Archives of Academic Emergency Medicine. 2019; 7 (1): e70

OR I G I N A L RE S E A RC H

Problem-Based versus Lecture-Based Method in Pre-
hospital Trauma Life Support Training; a Pre-test Post-test
Study
Masoumeh Falaki1, Rouzbeh Rajaei Ghafouri2∗, Samad Shams Vahdati2

1. Emergency Medicine Department, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.

2. Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran.

Received: August 2019; Accepted: September 2019; Published online: 24 November 2019

Abstract: Introduction: Pre-hospital trauma life support (PHTLS) training is necessary for all emergency medical services
(EMS) personnel to increase their efficacy and skills. This study aimed to compare two methods of problem-
based learning (PBL) and lecture-based learning (LBL) for PHTLS training courses of EMS personnel. Methods:
In this pre-post-test study, 144 male EMS staff members were divided into two groups of PBL (n=72) and LBL
(n=72). Both groups received four sessions of PHTLS training based on 8th edition of PHTLS guideline. The par-
ticipants’ knowledge and skills were evaluated before and three months after training and the two groups were
compared in this regard. Results: The mean knowledge score (63.59±13.43 to 81.08±4.66; p<0.001) and mean
skills score (58.85±19.74 to 99.07±25.02; p<0.001) of participants had significantly improved after the training
courses. Both groups had similar scores before intervention, but PBL group had significantly higher scores in
knowledge (p<0.001) and skills (p<0.001) after intervention. There was also a significantly higher change in
knowledge (p<0.01) and skills (p<0.001) in PBL group compared to LBL group. Conclusion: PHTLS training
improves EMS personnel’s knowledge and skill in managing trauma patients. PBL was more effective than LBL.

Keywords: Multiple Trauma; Emergency Medical Services; Problem-based Learning; Education

Cite this article as: Falaki M, Rajaei Ghafouri R, Shams Vahdati S. Problem-Based versus Lecture-Based Method in Pre-hospital Trauma Life

Support Training; a Pre-test Post-test Study. Arch Acad Emerg Med. 2019; 7(1): e70.

1. Introduction

Taking care of the critically injured begins well before the pa-

tient arrives at a large academic trauma center. Pre-hospital

care is the first part of the trauma treatment and care sys-

tem (1). Pre-hospital trauma life support (PHTLS) plays a

very important role in the effective management of trauma

patients and aims to provide high-quality care that reduces

injury and mortality in these patients (2, 3). The success of

the pre-hospital care depends on the knowledge and skill of

emergency medical services (EMS) personnel, which lead to

improvements in the response time, interventions and, ulti-

mately, the rapid transfer to the hospital (4-6). EMS person-

nel are the first ones to examine and treat pre-hospital critical

patients. It is important to increase the accuracy and speed

∗Corresponding Author: Rouzbeh Rajaei Ghafouri; Emergency Medicine
Research Team, Tabriz University of Medical Sciences, Daneshgah Street,
Tabriz, Iran. E-mail: rozbehrajaei@yahoo.com, rrajaei88@gmail.com, Tel:
+989143115624

of treatment to lower the mortality caused by these diseases

(7). For this purpose, we need efficient and operational per-

sonnel to deal with various types of crashes and diseases (8,

9).

It is important to increase the staff’s awareness regarding PH-

TLS to decrease the mortality rate and increase their confi-

dence and knowledge (10). A recent study has reported that

after PHTLS training, the mortality rate had decreased (11).

There is a need to improve EMS staff’s knowledge and atti-

tude regarding PHTLS. Primary trauma care courses can pro-

vide the basic knowledge and skills necessary for identifica-

tion and treatment of trauma patients in need of immediate

resuscitation and stabilization of the injuries. These courses

can teach an acceptable method for treating patients affected

by trauma (5, 12). There are two common methods used

for training, lecture-based learning (LBL) and problem solv-

ing methods (13). Problem-based learning (PBL) was imple-

mented in the 1960s, which is now found in many training

settings including medical sciences. PBL is an educational

method focused on self-directed learning and small group

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M. Falaki et al. 2

discussions, which can provide learners with more opportu-

nities for application of knowledge compared to traditional

LBL method. Nowadays experts believe that PBL has many

advantages over LBL, including flexible knowledge, promo-

tion of communications and collaborative skills, and self-

directed learning skills in a motivating format (14).

Trauma care learning needs both knowledge and skill im-

provement, so LBL alone may not enhance trauma manage-

ment skills. In this study, we compared the two methods of

LBL and problem based method in improving knowledge and

skills of EMS personnel regarding PHTLS.

2. Methods

2.1. Study design and setting

In this pre- and post-test study, 144 EMS staff members of

East Azerbaijan province who were participating in PHTLS

courses during 2017 were divided into two groups of LBL

and PBL. Both groups received four sessions of PHTLS train-

ing based on 8th edition of PHTLS guideline. The partici-

pants’ knowledge and skills were evaluated before and three

months after training and the two groups were compared in

this regard. Informed consent was obtained before admin-

istering the questionnaire. The ethics committee of Tabriz

University of Medical Sciences approved the study (Ethic No.

