they do it.

EMT training follows the same guidelines – show the student the right way to do things, and then supervise them doing it. Praise them when they get it right. Give them a break when they get tired. If it’s easier to sit and semi-consciously highlight the textbook or chat with their neighbor than listen attentively to what you are saying, have you contrived a situation where it is easier to do the right thing?

6. Never pass up a teachable moment.

Mistakes happen. Dealing with that fact of life will become much easier if you learn to view a student’s mistakes as learning opportunities. As EMT instructors, we strive to make sure those mistakes occur in the classroom rather than on the street, but this is an unattainable goal.

When I had retriever who appeared to have mastered a training scenario, I immediately started to get suspicious. I would add variables, trying to make it easier for the retriever to do the wrong thing. The difference was, I knew that the dog already knew what was expected of him. In other words, I was trying to create a teachable moment, contriving a situation where the retriever could make the mistake in a setting where I could correct it.

I don’t need to do that with EMT students – real life provides more teachable moments than I could ever hope to contrive on my own. But I keep my eyes open for the lessons that can be learned from them.

7. Practice does indeed make perfect.

And perfect practice makes for perfect execution. In the street, we’re going to screw it up. That’s a given.

Want a recipe for disaster?

Take one EMT student

Add practice in artificial, classroom situations.

Repeat until confidence is gained.

Let cool on the street.

Proceed directly to chaos.

After the student has learned the fundamentals of a skill, we add layers of complexity until we’re approximating, as closely as possible, street conditions under instructor supervision.

Most of the real work of retriever training is practiced endlessly on a baseball diamond, or on a field with grass no higher than a golf course fairway. Layers of complexity are slowly added in training, until we’re approximating situations the retriever might see in competition or the duck blind.

EMTs do not learn those basic skills on the street, and retrievers don’t learn them in the duck blind.

Those are the places where you find out if the practice paid off.

To be able to do things without conscious thought, especially under stress, there is no substitute for constant repetition.

8. Paper training EMTs and paper training retriever puppies is very similar.

If you’ve ever done chart review of EMS run reports, you feel my pain. Some of the veterans are as bad as the students and rookies, much like the retriever who was raised in the yard that suddenly becomes a house dog.

Like retriever puppies, EMT students’ paperwork tends to be messy, there is usually too much shit on the paper, and all too often something really important shit doesn’t wind up on the paper at all.

Given patience, guidance and positive reinforcement however, both of them seem to get much more efficient with paperwork as they get older. Some of them learn to do without paper entirely.

I’m talking about the retrievers, folks. Maybe your EMS system has pen-based run reports, but some of it still goes on paper, right?

9. EMTs and retrievers filter their information through a prism of past experiences.

Adult learners feel the need to relate what they’re learning to their own life experiences. As they become experienced EMTs, they’ll compare patient presentations and situations to ones they’ve seen in the past. The more experiences they have, the more meaningful a new learning experience is likely to be.

This puts a tremendous responsibility upon the shoulders of the instructor to ensure that these initial learning experiences be positive ones, because the student is likely to forever after approach new situations with “that’s not the way we learned it in class.”

When a retriever steps to the line in competition, or in a duck blind, he flips through a mental photo album of all of the past retrieves he has catalogued until he finds a photo that resembles the scene in front of him. If some of those photos are flawed, there is always the chance he will choose a flawed photo as the template to make the next retrieve. The more experienced the retriever, the larger his mental photo album and the more likely he is to find the right photo to help him make an accurate retrieve.

Like a good preceptor will make sure the student has made the right diagnosis, a good trainer recognizes when the retriever is looking at the proper picture.

10. Set limits, and stick to them.

Dog training is exactly like classroom management in this regard. Set clearly defined limits, let the students know what they are, and let them know the consequences for exceeding those limits.

Do not bend on this issue.

If you call for att
ention three times before you finally wind up shouting at everyone to shut the hell up and settle down, be prepared to have to call for attention three times and finally shout every time you need the students’ attention.

In dog training, the principle we follow is never give a command you are not prepared to immediately enforce.

