EP. 7, Affective Domain in Paramedic Education

This week we have the great opportunity to speak with the Chair of the SMCC paramedic program, Eric Wellman.

Today we are talking about the Affective Domain. Which is only helpful if you understand the context right? Bloom's taxonomy is a theory on how to create a better learning environment and more involved students.

The Three Domains of Learning:

  • Cognitive: mental skills (knowledge)

  • Affective: growth in feelings or emotional areas (attitude or self)

  • Psychomotor: manual or physical skills (skills)


Today we are focusing on the affective domain. As we mentioned, This has been introduced into the National Standard Curriculum. 

“Affective - Students must demonstrate professionalism, conscientiousness and interest in learning. The affective evaluation instruments contained within this curriculum were developed using a valid process and their use is strongly recommended. Just as with cognitive material, the program cannot hold a student responsible for professional behaviors that were not clearly taught. The professional attributes evaluated using this instrument references the material in the Roles and Responsibilities of the Paramedic section of the curriculum. The instruments can be incorporated into all four components of the program: didactic, practical laboratory, clinical and field internship. Students who fail to do so should be counseled while the course is in progress in order to provide them the opportunity to develop and exhibit the proper attitude expected of a paramedic. " (Director, n.d., p. 26)


“Using the results of cognitive scores has not guaranteed that students will succeed in a particular academic program. Therefore, finding a method to assess affective domains in potential applicants has been recognized as an important consideration. " (Lyman, 2014, p. 70

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Director, P. (n.d.). EMT-PARAMEDIC: NATIONAL STANDARD CURRICULUM. Retrieved from http://www.nhtsa.gov/people/injury/ems/EMT-P/disk_1%5B1%5D/Intro.pdf

Lyman, K. J. (2014). The Relationship of Affective Domains and Cognitive Performance in Paramedic Students. University of South Florida. Retrieved from http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=6455&context=etd


Blooms rose

EP.6 Chest pain, Zebras do exist!

LITFL: Chest pain DDx

EMBasic has a great review of evaluating the patient presenting with chest pain. It is Residents/Jr. Docs, but if a paramedic can do a physician quality assessment it just makes them a good paramedic!

While we should always think Horses before zebras, it doesn't mean zebras don't exist!

Ultrasound diagnosis of type a aortic dissection

Ultrasound Of The Week #17

While we are still waiting to see Ultrasound on our buses, I think it's good to start talking about the uses in the back of an ambulance. Evaluating for Pericardial effusion is a decently well-documented use (1,2).

  1. Bhat, S. R., Johnson, D. A., Pierog, J. E., Zaia, B. E., Williams, S. R., & Gharahbaghian, L. (2015). Prehospital Evaluation of Effusion, Pneumothorax, and Standstill ({PEEPS)}: Point-of-care Ultrasound in Emergency Medical Services. The Western Journal of Emergency Medicine, 16(4), 503–509. http://doi.org/10.5811/westjem.2015.5.25414
  2. Chin, E. J., Chan, C. H., Mortazavi, R., Anderson, C. L., Kahn, C. A., Summers, S., & Fox, J. C. (2013). A pilot study examining the viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol. The Journal of Emergency Medicine, 44(1), 142–149. http://doi.org/10.1016/j.jemermed.2012.02.032

EP.5 Managing Cardiac Arrest as a Paramedic Student

Welcome to the paramedics Guide to the Galaxy! Today I have an interview with a fellow Paramedic student,  Patrick Guziewicz. (@guziewiczp)

Patrick's take home points:

  • EMS is a team sport, be confident, stay humble.
  • Bystander CPR is ESSENTIAL to increase OHCA survival.
  • The paramedic running the code needs to run the code. Not the IV, IO, Drug box, Or monitor.
  • Early Chest compressions and Defib are the priority. 

Nicholas' take home points:

  • Some of the Greatest Atrocities in history were made "Just following orders"

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Nicholas (@nikolace)

EP.4 Cardiac Arrest... When to Transport.

Thank you for tuning into the MaineCrit podcast and checking out the show notes!



Cardiac Arrest... When to Transport.


First, Transporting a patient in cardiac arrest is NOT beneficial unless the receiving facility is prepared and equipped to continue the resuscitation by treating reversible causes that EMS cannot. This is for EMS and ED providers.