IR.TBZMED.REC.1396.421). The score of each participant

was kept secret and only the organizer of courses knew it.

2.2. Participants

All of the paramedics working in Tabriz EMS (154 persons)

were included as study population. During courses, 10 par-

ticipants were excluded from the study due to not completing

the sessions or filling the post-test. Participants were divided

into two equal groups of 72 cases. First group had the course

in LBL method and the second group in PBL method.

2.3. Data gathering

Demographic variables (age, employment duration, level of

education) were collected using a pre-designed check list

and knowledge and skill were measured and registered be-

fore and after implementation of the training course using

reliable and valid questionnaires, by an emergency medicine

resident.

2.4. Intervention

Knowledge of participants who attended four sessions in Au-

gust, September, October and November 2017 was measured

before (pre-test) as well as three months after the sessions

(post-test). Their knowledge was measured using PHTLS 8th

edition questionnaire (15). Participants’ skills on manag-

ing trauma patients in the pre-hospital situations were also

measured before and three months after PHTLS sessions us-

ing a checklist containing criteria of basic and advanced life

support, time to response and time to reach the hospital

(appendix 1). The checklist was prepared according to ex-

pert opinion and based on PHTLS concept and its validity

(0.72) and reliability (0.90) were defined using test-re-test

method. The skills of paramedics were evaluated when treat-

ing trauma patients who presented to emergency depart-

ment of Imam Reza, referral trauma center, Tabriz.

For each EMS staff member, only one multiple trauma pa-

tient was selected. In this exam, outcome of the course was

pass or fail. Paramedics who failed the exam had to repeat

the course in the same manner until they could pass suc-

cessfully. After 3 months, participants were evaluated in the

triage area while they transferred a multiple trauma patient

to emergency department. An emergency medicine resident

did the evaluation and filled the checklist of evaluation with-

out the EMS personnel sensing. There was not any interfer-

ence in the standard course of patient treatment. The resi-

dent responsible for data gathering was not aware of the type

of learning method as well as final scores of participants. The

PHTLS courses were held in Tabriz EMS center. We had no

loss to follow up because all of the trained paramedics had to

refer trauma patients of all around Tabriz to the sole referral

hospital of the region.

For preventing bias, the two groups were trained by one fac-

ulty member and outcomes (knowledge and skills) were mea-

sured by a trained emergency medicine resident.

2.5. Statistical Analysis

All data were analyzed using SPSS software (version 23; SPSS

Inc., Chicago, IL). The results are expressed as mean ± stan-
dard deviation or percentage. Kolmogorov-Smirnov test was

used to assess normal distribution of data. Chi square test,

independent T-test or Mann-Whitney U test were used to

compare data between the groups. Paired-samples t-test or

Wilcoxon rank test were used to compare pre- and post-test

results. P-values less than 0.05 were considered statistically

significant.

3. Results

In this study 144 male EMS staff members were evaluated in

two learning groups. The two groups were similar regard-

ing the baseline characteristics (table 1). The mean knowl-

edge score (63.59±13.43 vs 81.08±4.66; p<0.001) and mean
skill score (58.85±19.74 vs 99.07±25.02; p<0.001) of partici-
pants had significantly improved after applying the training

methods. Participants’ scores on knowledge and skills be-

fore and after training and their changes are shown in table

2. Both groups had similar knowledge and skills score before

intervention, but PBL group had significantly higher scores

in both items after intervention. There was also a signifi-

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3 Archives of Academic Emergency Medicine. 2019; 7 (1): e70

Table 1: Comparing the baseline characteristics of participants between the two learning method groups

Variable Problem based Lecture based P-Value
Age (year)
Mean ± SD 34.96±8.40 36.60±8.16 0.18
Employment duration (years)
Mean±SD 7.61±5.63 8.67±6.66 0.24
Educational degree
Bachelor 37 (38.9) 42 (47.7) 0.23
Associate degree 58 (61.1) 46 (52.3)
Data are presented as mean ± standard deviation (SD) or fre-
quency (%).

Table 2: Comparing the knowledge and skills of emergency medicine services (EMS) personnel before and after training with problem based

and lecture based learning methods

Variables Problem based Lecture based P value
Knowledge
Before 62.56±12.93 64.69±13.93 0.29
After 82.58±4.96 79.48±3.71 <0.001
Change 38.27±32.69 29.77±36.88 0.01
Skills
Before 57.80±18.88 60.00±20.67 0.45
After 116.91±12.85 79.81±20.20 <0.001
Change 121.69±65.03 39.09±21.37 <0.001
Data are presented as mean ± standard deviation.

cantly higher change in knowledge and skills in PBL group

compared to LBL group.

4. Discussion

Our study showed that PHTLS training improves EMS per-

sonnel knowledge and skill in managing trauma patients and

PBL method was more effective than LBL. Pre-hospital care is

a critical phase to improve trauma patients’ outcomes during

episodic care. EMS and first-responder personnel must be

capable of providing life-saving interventions at scene with

proper, quick and correct treatment decisions; so, there is a

need to train these personnel to have high confidence and

skills in initiating procedures under adverse circumstances

(16). For this purpose, PHTLS courses have been introduced

and used for training paramedics and technicians. Their aim

is to increase the skills of EMS personnel in managing trauma

patients by improving their knowledge of trauma care and

make them able to act faster in life-threatening situations.

