This post relays my experience at a 2-day First Aid and CPR training course in 2011 in Mississauga (Canada). There were so many issues with how the class was run, that I had to document it all. It is best relayed as a recounting of events. And so the story follows.

St. John’s Ambulance Offices, Mississauga. December 28-29, 2011

“You can get ace from breadth,” asserted our First Aid and CPR Instructor.

“We can get what from breath?” asked one of the students, puzzled.

“Ace,” responded the Instructor.

“I’m not familiar with that condition,” relayed another student who was confused like the rest of us.

“You know, ace! H – I – V; Ace!” exclaimed the Instructor.

“Oh, you mean AIDS!” chimed in several of us students.

The Instructor was early into Day 1 of our First Aid and CPR course, explaining why a First Aider wears gloves and the protocol of using a breathing barrier when giving breaths into an injured person’s mouth.

“I don’t think you can get AIDS from someone’s breath” I gently asserted. But the Instructor nodded his head, “Yes, you can get it from the breadth”. Several of us students looked at each other confused and re-iterated, “Certainly from blood, but not from human breath!”.

After a couple more seconds of processing, the Instructor nodded and said, “Yes, from breadth”. We re-iterated, “So do you mean blood and not human breath?” to which the Instructor nodded and we finally had understanding. This set the tone for the level of misunderstandings the Instructor’s accent and grasp of English would portend for the rest of the course.

It doesn’t take a lot of imagination to see how in a subject like first aid, dealing with minutes, unconsciousness, life and death, nuance matters.

I believe that we have a false sense of safety when it comes to First Aid readiness. The more people who legitimately know First Aid and CPR, the safer we are, no doubt.

I just took a two-day course with St. John’s Ambulance in Mississauga, Ontario and was very disappointed on so many levels. We have a moral obligation to share such observations. So I put my thoughts down into words.

I believe our system of training in such important matters, needs some CPR of its own. We’ve become complacent. From the way the course is taught, to the lack of a practical exam to the lack of a true written exam before certification is granted, the entire course seems like it was designed to check a box. A box in a paper shuffling bureaucracy between employers, their employees and training organizations. For someone hurt and in need of first aid, this could quite literally be insult to injury. So how bad is it?

Sampling just my own class, I doubt more than 25% of the class would know how to perform more than 25% of what was covered in the two day course.

We are fortunate to live in a society where we can dial 9-1-1 and have emergency responders at our door in minutes. Sometimes that can still be too late to save a life or reduce the risk of permanent injury.

Enter the First Aider. Our workplaces often have one or more people assigned to keep their First Aid and CPR certification current. If we’re out on the streets and someone is hurt, a First Aider may get to the scene before 9-1-1 responders arrive. They can start CPR, triage multiple casualties or stop the bleeding from a knife wound.

There’s no doubt that these skills play an important role in the physical safety of our communities for when accidents and injury strike.

Growing up in Canada, I always held the St. John’s Ambulance non-profit organization in very high esteem. They have a tradition of competence and service. So when my VA short listed them in response to my query for First Aid and CPR training in my area, I was excited about getting what I anticipated to be top notch training in the field. I don’t have a medical background, but I believe we all have a civic and familial responsibility to proactively develop and refresh such skills.

The Instructor

Our Instructor had been teaching the course for many years. You could tell that he himself was competent and would know what to do in a myriad of emergency situations. Knowing is of course, not the same as teaching.

I liked that the Instructor had enthusiasm in his teaching and I know his desire to teach comes from a good place.

The Instructor exudes a warmth where you just don’t want to be critical of him. Objectively speaking though, the course was not taught well.

There’s not even a good feedback mechanism for the course. Evaluations at the end of the course are attached to and handed in with a student’s answer sheet.

“May I mail in my evaluation sheet?” I politely asked after writing my exam at the end of the course.

“No, you have to turn it in now,” explained the Instructor.

Knowing students can’t anonymously give feedback after a course, how candid should we expect it to be? Most organizations don’t set themselves up for such failure in feedback. I don’t know why St. John’s Ambulance doesn’t have better procedures (a simple locked feedback form deposit box that only the Instructor’s superior can open would suffice).

Back to the start of the class.

The Instructor started off with trying to create a comedic environment, and this went on for several minutes. But we’re here for a First Aid course. Do we really need to start off with awkward levity, half of which we won’t even understand because of the Instructor’s broken English? We’re now confused, and the Instructor hasn’t even taught anything yet.

I grew up in Canada and am no stranger to using humour, movement, and interactivity to awaken and engage an audience. This was not that. It was out of place, awkward and confusing.