The Case:

A 42 year old man awoke in the middle of the night with sudden, sharp chest pain and shortness of breath.  He had no previous cardiac history and appeared very fit.  His wife called 911.  EMS arrived to find their patient in severe extremis and poorly perfused. He progressed to PEA arrest and the crew performed high quality CPR immediately. Advanced airway Obtained IV access. Several rounds of epinephrine. They worked the code for 20 minutes per protocol but did not get ROSC in the field so they called it.


The patient had minor surgery within the last week...


The hospital was half a mile away...

Take Home Points:

  1. Most patients who suffer an OHCA will not survive intact unless ROSC occurs in the field.
  2. There are reversible causes that most EMS systems cannot treat but an Emergency Department can.
  3. There will be a small subset of viable patients that may be saved if transported expeditiously.
  4. It is possible to transport patients in cardiac arrest safely with manual CPR and, perhaps someday, mechanical chest compressions and ventilation will open up additional options for longer transports to tertiary hospitals.
  5. We must give every patient a chance for a successful outcome if such a chance exists.  That is what Resuscitationist do!  We must not give up unless there is nothing else that can be done.



SMACC/Cliff Reid - When Should Resuscitation Stop

ED ECMO - Annie (May 2013), 60+ minutes of CPR

Dr. Smith's ECG Blog - 68 minutes with chest compressions, full recovery.

Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity

Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest

A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity.

Medic to medicine part 2, with Michael Lauria.

Cricothyrotomy, Training, and mental simulation.


Twitter references:

Minh Le Cong @ketaminh

Scott Weingart @emcrit

Cliff Reid @cliffreid

Anand Swaminathan @EMSwami

Social media

Last Mile Health


Thank you so much for listening! Stay tuned for more material from MaineCrit!

Medic to Medicine: Michael Lauria

Review our show notes as you listen to the podcast!

Michael Lauria, Paramedic and MS-1

MaineCrit traveled down to Hanover, NH

 to interview flight paramedic and MS-1, Michael Lauria(@ResusPadawan)

Toughness Part I with Michael Lauria

Scott Weingart's interview with Michael on Mental toughness.

The Importance of GRIT

John Greenwood's post about GRIT on IteachEM.

Hofstra North-Shore

"New Med Students Training as EMTs"

Victoria Brazil - Evidence-Based Education- What Works

SMACC Gold lecture on what works in education. The answer is yes. The answer is also no.

Mental practice: a simple tool to enhance team-based trauma resuscitation




Full article: Mental Practice for Trauma Resuscitation http://t.co/k1zOBjPRt8#FOAMed@CJEMonline@ResusPadawan@EMSwami@Inject_Orange — Christopher Hicks (@HumanFact0rz) April 11, 2015

And finally, Dat library...

Just a small piece. 

Shock Essentials in 8 Minutes

Shock:  Inadequate perfusion at the cellular level.

“The rude unhinging of the machinery of life” ~

Samuel D. Gross

Adequate Perfusion requires:

  1. The Pump (heart)
  2. The Fluid (blood)
  3. The Container (vasculature)
  4. Air Exchange (oxygenation / ventilation)

The Pump

  • Adequate Cardiac Output
  • Stroke Volume X Heart Rate (4-8L/minute)
  • Affected by Preload, Contractile Force, and Afterload

The Fluid

  • Volume of blood must fill container

The Container

  • Vasculature is properly sized
  • Pre and post capillary sphincters at local level

Air Exchange

  • O2 into lungs and circulation
  • Elimination of CO2 and waste products
  • Adequate FiO2 and ventilation
  • Diffusion across alveoli / capillary membrane
  • Adequate number of RBCs
  • Efficient offloading to target cells

Stages of Shock

  • Compensated
  • Decompensated
  • Irreversible

Types of Shock

  • Hypovolemic
  • Cardiogenic
  • Distributive
  • Obstructive

Managing Shock

  • Primary Survey / ABCs
  • O2
  • BVM
  • C  spine
  • Major bleeding
  • Supine / Keep warm
  • IV, monitor

Specific Treatments

  • Fluid challenge
  • Epi / Benadryl (anaphylaxis)
  • Chest decompression (tension pneumothorax)
  • Pericardiocentesis (cardiac tamponade)
  • Dysrhythmias (ACLS)
  • Pressors (fluids first)
  • Narcan (opiod OD)

Take Home Points

  1. Shock:  Inadequate perfusion at the cellular level.
  2. If you think shock, your patient is already there.
  3. Know and treat the root causes.
  4. Set a target MAP.
  5. Be aggressive!

~Chip Getchell