Can Immediate Action Drills Improve EMS Education?

It’s been nearly 20 minutes since your patient was on the losing end of a conflict between his motorcycle and a guardrail. You’ve since intubated him, started two large-bore IVs and you’re now 10 minutes away from the trauma center. Just then, you hear your monitor alarm—“Low SpO₂.” A single word immediately enters your mind: DOPE. You’re not thinking of reasons why your patient might have crashed his motorcycle, you’re troubleshooting. You quickly work through this mnemonic, which stands for Dislodged, Obstructed, Pneumothorax and Equipment. You detect a left-sided pneumothorax and immediately perform needle decompression of the patient’s chest. His oxygen saturation begins to climb.

In less time than you could gather your thoughts, you performed immediate and critical actions that had a positive impact on your patient’s outcome. You begin to reflect on how this sequence became so automatic and you recall stumbling over your actions as a new medic. This is a challenge that all EMS educators deal with as we guide our students through the learning process. While there is no single proven technique for achieving high-level performance, this article will introduce you to the concept of immediate action drills and how its application in EMS education might improve performance under pressure.

Background

The work of a paramedic is done in a highly unpredictable environment, in which life or death decisions must be made.^{1, 2} This challenge is amplified by environmental factors, such as exposure to loud noises, poor lighting and chaotic events.³ To perform effectively and independently in this dynamic environment paramedics must possess confidence and demonstrate excellent judgment.⁴ So how does a new paramedic achieve this level of performance?

Throughout your life you’ve probably encountered many sayings about achieving mastery performance in any given domain. One that immediately comes to mind is, “practice makes perfect.” While this phrase speaks to the importance of repetition—and is reasonable for something like learning to play an instrument—it doesn’t address contextual challenges. Another saying often used to address performance in high-stakes environments (e.g., tactical operations) is that given a situation, you will not rise to the occasion, but instead default to the level of training you’ve mastered. This one does a far better job of capturing the essence of mastery performance as a paramedic, but still leaves room for improvement.

When it comes to skills training in EMS, students are typically tested or asked to demonstrate these skills in a manner that allows them to anticipate the process. We give students a skill sheet and ask them to remember a sequence—something akin to an actor memorizing lines. Our national certification process even includes this practice. But we all know EMS calls don’t follow a script. This is why seemingly intelligent students sometimes choke when faced with a dynamic situation. It’s not that sequence training is bad, but we must focus on short sequences that can be taught and tested dynamically.

Immediate Action Drills

The concept of immediate action drills (IADs) comes to us from our tactical brethren. These drills have been described as the execution of preplanned actions when an unanticipated threat is encountered.⁵ Such sudden developments do not typically afford time to think about the situation, so successful performance is dependent on immediate and instinctive actions. IADs have also been described as a programmed sequence of actions intended to accomplish a particular task.⁶ Classic examples of IADs in the tactical context involve actions intended to respond to an ambush or weapon failure.

The concept of IADs is adaptable to EMS because it’s not about specific skills or products, but rather it’s about the cognitive aspects of responding quickly to a situation based on having previously drilled in preparation for that situation. IADs must be tailored to the specific challenge you’re seeking to overcome.⁵ These short sequences must then be practiced repetitively—and in response to a designated cue—until they become second nature. Incorporating IADs into EMS education can raise our level of training to accommodate challenges representative of our environment, thus overcoming potential performance limitations.

Theoretical Support

There are several theoretical perspectives that support the concept of IADs, as well as the use of IADs in the context of EMS education. They include the stages of learning a new skill (i.e., stages of competence), explicit monitoring theory and the neuropsychological construct of habit loops.

Stages of Competence

The four stages of learning a new skill, often referred to as the four stages of competence, is a theory intended to explain the way we progress through the acquisition of a given skill.⁷ In the first stage, the learner is unaware of what they don’t know. This is often referred to as unconscious incompetence and is what might be expected of students at the beginning of a training program. In the second stage of competence, known as conscious incompetence, the learner becomes aware of their deficiency but remains inept. Recognition of such deficiency is an essential precursor to learning. The third stage is known as conscious competence. In this stage, a skill has been acquired, but performance of that skill requires concentration. It’s believed that a student who is performing at the conscious competence level might experience a deterioration of performance if a distraction is introduced during the performance of a skill. Given sufficient practice, the learner may progress to the fourth stage of competence. This stage is known as unconscious competence and signifies the ability to execute a skill or action without focused thought.

Given sufficient lab time, EMS educators are likely capable of guiding their students to skills performance that is consistent with the notion of unconscious competence. However, this still leaves a gap between primary education and actual performance in the field. If you ask your local EMS agency training officers, you might hear stories of model classroom students who struggled to get knowledge from their brain to their hands when faced with a dynamic situation. This might be attributed to an unrecognized fifth stage of competence, which can be referred to as dynamic unconscious competence. In this stage, a given skill can be executed without thought, despite the dynamic characteristics consistent with the practice environment of an EMS clinician. IADs may be one way to promote the achievement of dynamic unconscious competence and avoid choking under pressure.

