When Are You a Competent Medic?

I recently received the following question in the comment section:

At 10:31 PM, DavisEmt said…
This is going to sound stupid:
But I don’t really have anyone I trust to ask.

How do you know when you are a competent medic, because I know every call isn’t going to run perfect, but I’ve been a medic a year (only 3 months for a busy service) and it just feels like the mistakes are never ending. I haven’t hurt anyone, but I definitely don’t feel I’ve helped anyone either.
Is there a way to know when you’re just not cut out for this job, I just don’t want to hang on in denial until I actually do cause damage.

Any input would be great, and well today was a bad day…..

Here’s my take:

Competency comes in small steps.

I think most medics when they are first starting question their own competency. This is because no amount of schooling, ride time or precepting can prepare you for everything you will have to deal with. Also, I think beginning medics may think they need to be perfect, when the longer you do this, the more you recognize there is simply no perfection in this business. (Being perfect is different from trying to be perfect, which we should all attempt.)

I think it took me about a year before I started feeling competent. This came from starting to handle the routine calls ( the 02/NTG/ASA chest pain, the breathing treatment dyspnea, the D50 hypoglycemia) well as I developed a rhythm and system that seemed to work. But then every now and then a call (asthmatic arrest, pedi struck by car) would come along and kick my ass, and I would go through the whole “Am I fraud?” “Am I going to kill someone?” agonizing, which I think all medics go through.

As the years have gone by, I have gone through a series of plateaus. I’d pound out the calls, feeling like I was not progressing, and then all of a sudden I’d do a call(a flash pulmonary edema — and the guy whose head was purple and who looked like he was going to die would get better), and I’d think, hey, I am actually getting good at this, and I’d find myself suddenly bumped up a level, and then I’d stay there for awhile, until the next breakthrough call. In time, many of the calls that I had thought were challenging (cardiac arrests, multisystem traumas) become more routine. And those calls that kicked my ass, well, I still had calls (admittedly fewer) that kicked my ass, but maybe my expectations were lower. I don’t expect to save everyone. I am no longer a “paragod,” I simply try to do the best I can with what I have to deal with.

There is a knowledge curve in EMS. You start out at knowing nothing, go to knowing something, progress to knowing alot, maybe come close to thinking you know everything, and then slowly start to slide down as you realize more and more you know less and less of what you thought you knew. And that is probably the place you want to end up. You need to have respect for the unknown. That doesn’t mean I don’t try to learn it, it’s that I recognize that knowledge is not finite, it is infinite. I just try to learn as much as I can and do the best I can. My youthful pride has been replaced with middle-age humility.

I still always evaluate each call I do for how I could do it better. I recently had a tough multi-patient critical call that I think went very well, and I was proud of how I handled it, but if I had to do it all over, I would do it much differently.

I guess today I don’t beat myself up as much for not being perfect. I do the best I can. I try to learn from the lessons each call gives me.

And when I don’t know what to do, I remember the wisdom of my first EMT teacher, Judy Moore: “If you can’t remember or don’t know what to do, remember to at least put the patient on the stretcher and take them to the hospital.”


In the previous comments Rogue Medic offered DavisEMT some excellent advice:

At 5:56 AM, Rogue Medic said…

Keep working at improving. Keep asking yourself what you could do better on every call. Keep asking others for advice, especially the doctors and nurses at the hospital when you bring in patients. Bug people, but learn. Think about ways you can apply what you have learned.

Review calls in your head. How could you have done things differently? Would it have made a significant difference?

Get a set of questions that you ask everyone, so you have both a starting point for questions and something to return to so you can cover the important stuff.

I ask everyone about chest discomfort, difficulty breathing, weakness, dizziness, nausea, vomiting, diarrhea, fever, head ache, visual disturbances, changes in things – medications, appetite, urination, BMs, . . . . Anything answered with a positive, even if only tangentially related, gets investigated – when did this begin, PQRST, SOAP, whatever works for you. Once you have a set of questions, and you feel that it is in an order that helps you to remember, but also helps you get to the important stuff first, just keep using it, modify it as needed for your style, keep returning to where you left off asking questions once you follow one line of questioning. You may still be asking questions when you arrive at the ED – that’s OK. Stick around and listen to the questions the nurse asks, the doctor, too.


