The Expense of Experience

Excuse Me Sir, Would You Please Have A Heart Attack So I Can Learn?

Know any finance or accounting majors? Here's an interesting thesis for the masters or even doctoral level.

Run a in-depth financial analysis on the patient's seen by a paramedic in a month. (Even that is probably going to take semesters to complete.) If the medic runs a genuine heart attack, that is going to increase his experience level with recognizing and treating heart attacks. But how much was that hospital bill and successive bills for the patient. For insurance. What was the total cost for that experience? Add up all patient's seen for a month, that would be a large sum for sure! It's clearly possible that a veteran medic's experience came literally at the cost of a billion dollars. (when a single heart attack could cost a million. (and that's an old article)

And this doesn't take into account the non-medical - the vehicle or property damage, missed work, that a firefighter is likely to witness in their career. The author takes note - wow, they really DON'T pay us enough!

Here's something that happens more than you think :

You’re at a Thanksgiving party and one of your nephews, a 10-month-old infant, stops breathing. (If you are in Public Safety, imagine you are a layperson for the time being.) 911 is called, paramedics soon arrive and quickly go to work. You overhear one of them telling a distraught mother, “Ma’am, I’ve seen this type of respiratory problem hundreds of times, we’ll take good care of him.” The child is rapidly transported to the hospital. Later, you hear the child was successfully resuscitated and is doing well, and is diagnosed with some condition you’ve never heard of.

Clearly this is a happy ending, but one thing I’d point out is the paramedic who said he'd ran that same call hundreds of time. Obviously, he’s trying to calm down the mother and maintain control of the scene. But let’s assume he is telling the truth and ask the difficult question: How much better is he at that call than the first time he ran it? Common sense would say he must be better. (To be fair, common sense would also say there’s no way to truly know). Another way to phrase the question is, how much better service did that customer receive? Just because we don’t have inexperienced personnel making huge mistakes left and right, doesn’t mean we couldn't stand to become better.

It’s important to understand what we mean by “experience.” There are many definitions of experience, my personal favorite is deeply ingrained proficiency. A good example of a deeply ingrained proficiency is your ability to read. It’s so deeply ingrained you can’t NOT read something, I’ll prove it – hippopotamus.

There’s no way you continued this article and NOT process that word. Your brain has done the skill of interpreting letters so many times, the skill is automatic. Apply this analogy to a seasoned paramedic who encounters a relatively uncommon condition – he’s so experienced, he can’t fail to quickly identify the problem and begin correcting it. He can't not see it because he's processed it so many times.

The problem is: we only “real experience” on real calls, particularly on critical thinking skills like patient assessment or incident command. Don’t believe me? Look at the field of medicine – you don’t train on medicine, you practice it, i.e. you learn by doing. PowerPoints and lectures are important to have as a foundation, as a context from which to build. However, in terms of gaining experience, you need to see the illness, the incident. Look at clinicals or residencies – physicians or preceptors will get their students and say, “come look at this patient, I want you to see this.” Then the student sees the patient sweating, their pale skin, the discomfort in the face. The student just gained some, although minor, proficiency identifying a heart attack – but someone had to have a heart attack in the first place. How much did that cost? It’s a bit macabre but the amount of damage that led to your experience level may very well be in the billions. (not to minimize the intangible value of human life)

So, if this is such a problem, why aren’t firefighters or paramedics clamoring for change? Where’s the fire? Think about the Fire Service as a culture. We are bred to be self-reliant and to “adapt and overcome.” We are used to not having what we need. We need more staffing, more apparatus, more everything. Experience can get in line. And it’s is something we’ll get, albeit haphazardly and inconsistently. However, something has to burn or someone has to hurt for us to become more experienced.

What happens in our brains when we actually get experience? The best way to think about it, without delving into neuroscience, is a toolbox versus tools. When we train on a particular skill or even a type of medical call, that’s a tool we toss into our toolbox, which is our pool of experience. The problem is, unless you just used that tool very recently, it’s not going to be at the top of the box. You’ll have to burn precious time sifting through your toolbox to find the bit of information you want. Over the months and years, as you run the calls and gaining the real experience, this helps organize your toolbox.

I go into more detail on how the brain receives “experience” in the Pattern Recognition Article. For now, just remember that it involves sensory information, seeing and hearing things, and then forcing the brain to adapt by exposure to stressful, chaotic events.

Ultimately our training methods must evolve. We must embrace technology much faster than we have had in the past. Remember, modern SCBA was invented in 1945 yet we didn’t adopt them until NFPA 1977. Even as late as 2008 we had firefighters using yellow kitchen sponges instead of their regulators. We cannot afford to take years to adopt something that we know works. Let's do our best to run the worst call of our career before we ever leave the station, by gaining experience before the tones go off.