Using Case Studies in EMS Courses

[Part I]

Daryl Boucher, MS, RN, EMT-P; EMS Coordinator, Northern Maine Technical College

Published in the Fall, 2003 edition of the Maine EMS I/C News

As EMS instructors and providers, we have all become accustomed to using case studies and scenarios as an integral part of lab practice. Instructors develop complex patient assessment scenarios and make up data as they go. Though these scenarios are effective at evaluating already-learned material, they are simply not effective at “teaching” new material for the first time. Unfortunately, it is crucial that our students, especially EMT-Basic students, are exposed to a large number of case studies, primarily because most of the National Registry exam questions are set up as scenarios. In order to be effective, not only should lab evaluations be set up in scenario format, instruction and written evaluations should be too. This is the first in a series of articles that will introduce instructors to instruction, development, selection, and evaluation using case studies.

Three fatal errors occur when using case studies as a method of instruction that eventually lead the instructor to give up the method. First, the instructor usually ends up lecturing before commencing the scenario. Consequently, there is not enough time to do either correctly. We have all fallen into the trap of starting the class with a two hour lecture, and spending the last hour trying to “cram in” a few case studies. Though this is a good evaluation tool to determine how successful your teaching has been, it does not meet the primary goal of case studies: to get students to think critically in a given situation, and to be able to change their thinking and treatment when the situation changes. It is time-consuming to develop high quality case studies with critical thinking questions, but doing so really improves the quality of the learning.

A second error we instructors make when using case studies is that we tend to be pedagogical in our EMS teaching approach. We give students the case study, and evaluate their performance using a checklist. We identify critical skills and non-critical skills. Thus, what students learn is what they have memorized from that checklist. How would students perform if we didn’t use a checklist, or if we included additional information that wasn’t part of the checklist? A key component of effective case study use is to have high quality critical thinking questions built into the case study. We should also have preplanned alternatives, based on the students’ response. If the student chooses a wrong treatment choice, we should allow the student to progress through the case study to learn the possible, realistic consequences of that action. To promote learning more consistent with adult learning styles, we need to allow students to debate treatments or pathophysiology before providing them with answers.

Using realistic case scenarios prevents having bizarre vital signs, or actions that are unrealistic. Case studies should initially be very short, providing minimal details. Students will build on the detail as the scenario progresses. In some classes, I have used two or three case study scenarios that progressed in complexity throughout the entire course. For example, I used the case scenario described below initially to teach scene safety and possible scene hazards (i.e., where should the provider park), then progressed to include the correct assessment of vital signs, correct positioning of patients, airway anatomy and physiology, advanced airway management, shock treatment, body systems isolation, etc. One well-developed scenario can be just as effective as multiple scenarios, and may be easier to develop. It is important, however, to be sure that students are aware of the learning objectives of the scenario, in order to stay on track.

The final error instructors often make is not clearly setting out an expectation that students come to class ready. It is difficult to do a case study if students have not read before class, are not even familiar with the content, and have had no expectation imposed on them by the instructor that they be ready. An instructor’s role is to teach beyond what is in the book. Students should be expected to have read the required material before class to prepare them for the class, and then the case study reinforces what they have read, provides an opportunity to apply what they have read, and permits evaluation of their understanding of the concepts. In my classes, students who have not read are not allowed to participate in the case study. (Typically, I send them to the library to read the material. Rest assured that the students feel like they are missing out, and they typically come to class very well prepared in the future!) To evaluate preparedness, I ask students to come to class with a list of written questions about the readings. I try to address these questions as part of the summary at the end of the session, though most are answered during the case study presentation itself.

To illustrate these points, here is an example of a short but effective case study. Students should come to this case study familiar with vital signs, physical assessment and kinematics of trauma. They should have read the chapters on abdominal and thoracic trauma, but this will be the first class where these are discussed in detail. The purpose of this case study is to identify treatment and positioning of trauma patients. (Students are made aware of this objective.) I will not do any introductory teaching on the topic, but will leave time at the end of the session to summarize important points or to reinforce areas of concern. (I have selected a few, but not all, of the questions I use with this case study.)

It is 11 p.m. on a cool fall evening. A patient is shot in the left upper chest with a high caliber weapon and is complaining of severe shortness of breath. The entry wound is 1 cm to the right of the left nipple, with slight oozing. He is lying supine, in a pool of blood. Police and bystanders are surrounding the patient. The ambient temperature is 45 degrees.

After you have assured scene safety, what assessment data do you want? (Because the focus here is positioning and treatment of chest injuries, I will not focus on previously learned treatment.) A comment like ABCs, O₂, IV, and monitor would be sufficient. I would expect someone to talk about lung sounds, exit wounds, vital signs, etc. At some point, perhaps in the summary section, we would place these treatments in the correct order. I make the scenario realistic, with ordinary findings initially. Later, we can introduce abnormal or unusual findings.

Discuss organs which may possibly be injured, and what you would expect to find if that organ were hit. I go around the group and pick on people, until we are out of organs. I don’t correct errors; instead, I let the students do that. For example, if a student says the liver might be hit and identifies the correct signs and symptoms of a liver injury, I might say something like, “Describe the trajectory of the bullet that would make it possible for the liver to be involved,” or “What assessment data would you have to find for a liver injury to have occurred?”

What is the best position for this patient and why? Once they have answered that question correctly (i.e. in the lateral recumbent position because…) I will ask a follow up, with a change in scenario: What if he was shot in the right chest? What if it was a low speed bullet? How would your treatment change if this patient was pregnant? Would you consider PASG? Why or why not? What might happen if you placed the patient supine?

This type of “Socratic” questioning is frequently augmented by “Why” questions. I am frequently not looking for any particular “correct” answer, but instead I want students to become used to questioning why we do things in certain situations. I consistently use open-ended questions, and assure everyone is chosen to answer a question. I immediately give positive feedback for both correct and incorrect answers, recognizing that the fear of making an error in a class of adults is very threatening. For incorrect answers, I might say, “Oh, that is a really good thought process. Let’s consider…”) By creating an environment that permits errors, students become more engaged and willing to participate.

Just like a good short story, a case study must have an organized introduction and background section, clearly identified objectives, one or two major issues, effective questions or issues that stimulate thinking, and a good conclusion. The conclusion should include a summary of all the high points. However, the conclusion doesn’t have to include a patient living or dying, or an improvement or worsening of vital signs. Instead, the closure can simply be a review of all the actions, placed in the correct order. The end result is frequently the production of students more satisfied with the learning process, more confident in their skills, and better able to think critically.

For additional reading on the case study method and Socratic questioning, try the National Center for Case Study Teaching at the University of Buffalo: <http://ublib.buffalo.edu/libraries/projects/cases/teaching/flesch.html>.