What exacerbated the entire learning experience, was the Instructor’s thick accent and incoherent English. He could technically speak English, but not well.

The average person could articulate and understand a typical first aid concept in say, fifteen seconds. This same level of complexity of an idea would however, take a full minute for the Instructor to convey in broken English. And the majority of us students, would still not be able to comprehend half of what was taught in that time.

At first, I didn’t interject, but as I saw this confusion and misunderstanding continue, I begin to ask clarifying questions after every few minutes, rephrasing what I thought the Instructor meant, and then asking him to confirm. This was helpful to me (and I believe others), but it shouldn’t have been necessary.

As Canadians, we embrace immigrants and we do our best to accommodate fellow Canadians who on the surface look and sound very different than us. I am proud of this tradition of ours. My own parents coming to Canada in the 70’s were granted opportunities because of this wonderful multicultural acceptance, irrespective of their coloured skin.

Some would advocate not having non-native English speakers taking on teaching roles. But I do believe they can still be effective, if they and their organizations put in the work to compensate for the gaps their lack of language proficiency creates.

This is what was absent (see my thoughts further down on how we can better support teachers who aren’t fluent with English).

I believe when dealing with things medical / emergency related, nuance does matter. You can’t effectively communicate nuance if you’re not reasonably articulate.

Support Materials

Throughout the course, we’d switch to short segments in a DVD prepared by St. John’s Ambulance, that the Instructor would often use as an introduction or a synopsis of the particular lesson. While these helped, there were often times where the dramatization conveyed inaccurate techniques (e.g. bandaging up way too tightly such that circulation would be impaired, etc.).

The Instructor would often call out these mistakes himself. Sometimes, us students could be heard rumbling that something looked off.

The Instructor did encourage us to write to the St. John’s Ambulance organization to suggest the DVD be updated to fix these mistakes. One would hope that a long time instructor within the organization could make that suggestion and it would have been acknowledged and acted upon.

The First Aid book we received on the morning of Day One was superb. This is the level of quality I expected of the St. John’s Ambulance organization. I will be reading this book to fill in the numerous gaps I myself still have.

The Course

The course follows a set syllabus; some DVD segments are played, with much writing on the white board and some hands on exercises sprinkled throughout both days. We paired up with other students to test out putting them in the recovery position, splinting a simulated broken arm and performing CPR on a dummy (among other hands on exercises).

Many elements of the course contain lists of steps and priorities. Often times, the Instructor would repeat these steps as he introduced the material. Instead of internalizing these steps in our minds, we students would be busy trying to decode what the Instructor said. And that meant we would miss what he said next.

As the course progressed, I would interject more frequently to clarify what was said. I could tell that the Instructor became anxious that we wouldn’t finish in time if this became a pattern. I do believe that in the time allotted, an articulate and effective teacher could have conveyed significantly more nuance and depth of understanding.

From the start, the Instructor emphasized preparing us for The Test. He’d wink at us multiple times when covering some material that was sure to be on the test. In small doses, telling us to pay attention here and there is fine. I did feel however, that this was done in excess.

An instructor shouldn’t have to wink at students to remember material. That should be a natural consequence of good instruction and diligent participation.

The Students

“My employer sent me,” relayed one student. On the first day, we all introduced ourselves.

“I need this certification to apply for such-and-such program,” remarked another.

Our particular class had almost 20 students, which is apparently the norm.

I introduced myself, “I’m here independently, and not from any company, because I believe it’s personally an important life skill to have.”

It struck me: most of the class didn’t volunteer to take First Aid + CPR training, they needed it to fill a requirement. I could tell that there were a handful of students who diligently paid attention and truly did want to learn the material. Most of them were too shy to interject when they didn’t understand, although I did witness this change well into day two, as other students began to realize that they would need to interject to obtain clarity, if they were going to leave the course with any meaningful take-aways.

A good portion of the class came from blue-collar industries where they are exposed to more occupational hazards. Enforcing first aid training makes a lot of sense. In these same industries, we also see a large portion of immigrants – non native English speakers. For them, understanding a perfectly articulate instructor is still a challenge. Layer on top of that, a non-native English speaker, speaking in broken English. It starts to become like the children’s game of broken telephone.

I wouldn’t mind all this signal loss if we were taking a class on painting. But this was First Aid and CPR.

From my subjective judgment, about 80%+ of the class would not have come if it weren’t a requirement for a job, some institution or they had to pay on their own.

