By Craig Hall
If we look back over the past 10 years in EMS, a lot has changed in regard to the type of training we do. Active shooter scenarios and classes like TCCC (Tactical Combat Casualty Care) are now commonplace in civilian EMS. One of the things that I constantly ask myself is, “Is the training we do effective?” Having the opportunity to be both a civilian and military medical instructor, I get to see how training is conducted in multiple settings. While there are many similarities in how the training is conducted, it is the differences where I really get to learn. In the civilian world we focus on things like adult learning theory and starting every practical scenario with the phrase “scene safe, BSI." The military tends to focus on muscle memory, conditioned responses and training scars. What is a training scar? To put it very simply, a training scar is a bad habit that we teach people during our training. While the military and law enforcement have realized that not all training is good, EMS is still playing catch-up. Law enforcement training scars came to the forefront in April 1970 following the Newhall Massacre. The Newhall Massacre was an incident in Los Angeles, CA where four California Highway Patrol officers were killed in less than five minutes by two gunmen. During the after-action reviews of the incident, several bad habits that these officers were taught during training came to light. The officers were issued .357 Magnum handguns and carried .357 Magnum ammunition while on duty. However, the officers may have not have been used to the recoil, thus affecting target acquisition, because they only ever trained with .38 Special ammunition. One of the officers approached the gunman with his weapon in the high port position instead of a combat ready position. The high port position is how they were taught to carry the shotgun at the range in order to keep it pointed in a safe direction.One of the officers ended up ejecting live ammunition from his shotgun and was found deceased with his empty weapon on him. It was discovered that CHP never did any training with rapid fire shooting with the shotgun. While widely disputed, one of the reports stated that one of the officers had empty shell casings in his pocket. What this means is that the officer took the time in a gunfight to pick up his spent ammunition. This habit was attributed to fact that officers were taught to pick up the spent ammunition at the range in order to make clean up easier. While this specific incident is open to speculation, there have been several documented cases of officers involved in shootings being found with spent casings in their pockets. Following the Newhall Massacre, the CHP revised several of their training procedures in order to prevent similar future incidents. If you bring this concept to EMS, our training is full of training scars. They may not be evident every day, but when we are faced with a crisis and providers fall back on conditioned responses, these scars could prove fatal either for the provider or their patient. When I develop training programs, I try to be mindful of these training scars and make sure I am not sending my students back to the street with potentially dangerous habits. Here are some of the key points that I feel help build a strong training program. “Train as You Fight”
This is a concept that the military is very familiar with but I have noticed that it isn't very prevalent in EMS. What it means is to provide training that is a true representation of how we will end up using our skills. As I mentioned earlier, one of my pet peeves is the starting of every practical scenario by raising hands and saying “Scene safe, BSI”. This practice alone has several potential training scars. First of all, if you are teaching BSI, make your students don the appropriate level of PPE based on the scenario. Secondly, force the students to actually evaluate the scene for potential hazards and communicate them to their partner. This could be as simple as a sound effect of a large dog barking in the simulated residence, or upset family members. I also try to evaluate whether students do things like block their exit or let someone get between them and their escape route. This teaches the students to maintain a situational awareness from the beginning. "Train as you fight" can also include things like having the students backboard a patient who fell between a wall and a toilet. I don’t need to tell anyone in EMS that not every patient in need of c-spine precautions will be in the middle of a classroom with no obstructions. During an intubation practical, have your students intubate the manikin on the floor or on a litter. We all know that in the prehospital setting we don’t always intubate at table level.
Provide Realistic Patients
One of my goals in my training is to eliminate having the instructor give assessment findings. I do this by using realistic injuries and medically trained “victims” who know how a patient will act and how they would respond to interventions. My opinion is that we are training students to prompt the instructor to give them assessment findings as opposed to training the students to do a complete exam and make the findings themselves. This was extremely evident when I had a student ask a "victim" where he was shot and the victim said, “I was hit in the arm.” Despite a realistic wound and a high-end bleeding simulation system providing profuse arterial bleeding on the left arm, the student proceeded to apply a tourniquet on the victim's right arm. When asked why he did this, the student replied, “Sorry, I’m not used to having to look for wounds, the instructor normally just tells us what we would see.” While I realize that moulage and realistic injuries can be time consuming or expensive, the benefits outweigh the cost. .
Provide Realistic Training
We would never expect a firefighter to go to his first call before he did a live burn, and we wouldn’t let a police officer go on patrol if his preparation didn’t involve training with live ammunition and actually having to fight an opponent unarmed. We do this stress training so that in a stressful situation we can elicit a conditioned response and the firefighter or police officer can function in the high stress of their job. However, with EMS we tend to keep our training on the projector screen and in the classroom. I can’t explain why we do this, but we can all agree that it’s much easier to extricate a patient from a desk chair than it is to find a suitable vehicle. By providing a realistic setting for something like a vehicle accident, we are forcing our students to assess the entire situation and find not only injuries but possible hazards. Another thing we may want to consider is how an actual incident may play out. I have talked to numerous people that expect me to be impressed that during their MCI drill they had 40 “patients” triaged, treated and transported in 15 minutes. We can all agree that this could easily be done in a situation where we had 40 ambulances staged at the MCI when it begins. Things like releasing ambulances from staging after a realistic “response time” passes, or having units go down mechanical all provide that realism that we need to give our providers.
Provide Realistic Outcomes
I once had a wrestling coach who told me that during my preseason matches, he would rather see me lose every match than win them all. At the time, this made no sense to me. His logic was that if I won, I would see no room for improvement, but losing would force me to go back and evaluate my performance under a microscope. The same holds true in EMS training. We tend to try to train to success and don’t allow the situation to end realistically. I remember long before I was even an EMT, I had to do CPR on a 14 year-old who was hit by a falling tree. Unfortunately, he did not survive. I remember being racked with guilt thinking I did something wrong. Why did I think this was my fault? Because in every CPR class I took, the practical scenario ended with my “patient” getting a pulse back. So in my mind, when my real patient didn’t get a pulse back it must’ve been poor CPR, not severe trauma that resulted in death. By preparing people for the unavoidable outcome we can help ready them for future calls while assuring them that they did what was needed.
Training scars are inevitable in EMS, but through a little bit of preplanning we can help minimize them. The next time you develop a training scenario, try to keep some of these points in mind. If you do incorporate some of these concepts, I’m sure you'll not only make your training more valuable; you will also make it more enjoyable for your students.
