Part 30: Three Ways to Failure

After the in Havre de Grace, I had a meeting with training officials at the Maryland Institute of Emergency Medical Services Systems (MIEMSS), located in the venerable Greene Street Building across the street from University Hospital.

I decided to meet with them without Bill Brown – not because I thought he or I were wrong in any way, but just to eliminate another variable.  So far his friendship had brought me nothing but trouble.

We went over the exam results in detail. Bill and I had each failed three out of the 20 skills testing stations.

The multiple-trauma station I already knew about. Bill and I had treated two simulated life-threatening conditions – a sucking chest wound and an arterial bleed – simultaneously rather than completing one task before attending to another.

This was never mentioned once during the refresher course, I pointed out. And as a practical matter, I’m not about to let an artery bleed out while my partner puts an occlusive dressing on the chest wound.

No matter, they said. That’s how the exam is scored, and that’s an automatic flunk for that station. That’s the Maryland way.

At another station, Bill and I each reached over the patient, which is apparently a no-no in Maryland. Never reach over a patient, the MIEMSS guys said. That’s an automatic flunk for the station.

Gee, I never heard that before, I said. It doesn’t make sense, but whatever. I was beginning to discern a pattern. I said that there is a disconnect between testing standards and course curriculum. If these skills are critical do-or-die standards, we’d have been better off discussing them during the refresher course rather than talking about .

And the third station? I failed to measure a blood pressure within 2 mm of what the instructor found.

That’s ridiculous, I said. I’ve done blood pressures hundreds of times. Thousands of times. I know how to take a blood pressure.

Here’s how the station was set up: Inside a closed office, the instructor measures the blood pressure of a standing volunteer. The subject lies down on the floor, the door opens, and the student enters the office and measures the volunteer’s blood pressure. The second measurement is supposed to be plus-or-minus 2 mm of the first measurement.

I sighed with exasperation. Guys, the way you have it set up is wildly unpredictable and uncontrolled. The blood pressure is not the same standing and supine.  There’s no way you’ll get the same blood pressure. The BP can fluctuate on its own from minute to minute. It isn’t reasonable to expect a person to get the exact same measurement that somebody else got minutes earlier with the patient in a different position.

It would be more accurate had the volunteer been left in a supine position on the floor. That would at least eliminate orthostatic differences from standing. Even better would be to use a standard training stethoscope with two sets of earpieces, so the instructor and student hear the same sounds at the same time. That’s the only way to be sure two people can get the same measurement at the same moment.

The two MIEMSS training officials looked at each other. You’re right about that, they conceded. Good idea. From now on, we’ll use training stethoscopes.

But you still failed, they said.

I suggested that Bill and I be given an opportunity to re-test the three stations in question.

Can’t do that, they said.

They told me I could repeat the fresher course. All you have to do is finish the course again, pass the written test, and pass the practical exam.

Nope, I’m done, I said. If Maryland doesn’t want me, I don’t want to be a Maryland EMT. Maybe this Maryland way isn’t all that it’s cracked up to be.