  • Rogue Medic says:

    Thank you for the kind mention. It’s kind of like the frog trying to get out of the well. He climbs up a few feet, only to slide back a bit, then repeats until he is out, but there is no real top of the well for skill or perfection. If you are driven to improve to that level, you will probably be dissatisfied at your ability when you are there.

  • Anonymous says:

    I appreciate the fact a person seeks to be better. The ones who believe they are “super medic” make me nervous. I have been in EMS 30 years and I still learn things most days. There is a huge difference between confidence and arrogance. Paramouse

  • Rogue Medic says:

    Confidence is knowing that you can fall back on the basics of assessment and treatment and transport when you do not know what is going on. At least you will be providing that for the patient.Arrogance is thinking that you always know what is going on. Jumping to conclusions that a good assessment would not support.

  • Gertrude says:

    Consistently try to do better, and ask questions even if you have to ask them over and over. I like to review my calls with other medics for their input. This a constant learning experience. I think both of you are right. There is a learning curve and we all slide back. I’m a competent medic when I do the best for my patient with what I have to work with and get them to definitive care. I realized I did that more when I stopped agonizing over every decision, mistake and detail and looked at the big picture.

  • Rogue Medic says:

    Gertrude,I did not mean to suggest thay we should be worrying about every little thing we do, but I realize that I did not make that clear.Improvement in the big picture is what is important.I know I will always be making a bunch of little mistakes. I am not concerned about them. The big ones are what I work on avoiding.

  • So Illinois Medic says:

    Agreed to the always striving to impove but as to attaining that self-perception of competent…When I entered this profession, I was astounded by many of the people I met. Fire and EMS personnel had been just abstract figures on the TV news. As I interacted with these people as a student and new EMT, I was stunned by the caliber of character and dedication of the people that formed the ranks I wanted to join.So when did I feel competent? It happened after a very strait-forward call. We were called to a residence of an 60+ y/o f. Her sister had become concerned when the pt had missed calling her before church. The sister went to the pt’s house and saw her unresponsive on the bedroom floor and called 911.The local fire dept first responders met us at the door. Told us it looked like a diabetic problem. The pt’s blood sugar was 28 but she had probably been down all night. My partner and I walked into the bedroom. I knelt beside the pt, did a quick assessment before pulling my IV kit and dextrose from the jump bag. Slid in the IV no problem, pushed an amp and got ready to reassess. One of the first responders was beside me, helping to hold her arm still.So only I could hear, he quietly said, “Patients get good care when you’re around.”The patient quickly roused to CAOx4 and agreed to transport to get checked out at the ER. During the trip, I realized that I had managed to earn professional respect from the group of people I respect so much.That firefighter had no prompting to say what he did. Maybe he knew I needed to hear that I was competent in the eyes of my peers.My patients deserve my efforts to give my best and so do my colleagues.

  • Rogue Medic says:

    So Illinois Medic,When I have made similar comments to people, it has been because the person really stands out from the rest. In part a negative comment about the persons coworkers as well as a positive comment about the person I am talking to.

  • Coach says:

    This is a great question to address, and I appreciate the person who asked it.My goal, 30 years ago, was to be the “best.” That later morphed into the “best I could be.” During that time I had a unique ability to sort out some wheat from chaff.From working the busiest ambulance in Oregon and then moving to the Suburbs to be a firefighter/medic, I saw a big change. In the city, I worked with Minimum wage, 96 hrs a week medics. In the ‘burbs, I worked with very well paid, 56hrs/week firemedics. For some reason, the city medics loved taking care of patients and it showed – even the stew-bums on the street. Unfortunately, that same level of care wasn’t provided in the ‘burbs. I don’t know why.I loved my years in the city; and because of those years, my learning curve was steeper and deeper. Some of my colleagues in the FD never saw the call volume to push them past the rookie stage. And because they didn’t transport, they rarely had the contact hours with their patients that allowed them to see the results of their care (or care mismanagement).In my experience (and from being an FTO, senior medic, training officer, and operations manager), it takes at least a year post-certification to really understand what one is doing. It takes at least three years post certification for it to really sink in.But what really matters, in my not so humble opinion, is that one loves what they’re doing. They love taking care of people (vomit, incontinence, and derelicts alike), and they love to learn.

