Using Case Studies in EMS Courses -- Part III

When EMS instructors imagine using a case study for evaluation purposes, their initial thoughts go directly to the National Registry Exam format: students are provided a scenario, and based on their assessment findings, follow a systematic checklist of critical and non-critical skills. Clearly, this method is a poor method for instruction and learning; however, for testing it has a few legitimate (and several not-so-legitimate) purposes.

The first disadvantage of this method is that the simulated patient cannot be real—the only true way to evaluate performance is to observe students in the clinical setting. Within the testing format as we know it, students simply memorize the testing sheets and regurgitate the information when requested to do so at the exam. Those who memorize well will do well, those who don’t will fail. As most experienced instructors know, the best field providers are not necessarily those who did well in a lab setting.

A second disadvantage of using the “checklist” method for evaluation is that the system does not promote critical thinking, and is not instructional in nature. The format in place is intended to be black and white for obvious reasons. However, based on this “black and white” test, students are deemed as having met minimum competency for practice in an EMS world that is clearly not black and white. However, from a fairness and consistency standpoint, using the checklist assures fairness and consistency among all students, all tests and all regions. In recent years, some flexibility has been added. For example, in the splinting station, it does not matter how one achieves the goal of limb immobilization, as long as strict principles of care and assessment are followed. Additionally, the format stresses those skills in practice which are most important and most critical. The system really helps students prioritize care, an important skill for EMS providers to possess.

There are, however, ways within the classroom that this same system can be used to not only evaluate, but also to promote learning. For example, students could be provided with a written scenario before the actual test day:

EMTs are called to the scene of a six year old who has fallen off the monkey bars at the local school. The school nurse relays through dispatch that the child is responsive but confused. He is complaining of neck pain and had a short loss of consciousness.

At the next class, you will be evaluated on how well you complete a trauma assessment and spinal immobilization on this patient. Be sure to review age appropriate care, closed head injuries and spinal care in children.

Though the instructor will use the checklist to verify that minimum competencies are being met, students continue the learning process by preparing for a very specific type of patient. A variation on this would be to provide students with several scenarios to study, and then testing them on only one of them.

Another effective method to promote active student learning during the evaluation process is through the use of take-home examinations. The process of finding answers to questions, either alone or in groups, can result in high quality learning, and develops students’ collaboration skills. Additionally, students are encouraged and rewarded for finding supporting data for their answers.

Using critical thinking papers (versus “term papers”) allows students to explore problems from a perspective of discipline they may not have thought about before. Imagine having to defend this example in a critical thinking paper:

EMTs respond to a motor vehicle crash and transport the patient to the local rural hospital after providing expert care. They have extricated and immobilized the patient, assessed the patient as critical, have applied high flow oxygen, started an IV, and cared for the client’s fractures. Upon arrival at the ED, the doctor removes the collar, and the nurse replace the non-rebreather mask with a cannula.

Your job is to defend the physician’s and the nurse’s actions using examples from the literature. Use whatever resources are necessary to complete this project.

Such a paper forces students to analyze education, work roles, and functions. They may interview others and will learn what their personal contributions are to the team, as well as develop a greater understanding of others’ roles. This interactive process contrasts significantly with the typical scenario provided by EMS instructors. However, from an evaluation standpoint, multiple objectives can be accomplished. Students can be graded on the effectiveness of their argument, eloquence of their writing, and on the evidence that they provide. This could be followed up with a formal debate where students take sides. The essential component in this process is to assure that the evaluation criteria are established at the onset of the project.

Finally, perhaps the most common method to evaluate students using case studies is through the use of formal written exams. When written effectively, high level critical thinking questions serve to evaluate a student’s ability to perform in the clinical setting. Using Bloom’s taxonomy is an important step in writing high level critical thinking questions. Some standardized national exams (like the nursing NCLEX exam) establish that a majority of questions developed are scenario-based and use the higher levels of Bloom’s taxonomy. This is accomplished by assuring that every test item has a provider and a patient. Using this format, students are required to solve live problems in a forced critical thinking scenario. Compare the two questions below. Note that both are asking similar content: one stimulates critical thinking, the other requires memorization. The likelihood that the memorized content will be remembered long term is low, when compared to the application level question.

2. EMTs respond to the scene where a child has sustained “road rash” following a fall. The two external skin layers have been destroyed, leaving a layer composed largely of fat. What is the name of the observable layer remaining?

In this case, good follow-up questions would be: “Which layer has been destroyed?” or “The EMT would expect the bleeding from this skin layer to be….” Such questions require that students not only have the knowledge about the layers of the skin, but that they also have the ability to apply that knowledge.

Bloom’s taxonomy is a classification system used for educational objectives and for writing test questions.

Knowledge level questions require verbatim recall of specific content. The student need only memorize the information. They do not need to understand it to be successful in the test. For example:

1. A patient asks the EMT what MCI stands for. The EMT knows that MCI means: _____ .

Comprehension is the next level of information, and like knowledge level items, does not require or imply understanding. Rather, it illustrates the student’s ability to utilize the same terms as the instructor or text. Students are able to choose similar answers, which they have seen previously. It does not assure that the EMT can perform at the level of the question. For example:

2. EMTs respond to the scene of an MCI. The crew chief of the first responding unit assumes the role of: _____ .

The EMT does not need to know how to be a triage officer or what the triage officer does. Instead, she just needs to remember the labels attached to the order of the EMTs’ arrivals.

The ability to use newly learned concepts in specific situations signifies the Application level of learning. Again, experts agree that a majority of questions at the end of a course should be application level or higher. Application items require students to know how to think, rather than how to memorize.

3. The triage officer at the scene of an MCI finds seven patients. Four are tagged “red.” Of the following patients, which would have the highest acuity, and therefore would require immediate transport?

In this question, not only does the EMT have to “organize” care, he must also demonstrate an understanding of the role of the triage officer, and must know the terms (e.g. MCI). So the application level questions require knowledge and comprehension to be answered correctly.

Analysis items break an idea, problem, or disease into component parts. These questions take a known concept and require in-depth analysis. They are high level in that students must choose the best choice out of multiple correct choices.

4. The EMT at the scene of an MCI must utilize resources efficiently. Of the following patients, which would the EMT elect to not transport first?

The student answering this question will want more information, but given the information provided, they must be able to deduce the patients who are most likely to live or die. This requires an understanding of head injuries, EKG interpretations, etc. This is a very high level question that requires full analysis. It is a question that is difficult to answer if one has simply memorized the content in the book.

Finally, Synthesis items require the EMT to develop his or her own plan of care. Multiple choice questions cannot be written at the synthesis level easily, though they represent the highest level of learning. It forces EMTs to make bridges between the known and the unknown.

As instructors are writing questions which stimulate critical thinking, in a scenario format, it is useful for them to review the verbs that go with the Bloom’s taxonomy (Table below). It should be noted that most EMT test banks include mainly knowledge and comprehension level questions which do not stimulate critical thinking; consequently, instructors should begin to develop their own tests banks that have higher level questions. This will undoubtedly improve students’ success and promote critical thinking.

Knowledge	Define, distinguish, list, recall, reorganize
Comprehension	Translate, paraphrase, restate, rearrange identify
Application	Apply, generalize, organize, classify, separate
Analysis	Contrast, deduce, analyze, discriminate, categorize
Synthesis	Propose, plan, produce, design, formulate

Case studies and scenario based learning in EMS are relatively new. However, as prehospital care becomes more complex, students must learn the reasons behind what they are doing. Case scenarios and test questions written in this format promote a greater understanding, increase the effectiveness of the learning, and eventually result in better prepared, better thinking EMTs.