It felt to me that many students were here to check a box; so the fact that the course and teaching was sub-par, didn’t phase them. They got paid for a couple of days off work, and got to sit back, and watch an instructor try to be funny at the front of the class. Why complain about not learning enough?

On the first day, when we went into an open classroom to do our first hands-on lesson, we were split up into two groups, the hypothetical injured (known as a “casualty” in First Aid terminology) and First Aiders, arriving at the scene. The Instructor asked us in the First Aiders group to enter the situation and follow up with the Scene Survey. At some point, one student refused to participate, citing he disagreed with a particular technique. The Instructor, to his credit, was incredibly patient with the recalcitrant student, a man in his late 50s.

The Instructor exhorted the student to follow the method of this course, trying to change the attitude of this uncooperative student, “If you’re going to take our course, then please follow our protocols. This is the technique we teach to help people!”

“I don’t want to help people,” calmly replied the defiant student. The rest of us stood in disbelief.

“If you don’t want to learn the Instructor’s way, then please leave and let us continue,” muttered some in the class.

Eventually, the uncooperative student passively and grudgingly went along with the lesson. Clearly, he needed a box checked on some form by some organization.

The Test

Our certification test was done in two parts, one part at the end of each day, but you could correct your answers on the second day, from the first day. It was all multiple choice.

“Do we look at signs and symptoms before the history step?” asked one test taker to another early on during the exam.

People writing the test could be heard whispering to each other, discussing the merits of one possible answer over another.

The Instructor walked around as people struggled with answering. He didn’t interject in the collaborative test taking. In fact, the Instructor could often be heard challenging a student, “Are you sure you want to answer ‘b’ for this one? Do you remember the steps of the Secondary Survey? Look at the board. It’s right there.”

There was no hands-on component to the test. Students didn’t have to demonstrate their knowledge in a test scenario, of anything. In group settings during the lessons we’d practice together, and you could ask questions, but that was it. If you did ask questions, there was no time to redo the practical component with your newfound clarity; the next lesson had already begun.

In my estimation, we should incorporate these hands-on skills (CPR techniques, AED usage, helping a choking victim, tying a sling to support a dislocated shoulder, etc.) into the test. We should do so in a manner similar to the way in which we conduct a practical exam for one’s driving license.

If we did test this way, the majority of the class I’m sure, would fail spectacularly.

“Here’s my answer sheet Sir.” I handed in my finished test paper. It was the end of Day Two.

“Thank you,” remarked the Instructor, as he was collecting papers.

“I’d actually like you to mark it so that I can then look at the answer sheet and correct my understanding for the answers I got wrong,” I requested.

“Here you go.” The Instructor handed me the answer sheet, “just correct your answers, don’t mark it as a mistake. Everybody gets 100 per cent!”

“No,” I remarked, “I’ll mark my mistakes as mistakes. I get what I got, but I just want to know where I went wrong so I know what I need to review.”

“Don’t mark it as mistake, just correct it,” insisted the concerned Instructor. I knew the Instructor liked me, despite what must have been annoying interjections during the class. He could at least tell I genuinely wanted to learn.

“No, I’m pretty sure I passed anyways, but I want the test to accurately reflect how I did,” I insisted.

“Okay, that’s the best way! I’m sure you did good!” quipped the Instructor with a smile, knowing I wasn’t going to change my mind.

Fifty out of Fifty-Four. Not bad I thought. I didn’t need to be gifted the one hundred per cent that was being dolled out. What purpose would that serve? I didn’t want to check a box. I had no need for a certificate. I just wanted to confidently know I knew First Aid and CPR.

An Emergent Picture

Remember that recalcitrant student who didn’t want to help people? The Instructor later remarked to some of us after class, that as an instructor of the First Aid course, he has the authority to fail any student he doesn’t feel should be certified. A few of us students remarked that situations like that student who clearly didn’t care, are exactly the kinds of situations in which this authority should be exercised by an Instructor.

Wouldn’t you want to have this student fail certification if he was a colleague of yours at your workplace and refused to participate in First Aid class?

Wouldn’t you want someone else on your shift assigned the role of First Aider, in the event of a real emergency?

Wouldn’t you implicitly trust that if a reputable organization like St. John’s Ambulance certified someone, that they would be very capable in a first aid situation?

What we should all be asking is, why is there such a reluctance to fail anyone?

With what I’ve already conveyed, astute readers may already see that we have a wider issue here. It’s not about one instructor – that would be scapegoating. It’s systemic. Here’s my hypothesis.