  • Anonymous says:

    Not to hijack the thread, but what strikes me most about the question is that DavisEmt feels better asking strangers on the Internet than anyone he knows personally or works with. Sounds like our friend has a serious lack of mentors, which is unfortunate for everyone.

  • Rogue Medic says:

    In some places, to appear to be less than confident is seen as a sign of weakness. The clique of “in crowd” medics will tease anyone they see as weak. This is a horrible culture, but one that seems to be a way a bunch of people try to compensate for their own fear about their own abilities. If everyone else is worse than you are, then how bad can you be.I don’t know if this is what he is experiencing, but it is something that I have run into in a few places. Usually there are those who oppose this, but they may be viewed as outcasts. Kind of a jocks and geeks of EMS.One of the best antidotes to this is an involved available medical director, who encourages understanding. The more everyone understands of what they are doing (assessment, pharmacology, critical judgment, . . . ), the more secure they should be, at least EMS-wise.

  • DavisEmt says:

    I just wanted to thank everyone for the support and ideas. I have definitely started sticking around and watching the docs and their assessments. I have also come to realize there doesn’t always have to be a divine intervention while in my ambulance. I work in a system that often pushes drugs just to do so. You will also find even the stubbed toe gets a bloodsugar. As this system is new to me, I was kind of feeling overwhelmed with things I disagreed with, so naturally as a new medic, I felt I was wrong. In the past few weeks I have decided to trust myself and not worry about the minor stray from protocol or what the doctors may lecture me about. I am concentrating on my patients needs, not what my colleagues will think of me. At times this system seems to live a motto of “Go big or go home”I will admit that I don’t really have any people I look up to here, but “bullies” are rare, while most are generally supportive, it is often hot air, with little substance. I decided to call on Peter because through books and blog, I knew I would get ideas to work with.So thank you to everyone, I have renewed roots to grow from.

  • Rogue Medic says:

    Have you talked with your medical director about the kind of treatment that is expected? Using some examples of protocols, or expectations that are not written into the protocols, but expressed by the ED staff or coworkers, might help to clarify the position of the medical director. Sometimes they are not as familiar with the protocols as they think. I have pointed out some things that were in protocols, that the medical directors never intended, but by the time the draft is rewritten the fifth time, you don’t notice some changes, whether they are typos or somebody thinking they are correcting a typo that was not a typo.The medical director should be the one who has the final say on what is good care and what is selected for criticism.

  • Michelle Davis says:

    Biggest problem. Fire runs ALS under one med. director, our ambulance, also ALS runs under another med. director. Little communication happens between the two, expect for us guys on scene. And the two entities usually see things very differently. While protocols are the same, there are gray areas, that may not seem important but come down to patient advocacy stuff. The little things the med. directors don’t care to get involved with.

  • Rogue Medic says:

    Sounds as if these are some absentee medical directors. A lot of the QA/QI/CYA is probably done by people who are doing what they think is important, without any direction from the medical director. “Well the medical director was in the ED and saw Treatment X one day. When he did he made a face that looked displeased, so we will punish anyone who does this, even though it is in the protocols.”When I was a medic student, doing my ride time, I wrote a PCR about a patient who was weak after a car collision. I documented that orthostatic vital signs were not done due to immobilization. The protocols may not have required orthos, which are not based on research, but the protocols did encouraged them for weak patients.My preceptor and his partner were written up as having created a serious danger to the patient (one step below being suspended), for considering orthostatic vital signs, or for not making sure that my paperwork did not mention this.Why? Because the people in QA/QI/CYA were so far removed from reality that this is the kind of thing they do to justify their existence. I had an excellent preceptor and his regular partner was also excellent. If I had suggested anything dangerous, they would have prevented me. Documenting to avoid a write up by chart review medics was what I was doing, but I had no idea how far beyond the pale they really were.Anal Medical Retentives at work.

  • Ryan G says:

    In looking at the field of the EMT, it is important to take into account the upcoming skilled worker shortage. A recent study by the Imagine America Foudation found that career colleges will produce 12 % of the 6000 EMT job openings in the future. To find out more about this study see http://www.imagine-america.org.