Eating the Elephant

EMS competence and confidence comes from constantly learning.

Overcome analysis paralysis by focusing on the sequence and process of patient assessment and treatment.

“He’s a good student, but he just freezes whenever he’s asked to run the call. Got good grades in school, proficient in all his skills, but he just can’t seem to put it all together. If you quiz him after the call, he can tell you exactly what he should have done, but he just can’t do it when it counts. How do I help him?”

I get that sort of message fairly frequently. Most often it’s from a preceptor or FTO, but occasionally I get a direct request from a struggling Paramedic or ECA who needs the help. The reasons for it are many and varied, but most boil down to this: none of them know how to eat an elephant.

When your education program consists of dry lectures and skills labs, with little thought to practical application, the student leaves class ill-prepared for street medicine. They spend valuable classroom time doing rote memorization of EMS factoids, practicing skills directly from an OSCE skill sheet and parroting assessment and treatment algorithms. While the “teach the test” approach may yield acceptable pass/fail ratios, let’s not kid ourselves that they produce good prehospital care practitioners.

Unfortunately, the learners enrolled in those programs don’t realize that until the day they are expected to be a good ECA, FREC, AAP or even Paramedic.

But one sure way to recognise you’re enrolled in such a program is if your instructors, preceptors, or other recent graduates of the program ever speak the phrase, “There’s the way you do it in class (or the exam), and then there’s the way you do it on the street.”

And so they are able to practice isolated skills, recite EMS trivia, regurgitate algorithms and dosages, quote the latest article on (fill in the blank) or function as a team member but lack the tools to be able to actually lead a call.

It’s an ugly realisation, one that can shake their confidence and without confidence the task of leadership is even harder.

Steve Whitehead does an excellent job of dispelling the classroom vs. street myth, as does Dan Limmer on his blog, explaining how active learning exercises can help your student apply classroom lessons on the street. In reality, it is possible to teach skills that will pass the exam and work well on the street. Anyone who says otherwise is either teaching it wrong in the classroom, or applying it wrong on the street.

This article is aimed at instructors, some of whom will be conscientious and try to apply those techniques, while others will ignore them and continue to “teach to the test” and perpetuate the book vs. street mythology. Where does that leave the student who has hit that wall, and the preceptor trying to get him through it?


The answer is in what I alluded to earlier: you have to learn how to eat an elephant.

In class, you can convince yourself that you’re an excellent IV sticker, or a rhythm interpretation whiz, or a samurai with a laryngoscope. You can ace a test, especially if it’s one composed of questions from the lower rungs of Bloom's Taxonomy and in scenario practice you always know what to do, because you’re clever enough to recognise it for what it is: practice. There’s no pressure because God forbid we can't be putting students under pressure can we?

The problem is that on the street, the patients don’t know the script, and you know it’s for real, your preceptor is watching every move and the gravity of the responsibility you have (pressure) looks like a big, intimidating elephant. And you freeze, subconsciously thinking, “How will I ever eat THAT?”

Answer: by focusing on your plate and taking small bites.

When you’re lost, go back to those memory aids and mnemonics that you memorised.

Focus on sequence and process.

We all know that patient assessment and treatment is not always a linear process, and as experienced medics, your preceptors may rightfully disparage those memory aids as crutches that limit your thinking, but if you haven’t been taught anything other than that linear process; that’s your only lifeline. If you have to choose between process and technique, choose process.

Hopefully, by this point in your clinical rotations, your skill technique has already been graded and deemed acceptable. It’s more important at this point to understand when and why to apply a skill than how to perform it yourself. In fact, you should be telling other people to perform that skill. It’s not your responsibility any longer.

So repeat in your mind the SAMPLE, OPQRST, VOMIT, SNOT or whatever acronym you memorized, and follow them. Accept that you are going to be imperfect. You will make mistakes. Your calls will not run smoothly. You will look and feel incompetent.

And that’s okay. You are incompetent, but you can change that rapidly. You just have to push through the wall and run the call. Keep going, and go through an after-call debrief with your preceptor, but make the most of that debrief; it’s not a “should’ve, could’ve, would’ve” dissection of what you did wrong. We learn more from our mistakes anyway. The only unforgivable sin is constantly repeating them. The after-call debrief is simply a verbalization of your thought processes, and a game plan for the next call.

Believe me, the more calls you run, the better those puzzle pieces will seem to fit, and the less you’ll have to rely on those crutches and memory aids. Pretty soon, you’ll look up from your plate, and discover that, much to your surprise, you have eaten the whole elephant.

It may be close to the end of your clinical rotations before you have eaten the elephant. Heck, you may have passed your exam and be on a truck in charge, and still be digesting. The important thing is, never stop chewing. Try to learn and apply something from every call, and competence (and confidence) will follow.


If you’re a preceptor like the one I quoted in the opening of my column, keep in mind that your job is to promote confidence and clarity, not conflict and character assassination. Don’t disparage the skills and knowledge your student learned in the classroom, and never project the attitude that things are done differently on the street.

Think of your students as completing class with a set of instructions; draw a square. Now draw a triangle on top of the square. Draw a rectangle and a smaller square within the big square. Now draw a little circle in the rectangle. Your job as a preceptor is to translate those instructions into, “Draw me a house.”

So first make sure your student is a competent team member. Review previous preceptor notes if you have access to them. Find out your charge’s strengths and weaknesses, and adapt your methods to fit his needs.

Once those isolated skills have been demonstrated to your satisfaction and it’s time to actually perform as team lead on calls, let them lead. Don’t throw them in the deep end and tell them to sink or swim. Plan likely scenarios on the way to the call.

Play “What if?” games. Ask “What would you do first?” and “What’s the most important thing to remember?” before you get to the scene.

Make it clear that you are a resource if needed, and don’t step in for anything but process errors. Errors of technique – how – unless they pose a significant threat to the patient, can be corrected in the post-call debriefing. Errors of process – when and why – should be corrected as they happen, but not in a “Stop, you’re doing it wrong” sort of way. Instead, approach these corrections with, “Do you think it would be easier if we did it this way?”

Keep them focused on their plate, don’t let them sweat the small stuff, pass them some antacids and steak sauce when necessary. Pretty soon the elephant will be a collection of bones, and your charge will be competently leading calls. Likely not leading calls as well as you, and maybe not even in the way you’d prefer, but well enough.

This compelling article was written by Kelly Grayson and published in EMS-1 August 11 2015

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