Saturday, March 21, 2015


Edited on 3/22 to clarify some content. It is not my intent to insult or offend, but rather to explore several interpersonal and intrapersonal phenomena I have observed in the cultures within the emergency services professions.

Rory Miller over at the Chiron Training blog engaged me in a conversation on experience thresholds within our respective professions, and asked me what kind of experience thresholds an EMS provider might through during his professional growth and development. 

The topic has been a strange thing to ponder. It feels like just yesterday I was working over 60 hours per week, sometimes seven days a week, at depressing and low paying jobs while going through EMT school and earning my paramedic pre-reqs (Oregon requires paramedics to have associates degrees). It took about four years for me to get the two year degree, drinking way too much caffeine and eating way too much fast food in order to keep up with the exhausting pace. At one point toward the end I recall having to make the decision to stay awake for 72 hours straight in order to complete my clinicals and still work my regularly scheduled shifts. It was an awful experience, but in retrospect it went by in the blink of an eye. 

I  began as the obnoxious, nervous, enthusiastic new guy that nobody could stand to work with, and then at some point, as if a switch had been thrown, obnoxious, nervous, enthusiastic new guys that nobody can stand to work with began asking me for advice on how to get better. Suddenly I had been in the profession for a decade, through two changes of AHA guidelines. MAST pants and combitubes went away, and we began discussions on doing away with long backboards. But after all that, it feels like I just got that little piece of paper in the mail yesterday. 

There are so many things I wish I understood better about this profession. Like, why do so many EMS providers deal with job stress by self destructing? Why are bullshit artists persistently allowed to achieve such high ranks despite low work output and poor quality results? Why do we allow some of our worst providers to instruct new providers? When will we learn the critical importance of quality education and self study? 

So here is my attempt to describe the experience thresholds an EMS provider goes through as they travel through their career. I have not yet discussed this with any other providers, and I do not claim to have first hand knowledge of all experience thresholds listed below, so if you are an EMS provider and you find this post, I would be curious to hear your opinion. 

The primary separation between thresholds would be the ability to make quick decisions, develop coherent plans, and execute them in challenging environments; but I also think it's important to consider emotional fortitude, attitude, and awareness of the world around them. I suspect these thresholds would be highly specific to American and Western cultures that are not routinely exposed to war and the ugliness of humanity and death. In visualizing these thresholds I see them not with clear demarcations, but as one color that gradually blends with and fades into the next color. I do not believe that a provider with no real accountability on the team progresses through these steps in the same manner as would a provider who is regularly in charge. I'm not sure I can articulate why I believe that right now, but I see it with some EMTs and nurses who are never placed in charge of a team. Also, many new providers seem to take a sort of spiritual attitude toward the profession, but for some reason providers in the fire fighter culture retain this spiritual brotherhood thing for a lot longer than other EMS providers. Because of this micro-cultural dynamic I have not made it a primary consideration in the following categories.
For this purpose I consider a critical event to be anything that might generate a CISD, such as an emotionally traumatic call, assault against the provider, or a line of duty death of a coworker.
Threshold I: Brand new.
The provider has little or no experience, and is unable to recognize serious situations or make critical decisions. Standard EMS education has prepared him poorly for real field work. At this stage, the new provider is eager, excited, idealistic, and dogmatic, and has not yet developed the psychological coping mechanisms necessary to handle emotionally difficult calls. In fire fighter culture, this person would be struggling for status within their tribe. Other aspects of EMS culture have more of a more lone wolf, produce or parish style to them, and tribal status is not often as big of an imperative for the brand new provider. In retelling the calls he's been on, the brand new provider might ham up the details a bit to sound more experienced. 
Threshold II: Some experience. One or two critical events. Loss of innocence
The provider is able to function but still freezes in some new situations. He is possibly still excited and idealistic about his profession, but is beginning to realize that the job is not really about helping people, and is more often instead about your superiors getting money or political power. He is realizing that humanity is ugly. The provider has been through a couple emotionally difficult events, but perhaps still lacks the emotional self-defense skills to fully cope with what he's been through. The shitty culture of the moderately experienced providers tell him that if he can't handle it he should quit and find a different job. Being the medic in charge at this stage is terrifying. The provider is still too new to be teaching others, and should not be permitted to teach others.
Threshold III: Moderately experienced. A handful of critical events.
The provider is comfortable in most situations, but still needs help figuring things out from time to time.  He has not seen everything, but has seen much of what the profession has to offer. Some anxious fear still lingers. He has no illusions regarding what this job is about. Emotional coping skills take the form of bitterness and detachment. The provider might try to teach others, but should not be teaching at this point.
Threshold IV: Experienced.
The provider is able to take command and make decisions confidently and competently in unfavorable conditions. Patient care and situation management are natural actions. There is no real anxiety or fear about the unknown any longer. The provider has seen most of what the job has to offer, and adapts to new situations readily (not to say he has seen it all, but rather he has seen enough that freezing is no longer a reaction to new situations). He would be a competent instructor or leader if so inclined and skilled in those areas. The provider possesses good emotional coping skills. He is able to explore and grow within his role.
Threshold V: The crossroads.
Providers at this stage are at a crossroads. Many appear to be bored, unchallenged, and cynical, but a few remain well respected by others in the profession. The provider can choose to be a burned out field medic, or take on leadership roles to better their surroundings. Regardless of the pathway chosen, these providers have a wealth of experience and are highly competent, even though many of them have a tendency to lean on old practices. 

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