Consciously Incompetent

November 25

Back during our scene safety lectures the instructor said that EMS providers could be broken down into 4 categories and that each marked a different level of progression in our evolution as professionals.

The Four levels of progression as defined by our instructor:

  • Unconsciously incompetent – At this stage of development the provider doesn’t know how much they don’t know – I suggest most beginning paramedic students fall into this category.
  • Consciously incompetent – At this stage the provider begins to understand how woefully inadequate their knowledge base and skill set really are. – This is where I am finding myself these days.
  • Consciously competent – When they reach this stage if they really focus on what they are doing and concentrate fully on the task at hand they can perform their duties and provide adequate patient care.
  • Unconsciously competent – this is where the rockstar medic lives – they go about every call looking like they knew what was wrong with the patient before they even got there and make everything from handling an MCI to holding 95 YO nanna’s hand look like something were born to do. Executing flawless appropriate patient care without even thinking about it.

As a basic, I considered myself among the top two – certainly competent whether it was consciously or unconsciously depended on the call.

Now that I am a paramedic student, at the very beginning of my rides – I am more than aware what I don’t know, how much work “my game” needs and where I fall flat on my face.

When my preceptor for my second ambulance shift got in the bus he opened every sealed cabinet so I would know exactly what was in every box, gave me the narcotics code (hell I don’t even have the narc code where I work), and told me it was MY show to run that day… scene management, assessments, treatment plans, procedures ALL of it. “I will let you totally run the show, until you show me that you can’t, and then I’m going to take the call from you. I won’t let you kill you anyone and I will approve or squash your treatment plan before you implement it – you good with that?”

Seriously? You are going to take the proverbial leash off and let me run the call? HELL YES I’m good with that.

I am totally convinced that somewhere someone has etched “HELL YES I’m good with that”  down as famous last words…

Our first call was for a woman with stomach pain. I jumped out of the bus, grabbed the kit and was off. Ma’am I’m Jeff, I’m with the paramedics can you tell me the problem today? Was about as long as I lasted. She said her stomach hurt and curled up face down on the couch. I looked up at the preceptor probably with that deer in the headlight  look on my face, like now what? That was all the prompting he needed. He got her to sit up, asked his questions and got a response faster than I could even think what I should be asking next. I blew two IV attempts en route to the hospital and felt like a heel… Talk about screwing the pooch. Since I came back to EMS  I haven’t had to deal with someone who wanted our help but was uncooperative… I’ve watched my partner do it, but its never been up to me and my brain just wasn’t going to move that fast.

The second call was a guy who was punched in the face after trying to stop a shoplifter… my assessment was ok (there was really nothing to assess) but being unfamiliar with how refusals work I had to left him take the call from there so it was done properly.

Third call chest pain… I’ve been on a thousand chest pain calls… I had this one down cold – My assessment was good, my line of questioning solid and appropriate, I had come to the conclusion the lady was having a panic attack and so had he… she refused transport and I handled it – we’ll call it a double in baseball terms, good but not great.

Two more refusals and 5 hours of being posted at the airport later the shift ended. That 5 hours without patients was the best part of shift, not because I’m lazy and don’t want to run calls, but because it gave my preceptor time to TEACH me how to do the things I need to work on better. My biggest regret was that I didn’t get to show him how I could implement the suggestions he offered to me into my assessments. I learned a lot about myself in that shift and a lot about how to get better. The scores on this eval weren’t nearly as high as the first ones… but he evaluated me as a paramedic student not as a basic. He challenged me to get better, he pushed me to learn, he asked questions I didn’t know the answers to and then told me how to find them.

When my third shift came around I asked if I could work on the scene management and the assessments because I had identified weaknesses in those area on shift two. My preceptor was happy to oblige and add that he also wanted me to do the hand off reports at the hospital.

Awesome another challenge – now we’re talking.

My assessments were better and I was able to implement a lot of things I had been told the day before, still not great but a whole lot better then when I started. Hand off reports were a little sloppy, but again not something I get to practice often. I tried to implement all the suggestions and make things smoother and more orderly. I felt like I was getting into the rhythm – then we got a call for a sexual assault… It was a teenage girl – tops she was twenty. She had been severely beaten, most likely raped and left for dead naked in a heap on a snow bank.

That rhythm I had been developing was gone… I guess I just stood there unsure what to do because my preceptor jumped in and ran things right out of the bus. Evidence, the suspect, the tragedy this young woman had just endured, injuries My head was spinning and I had no clue which should come first.

My preceptor was a pro – he handled it all professionally, preserving/gathering evidence, assessing and treating all at once – it was impressive.

It was also the point when I realized just how incompetent I am.



Posted by on November 25, 2011 in EMS, EMT, Paramedic School


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5 responses to “Consciously Incompetent

  1. J. Hawk

    November 25, 2011 at 23:38

    As a Basic, you can be unconsciously competent and yet be unconsciously incompetent as a Paramedic. This is to be expected. Truly in your training, you are exactly right where you should be! You are, as you yourself said, an EMT with a whole bunch of advanced skills. You also said it exactly right: you just don’t know *when* to use those advanced skills. You aren’t expected to perform like a seasoned pro yet. Your preceptor just did you a HUGE favor though! He let you learn where you are and where you need to be, all without having to tell you.

    You now have some measure of enlightenment as to where you fit. This is crucial in your development as a Paramedic. You now know that you lack in certain areas and you know what you don’t know now and can work on improving those areas, under the guidance of your preceptor.

    Continue to ask questions about how you can improve and work on improving just one or two areas at a time. Eventually, you’ll just gently slide right into putting all the pieces together and you’ll realize you’re consciously competent and a safe beginning Paramedic. That is where you will need to be at the end of your internship. It’s a long road, you’ll have some plateaus and setbacks, but you’ll ultimately come out OK, if you let the process work and actively participate in it!

    I was once a student Paramedic like you…

  2. J.Jose

    November 26, 2011 at 04:21

    Reading your blog post for Nov 25th was great. You are the student that seasoned providers want and NEED. Students that ask question and seek answers force a seasoned providers to stay on top of their game as well.
    Keep doing what you are doing and above all REMAIN A STUDENT ALWAYS and NEVER STOP LEARNING.
    Stay Safe !

  3. CJ

    November 26, 2011 at 20:50

    It gets better my brotha, but you got the right attitude! Keep up the strong work! I had an assault call on my third rides, they are never easy but you find that eventually no matter what the call is you build a system and use that same system every just realize one day that it has happened, there is no specific point when it just realize, shit..I’m a Paramedic.

    • hotlightsandcoldsteel

      November 27, 2011 at 14:24

      Thank you all for your support and encouragement. I hope my post didn’t come off as whining or complaining – that wasn’t my goal at all – I think its important for students to be challenged and put into “uncomfortable” positions as its the only way we’ll grow. I was also hoping that other students reading would get encouragement from knowing they weren’t the only ones who felt like it was coming together for them and then it all of a sudden fell apart again.

      Thank you all again for the support and encouragement !!

  4. hilinda

    November 30, 2011 at 12:13

    I don’t think your post came off as whining or complaining at all.
    As a teacher, I loved seeing someone who recognizes what they need to do to keep learning, to keep improving.
    Yes, it can be hard, and that “coming together then falling apart again” thing will likely happen over and over as you come to a better and better understanding of things.
    As they say, when you’re a beginner, you think about how much you know, but a master recognizes how much more there is to know.


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