Mod-4 is the medical assessment module. This module is referred to at my training center as "The Wall" that a student must get over. There are 10 separate sub modules in MOD-4 which should take at least 31 hours to complete. This is a quarter of a standard course. This is important since most of our patients in EMS fall into the medical category.
Lesson 4-1 General Pharmacology
Provides the student with a basic knowledge of pharmacology, providing a foundation for the administration of medications given by the EMT Basic and those used to assist a patient with self-administration.
Lesson 4-2 Respiratory Emergencies
Reviews components of the lesson on respiratory anatomy and physiology. It will also provide instruction on assessment of respiratory difficulty and emergency medical care of respiratory problems, and the administration of prescribed inhalers.
Lesson 4-3 Cardiovascular Emergencies
Reviews of the cardiovascular system, an introduction to the signs and symptoms of cardiovascular disease, administration of a patient's prescribed nitroglycerin, and use of the automated external defibrillator.
Lesson 4-4 Diabetes/Altered Mental Status
Reviews of the signs and symptoms of altered level of consciousness, the emergency medical care of a patient with signs and symptoms of altered mental status and a history of diabetes, and the administration of oral glucose.
Lesson 4-5 Allergies
Teaches the student to recognize the signs and symptoms of an allergic reaction, and to assist the patient with a prescribed epinephrine auto-injector.
Lesson 4-6 Poisoning/Overdose
Teaches the student to recognize the signs and symptoms of poisoning and overdose. Information on the administration of activated charcoal is also included in this section.
Lesson 4-7 Environmental Emergencies
Covers recognizing the signs and symptoms of heat and cold exposure, as well as the emergency medical care of these conditions. Information on aquatic emergencies and bites and stings will also be included in this lesson.
Lesson 4-8 Behavioral Emergencies
Develops the student's awareness of behavioral emergencies and the management of the disturbed patient. Restraining the combative patient will also be taught in this lesson.
Lesson 4-9 Obstetrics/Gynecology
Reviews the anatomical and physiological changes that occur during pregnancy, demonstrate normal and abnormal deliveries, summarize signs and symptoms of common gynecological emergencies, and neonatal resuscitation.
Lesson 4-10 Practical Skills Lab: Medical/Behavioral Emergencies and Obstetrics/Gynecology
Draws on the knowledge and skills learned thus far in this practical lab. Students will be given the opportunity to assess and treat a variety of patients with various medical complaints.
Lesson 4-11 Evaluation: Medical/Behavioral Emergencies and Obstetrics/Gynecology
Conducts a written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction.
The MOD-4 evaluation usually consists of a written test (50 questions in our training center) plus three or four practical assessments. At our training facility we run 4 practical assessments: Cardiac Arrest, Medical Assessment, EPI and Medical Protocols.
The MOD-4 medical assessment practical test is patterned after the MOD-3 test. A scenario is given to the student that covers one of the four drugs that an EMT-B can give with standing orders or medical control. These drugs are nitroglycerin, epinephrine, meter-dosed inhalers such as albuterol and glucose. Here is a typical scenario for nitroglycerin:
You are going to be evaluated in the MOD-4 patient assessment module. You have ten minutes to complete this evaluation. You may use any equipment set before you or request any additional equipment not present. Any information that you would normally see upon arrival will be given to you. I will answer any questions as though I was the patient. You may assume that you have an equally trained partner with you. Please remember that I can not read your mind. You may decide not to perform a procedure or assessment - and that may be the correct action depending on the scenario - but I do not know if you made a decision or forgot something. In either case if you say nothing you will fail the point. Please if you make a decision please let me know. Are you ready?
This rather stern message is to let the student know that they need to say things pertinent to the assessment. For example, if the scenario does not involve a significant mechanism of injury and the patient has good skin color, condition and temperature the student may decide not to use oxygen. This may be correct but if they don't mention that fact then I assume they forgot and they fail a critical portion of the assessment.
You and your partner are called to a local residence at 19:30 after a snowfall. Dispatch informs you of a 58 year-old male experiencing chest pain. Upon arrival you find the patient sitting in his living room. He appear conscious and is breathing. Please begin your assessment.
There are several objectives to be accomplished by the student. I look to see if they have maintained their skills from MOD-3. The MOD-4 test is traditionally held several weeks after MOD-3 and there may have been a degradation of skills. Some critical failures would be lack of proper body substance isolation, failure to ensure a safe scene, failure to contact medical control or verbalize standing orders. Of course I want them to perform a proper initial and focused assessment. I need to have the student verbalize that vitals would be taken before and after the medication is given. Other things I look for is a proper medical history with particular attention to SAMPLE and OPQRST.
The student needs to perform the tasks in a logical order and done decisively. I tend to fail students who show a lot of hesitation. We have to make sure that the student is not going harm the patient.
The MOD-4 practical exam also has a CPR/AED assessment test. What we have found at our training center is that it has been several weeks since they may have any CPR training. Students are supposed to enter the EMT-B program with a valid CPR card. Our training center is also a certified American Heart Association CPR training center so we train all of our students in CPR prior to the start of the EMT-B course. Unfortunately by the time the student gets to MOD-4 (in our latest course which started in September, we did not got to MOD-4 till November) their skills may be non-existent.
Thus I look for good, basic CPR skills in this assessment. I want to see if they recognize the need to perform 2 minutes of CPR for an unwitnessed arrest versus applying the AED immediately. I give them a scenario similar to this:
You are going to be evaluated in the MOD-4 CPR module. You have ten minutes to complete this evaluation. You may use any equipment set before you or request any additional equipment not present. Any information that you would normally see upon arrival will be given to you. I will answer any questions as though I was the patient. You may assume that you have an equally trained partner with you. Please remember that I can not read your mind. You may decide not to perform a procedure or assessment - and that may be the correct action depending on the scenario - but I do not know if you made a decision or forgot something. In either case if you say nothing you will fail the point. Please if you make a decision please let me know.
I usually test two students at a time and make the following addendum to the instructions:
You are testing separately from your partner. If your partner performs a skill that may harm the patient or result in ineffective care you both may fail the station. If you see and correct the actions of your partner you may pass and your partner may still fail. You need to show proficiency in your skills. Are you ready?
Sometimes we get students who are natural leaders and some who are natural followers. As an evaluator you need to balance their actions along with your students personalities. If you run into a situation where one student bullies another you may want to have the bullied student immediately retest. I complete the scenario as follows:
You have been called to a local residence for a 68 year old male who is unresponsive. His wife has called 911 but is unable to assist you in any manner other than informational. His down-time is approximately 5 minutes. Begin your treatment.
What I look for specifically in this station is good 2-rescuer CPR skills. I also look to see if the team is working well together. Of course I want to see the AED applied at the correct time and used correctly. Clearing the patient is a critical skill and needs to be emphasized. I also want to see oxygen equipment integrated into the treatment without delaying patient care.
One thing we need to keep in mind as evaluators is that the skill sheets that are published with the national curriculum are not consistent with the 2005 CPR guidelines.
Our training center integrates the EPI pen procedures and assessment into the regular patient assessment. We also add a new assessment into MOD-4. This is a medication protocol assessment. We make the student tell us the protocols for the other drugs that we can administer as an EMT-B
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