Cognitive knowledge, technical skills and clinical judgment

are the main pillars for healthcare providers (17). In this

study, we evaluated the knowledge and skills of EMS person-

nel before and after PHTLS courses and observed that overall,

there was a significant improvement in participants’ knowl-

edge of the situation, management, and their skills when en-

countering trauma patients after training. Frank and col-

leagues (10) reported that PHTLS leads to significant increase

in confidence and knowledge. Haske et al. (2) reported that

the participants’ skills and knowledge on pre-hospital care

of trauma patients would increase in short term, but the

knowledge and safety would not remain the same on some

issues in long term. A systematic review demonstrated im-

proved management of trauma patients and shortened time

to definitive care following PHTLS training (18). Improved in-

dividual management of trauma patients was also reported

following primary trauma care courses (19). Van Dillen and

colleagues (16) observed that simulation training improved

prehospital care providers’ confidence level in performing

two life-saving procedures. Therefore, any type of training

would help improve EMS personnel’s confidence and skill,

and as previous studies in the same area with our study have

suggested, EMS personnel require more education and su-

pervision to provide services according to PHTLS guidelines

(20). Previous studies indicated that the effects of train-

ing would decrease after a period (2, 18). Although we did

not evaluate the participants in long term, but it is obvious

that continuing training programs are necessary for an effec-

tive and sufficient EMS, and personnel should attend PHTLS

courses at least once a year. Besides these findings, we evalu-

ated the effects of problem based and LBL methods of train-

ing on achieving better knowledge and skills and observed

that problem based method led to a significantly greater im-

provement in participants’ knowledge and most importantly

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M. Falaki et al. 4

Appendix 1: Checklist for evaluating the participants’ skills on managing trauma patients in the pre-hospital setting

Action Weight
Done

Not doneˆ
Appropriate$ Inappropriate#

1. Cervical spine immobilization 10* – – –
2. Airway management if needed 10* – – –
3. Oxygen administration 8* – – –
4. Peripheral IV line establishment 8* – – –
5. External bleeding control 8* – – –
6. Spinal Immobilization 8* – – –
7. Serum administration 7* – – –
8. Immobilization of limb fracture 6* – – –
9. Vital signs 4* – – –
$: two points; #: one point; ∧: zero point

their skills in managing trauma patients. PBL enables stu-

dents to identify the gaps in their knowledge and enhance

their group functioning and generic skills (21). Most partici-

pants in medical courses prefer practical trainings to theoret-

ical knowledge. Faisal and colleagues (13) have also indicated

that PBL is more effective than LBL in the academic perfor-

mance of medical students.

5. Limitation

This study was confined by some limitations; being single-

centered and having a small sample size were among the

main limitations of the study. We did not follow the partic-

ipants to evaluate the long term efficacy of PHTLS training.

In addition, the effect of PHTLS training on reducing time

to respond and mortality rate were not evaluated. Although

we did not evaluate the long-term efficacy of PHTLS training,

continuing training programs are necessary for an effective

and sufficient EMS. In further evaluations, the proper time

to re-educate the personnel should also be evaluated. We

recommend evaluating the personnel in long-term periods,

like two and five years, for better results. Paramedics who

are working in rural pre-hospital centers were not included in

this study. It was not possible to gather all of the paramedics

working in East Azerbaijan province to participate in courses

at the same time. Another limitation is that we could not

follow up the maintenance of efficacy of education for more

than three months. It would be better if the knowledge and

skills of participants were measured 6-12 month later to eval-

uate the behavior change in management of trauma patients.

6. Conclusion

PHTLS training improves EMS personnel’s knowledge and

skill in managing trauma patients. PBL was the more effec-

tive method of training compared to traditional LBL.

7. Appendix

7.1. Acknowledgements

We would like to thank Tabriz disaster and pre-hospital man-

agement center. Authors also declare their special thanks to

personnel of emergency department of Imam Reza hospital,

Tabriz, Iran.

7.2. Author contribution

This study is derived from Dr. Masoumeh Falaki’s postgrad-

uate thesis to join the Iranian Board of Emergency Medicine,

who was responsible for data gathering 3 months after the

courses. Dr. Samad Shams Vahdati analyzed the data and

contributed in manuscript writing. Dr. Rouzbeh Rajaei

Ghafouri, the corresponding author, is responsible for study

design, pre-test/ post-test evaluation, and organizing the

training courses.

Authors ORCIDs
Masoumeh Falaki: 0000-0001-7646-6235

Rouzbeh Rajaei Ghafouri: 0000-0002-3760-572X

Samad Shams Vahdati: 0000-0002-4831-6691

7.3. Funding/Support

None.

7.4. Conflict of interest

None.

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	Introduction
	Methods
	Results
	Discussion
	Limitation
	Conclusion
	Appendix
	References