Explicit Monitoring Theory

The explicit monitoring theory provides a partial explanation for the construct of choking under pressure.⁸ This explanation holds particular relevance to the previously described gap between unconscious competence and the proposed stage of dynamic unconscious competence. According to this theory, mental pressure can lead to a disruption in the automaticity of a well-learned skill by causing the individual to think about the process of what they’re doing, rather than simply doing it.⁹

The threat of focusing too intently on the steps of a particular skill is particularly concerning in the context of EMS education. Consider the number of steps contained in a skill sheet for even the simplest psychomotor skill. Regardless of the specific skill being learned, most EMS skill sheets begin with scene safety and BSI, followed by a laundry list of overly specific actions. It’s no wonder a paramedic might choke under pressure when the individual steps brought to mind, following a disruption of automaticity, are not explicitly focused on executing the intended action. Granted, such a high level of detail is imperative for the introduction of new skills, but perhaps we need to evolve our approach once a higher level of performance has been demonstrated. By training paramedic students to utilize brief, targeted sequences, which are triggered by specific cues, the paramedic might be able to maintain the parallel processing associated with unconscious execution of a skill.

Habit Loops

Habit loops are formed when a sequence of actions is converted into an automatic routine.¹⁰ Formation of this loop involves chunking (i.e., clustering) of psychomotor behaviors that are subsequently transferred to the basal ganglia—a paired portion of the brain responsible for recollection of patterns and selection of action in response to those recognized patterns.¹¹

Habit loops involve three stages.¹⁰ The first stage is characterized by the activation of a cue, which triggers the routine (i.e., sequence of actions) at the core of the habit loop. Performance of that sequence is the second stage. The third stage of the loop involves some form of reinforcement. This reinforcement can be as simple as a positive emotional response to having successfully navigated the challenge or receiving praise from an instructor.

The downside of habit loops is that cues can be very delicate. If the context in which a cue is presented changes, the habit loop is susceptible to failure.¹⁰ We might perform poorly when suddenly exposed to stressful and dynamic situations because the context, and therefore the cues, has changed. This is why training to develop habit loops must take place in the context in which they are likely to occur.

Application

The concept of IADs can be applied to essentially any situation, skill or task that requires dynamic unconscious competence. Examples include troubleshooting a deteriorating airway, application of a tourniquet, responding to sudden changes in a patient’s condition or recognition of life-threatening dysrhythmias. Low-frequency/high-risk skills, such as needle thoracotomy and cricothyrotomy, are also ideal for the development of IADs.

When developing an IAD for use in EMS education, it is important to first focus on a specific situation, skill or task (e.g., needle thoracotomy). Next, you should identify the desired trigger (e.g., recognition of a tension pneumothorax). You should then develop a short sequence of actions that excludes all ancillary actions. The sequence must be limited to only those essential actions for mitigating the problem. Focus on simplifying the sequence and consider the use of a mnemonic or ditty to make the sequence memorable.

Suppose you determine that the essential components in the sequence of needle thoracotomy include palpating the appropriate landmark, inserting the needle over the top of the rib and entering the pleural space with the needle perpendicular to the chest wall. In a simplified version, your students are then taught to P.O.P. (Palpate, Over, Perpendicular) the chest of a patient in whom they recognize signs of a tension pneumothorax.

Finally, you must implement the training of your newly developed IAD by drilling students in a context that does not allow them to anticipate performance of the skill. Consider developing numerous IADs that can be drilled with minimal preparation. This will allow you to spontaneously switch gears and capture your student’s attention as you see fit. However, this is not a means of initially teaching a given skill. This technique is intended to simplify the sequence so when a challenge is encountered, the student won’t choke because they’re over thinking the process.

Conclusion

The individuals responsible for educating future EMS professionals are not only faced with the challenge of teaching knowledge and skills, but must also ensure their students’ ability to demonstrate mastery of those skills while faced with the pressures of functioning in dynamic environments. Immediate action drills (IADs) involve a programmed sequence of actions performed in response to a predetermined trigger. This type of skill development technique eliminates the students’ anticipation of skill performance and raises our level of training to accommodate challenges representative of our environment. This allows us to train our students to react in ways more consistent with what will be expected of them in the field.

References

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2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Emergency Medical Services: At the Crossroads. Washington, D.C.: National Academies Press, 2006.
3. U.S. Bureau of Labor Statistics. Emergency medical technicians and paramedics. Occupational Outlook Handbook (2010-2011 ed.).
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6. Hockey J. Switch on: Sensory work in the infantry. Work Employment Society, 2009; 23(3): 477–493.
7. Adams L. Learning a new skill is easier said than done. Gordon Training International. www.gordontraining.com/free-workplace-articles/learning-a-new-skill-is-easier-said-than-done.
8. Beilock SL, Carr TH. On the fragility of skilled performance: What governs choking under pressure. Journal of Experimental Psychology, 2001; 130(4): 701–725.
9. Beilock SL, Carr TH, MacMahon C, Starkes JL. When paying attention becomes counterproductive: Impact of divided versus skill-focused attention on novice and experienced performance of sensorimotor skills. Journal of Experimental Psychology: Applied, 2002; 8: 6–16.
10. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business. New York: Random House Publishing Group, 2012.
11. Carlson NR. Physiology of Behavior (11^th ed.). Upper Saddle River, NJ: Pearson Education, Inc., 2013.

Elliot D. Carhart, EdD, RRT, NRP, NCEE is an assistant professor in the Emergency Services program at Jefferson College of Health Sciences in Roanoke, VA. He earned his doctorate from Nova Southeastern University, where his studies focused on healthcare education. He is a former firefighter/paramedic and currently practices as a registered respiratory therapist at Carilion Roanoke Memorial Hospital. Contact him at carhart.elliot@gmail.com.