1. Most students have to check a box on a requirement form for a job they have or a job they want; they’re just looking for a pass, a certificate, and perhaps more than a cursory understanding while they’re in class.
2. Training / certification organizations like St. John’s Ambulance know that business and other institutions come to them because students get certified with few, if any failures.
3. If St. John’s Ambulance began failing students, organizations would seek out alternate certifying bodies to minimize employee time off work and training expenditures. Even non-profits need steady revenue to defray operating costs.
4. Training organizations know how effective or ineffective their instructors are. They are passively complicit with a lower quality of teaching, because students still get certified and this keeps customers (companies, institutions) happy and paying.
5. Instructors can give away test answers and attempt to be entertaining during lessons so that students seeking a pass won’t complain about the lack of quality instruction.
6. Passing all or nearly all students makes an instructor look good to the training organization they work for. This in turn, makes for happy customers because all of their people got certified.

So what do we achieve with all of this certification and check box checking?

I can’t deny that most of us students learned something of value in the course. What I do know is that we are not prepared for all the items advertised in the syllabus and we certainly don’t have the muscle memory to perform most of these techniques well.

I do know that if we had been given a practical exam with an instructor, for even 20 minutes each, most of us would have realized  that we don’t have enough practice to perform most techniques correctly. And we will likely be worse a month from now when our hazy understanding fades further still.

While I’m sure there are other organizations that do teach with more rigour, nuance, quality instruction and hands-on testing, I can see how they would feel a market squeeze from certificate factories like the class I’ve just experienced.

Remarking to an RMT and Chiropractor about my experiences, they weren’t surprised. They relayed how the best courses they’ve seen in this field are the ones arranged privately. Perhaps industry is trying to commoditize the certification of a skill that you can’t compress into a poorly run course.

The Risk

This lack of real training poses obvious problems: we have people in positions of “First Aid Responder on Duty” where the certified First Aider really doesn’t understand what to do. They won’t have the confidence or the knowledge on how to act or how to take charge. They won’t understand the context and underpinnings of the first aid treatment in their course syllabus to evaluate the unique circumstances of the situations they face.

In short, they will fail to be effective, and we are down to reliance on our emergency response services. We have a false sense of security in First Aiders certified this way, who themselves may not realize that the bar was set really low for them to pass.

Suggestions

For instructors who don’t have the best spoken English skills, such as the well intentioned Instructor who taught the class I took, I have several suggestions:

1. Don’t use comedy jumping back and forth between the wrong thing to do and the right thing to do. With hard to decipher English, we students cannot tell what the actual proper course of action is in a given situation. We can’t decipher the intent. This creates a lot more confusion than any entertainment value intended.
2. Have someone audit a few courses. This person will take notes of words and phrases which they and other students asked for clarification on, because of pronunciation. Compile this list and for each subsequent class, provide it as a translation handout that students can refer too (e.g. “‘blood’ may sound as if I’m saying ‘breath’, ‘AIDS’ may sound like ‘ACE’”, etc.).
3. Use traditional slides or a PowerPoint / Keynote presentation to go through the lesson plans. This way, as protocols with lists in them are being reviewed, the visible words and correct spellings will mitigate the verbal decoding needed to make sense of the instructor’s pronunciation.

For the course structure as a whole, I have additional suggestions:

1. FAQs: Incorporate these in each lesson. For example, I remarked while learning CPR, that my fingers would get sore, because my nails were being pressed into the casualty’s body. I then surmised we’re to lift the fingers and just use our palms for pressure. I can’t be the first student who’s asked this. If instructors captured the typical points of confusion in a lesson FAQ, we’d cover more and do it thoroughly, in the same amount of time.
2. Written tests: Treat these seriously. No collaboration, no fixing one’s answers after they’ve handed in the test paper.
3. Hands-on tests: Introduce these. Perhaps schedule evening slots where each student sometime within a week after the course, has a 20 minute exam appointment with the instructor. The student has to demonstrate a good subset of the skills taught.
4. Certification Standards: Enforce the standard of education. If a student doesn’t know the material, they fail. No exceptions. They can re-take the course and study harder next time.
5. Structure: Space out the course into smaller chunks where homework can be assigned and there’s time to read the supporting handbook (which is an excellent reference). Reading the material before the lecture will increase comprehension of the material. With the reference book for the course currently given on the day of the course, there’s no time to study it independently.

Finally, as there seems to be an incentive to race to the bottom in teaching this material to keep companies (customers) coming back, we need some regulated standards if we don’t already have them. And if we do have standards for these certifications, they need to be revisited and enforced.