11. The really good ones can amaze even the teacher.

I believe that some retrievers possess critical thinking skills. Laugh if you will, call it anthropomorphism if you want, but I’ve seen champion retrievers work out complex situations time and time again that I know they weren’t trained for. The only explanation I have is that they were figuring things out.

Like these once-in-a lifetime dogs, occasionally we have those students as well. They grasp abstract concepts in a flash, master skills without breaking a sweat, charm colleagues, patients and fellow students alike, and go on to bigger and better things.

If they were retrievers we would breed them, and make lots of money doing it. With our EMT students, what we hope to do is impress upon them the importance of what it is that we do, and their place in our wonderful profession. And we stay in touch with them as much as we can and keep encouraging, because we need these people to pass their gifts on to the next generation.

And maybe one day if we’re lucky, they’ll mention us by name in a national EMS publication or dedicate their first textbook to us – the EMS instructor’s equivalent of a “Hi, mom!” on a nationally televised football game.

12. At some point, you gotta let ‘em go.

You can’t ride the rig with your student, and you can’t go hunting with the dog after you’ve sent it back to its owner. By the same token, it looks pretty silly for the student to haul textbooks around on the job, and it looks pretty sad to see a retriever wearing a training collar in the duck blind.

You can be certain that once class is over, some owners are going to screw up their dogs, and some EMTs are going to wind up at agencies that waste their talents at best, or ruin them outright.

Your graduate will often make you proud, and sometimes they will embarrass you. Sometimes the best of them will do both. I’ve trained champion retrievers, and I’ve trained excellent paramedics.

The last two recipients of the Robert E. Motley EMT of the Year award were my students. I’m proud of both of them. They’ve also done things to disappoint me.

The best you can do is hope that the education you gave them will sustain them on the street, and that you’ve helped instill the attitude that the learning is now up to them.

Anything more than that is not worth your ulcer.

The parallels here could go on, but you get the picture. My last retriever, Epi, was trained using the same principles that I used to break in my last partner on the ambulance. It’s debatable which one is the better companion – Epi holds a big edge in the swimming in freezing water department and follows directions much better, but Bodie has a slight advantage in IV starts and EKG interpretation.

Bodie is also is a national award winner. Epi’s bad luck in being born without opposable thumbs, I suppose…

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I suppose the reason I was so disappointed is that none of my students were turds. I expected better of them. They’re all going to be good EMTs. Even the weakest of them is probably better educated and more skilled than some of their counterparts who are already on the job.

Lots of EMT instructors blame their students’ failings on the exam staff. They paint the exam staff as a bunch of trained seals who don’t really understand the nuances of the skills they are testing. Personally, I’ve always felt that was a cop-out. I was a Quality Assurance monitor at our National Registry Exam for years, and we had a good bunch of examiners. With very few exceptions, most of them were practicing EMTs, and good ones. They could think on their feet.

But judging from my students’ experiences yesterday, somehow we’ve gotten some trained seals in examiner positions. Some of them failed my students because of pure chickenshit, or simply not knowing how to do their jobs. That is inexcusable.

Don’t get me wrong. They failed some of their stations purely on stupid errors. Those are easy to fix. Most every time I’ve had a student fail an exam, they knew exactly what they had done wrong.

But when your best student (one who had already been an EMT in the past) fails his strongest station, and doesn’t know why, and then goes back and passes his retest by doing it in exactly the same way, we’ve got a problem with the trained seal doing the testing. I saw that pattern repeated several times yesterday.

I suppose I’m going to have to do more bomb-proofing of my students in future classes.

Before yesterday, that meant that I drilled them to the point that they could go to the exam hungover from the night before, get in a fight with their spouse that morning, have a flat tire on the way and hike to the exam site, get a call from their CPA telling them that they’ve been hit with an IRS audit right before they walk into the exam room…

…and still kick ass and take names.

Now it looks like I’ll have to include what to do when you are smarter than your examiner.

And Ryan, Missy, Matt, Frank, Joey and Tommy? It was a pleasure to be your teacher. I’m proud of each and every one of you guys.

Yeah, even you, Joey.

You’re going to be good EMTs, and it’s not your fault that you were smarter than some of your examiners yesterday.