(Author’s note: This is the longest post we’ve ever done, but also one of the most well-researched. It’s not a quick read, but we believe that what’s in here is worth knowing. So set aside some time, get a cup of coffee, break it into two reads if you have to… whatever you gotta do. But read it. Seriously.)
I stopped right in the middle of my mock patient assessment and stared off into the distance. Not to pause, not to collect my thoughts… but because I completely and utterly blanked out. I vaguely remember Chief Strobl telling me that I was killing my patient – I’d missed a major bleed stemming from her brachial artery and she was going into irreversible hemorrhagic shock. Now, in reality, my patient was just fine. In fact, I could see her rolling her eyes at me as I tried to stumble through and salvage what was left of the NREMT Trauma Patient Assessment I’d just botched. But I couldn’t remember the next step to save my life… or hers, apparently.
I’d taken the National Registry of Emergency Medical Technicians Practical Exam before, the first time I became certified as an Emergency Medical Responder. But that was three years ago. And although I’d certainly trained and refreshed my skills in the interim, that training hadn’t been on this level of intensity, not by a long shot. When I started the process of re-certifying for National Registry EMR over the summer, I mistakenly assumed it would be a slam dunk. I’d passed the written and practical exams alike with flying colors the last time I took them. Re-certifying should just be a simple refresher… I already knew all of this, right? Wrong. How hard could it be? Hard.
That first time attempting to run through the practical exam stations made me realize just how much I’d forgotten. It served as a stark reminder for me to get my ass in gear and train harder and more often, and on my own time. Thanks to some very generous help from fellow members of Cherokee County Search & Rescue as well as Lake Arrowhead Volunteer Fire Department, I started doing just that, in order to have a shred of hope of passing the exam. More on that later.
At SARCRAFT, we spend a lot of time talking and thinking and researching about how people learn. We are an educational institution, after all. Jonathan and I both are always trying to improve our processes and our course content in order to help people digest the knowledge we give them while they’re here, and help them retain it after they leave.
And one thing we’ve found is that most knowledge is highly perishable. In our credentialed society, we fall victim to the belief that just because we have a piece of paper that says we know something, we actually know it. That’s not always the case. We knew this already, of course – it’s why we train the way we do in Special Ops Battalion. Every critical skill has an expiration date. Our SARTECH certs are good for three years, like our NREMT skills. CPR is two, and our pack test for physical fitness evaluation is yearly. It’s not just Cherokee Fire/EMS who does this by any means, it’s any profession where lives depend on people being able to practice a certain skill set reliably and competently. All branches of the military, every fire department and police force that I’ve ever known of, even private companies that do dangerous work like hazmat mitigation, all build their training plans around this idea that learning high-stakes skills is not a once-and-done proposition.
If you don’t believe me, here’s a quote from POST, that is, the Commission for Peace Officer Standards and Training:
“Studies have shown that incidents involving perishable skills make up the majority of law enforcement and civilian deaths, injuries and resulting legal claims. The same studies show that after two years without refresher training, those skills begin to deteriorate. Perishable skills for peace officers have been identified as driving, tactical firearms, force options, arrest and control, and verbal communications.” (Commission for Peace Officer Standards and Training, 2017)
There’s that term again. Perishable skills. What are they, and why are some skills perishable and others not? Which categories of skills should we be concentrating on? And most importantly, how can we practice these skills so they stay fresh instead of withering like a two-year-old cantaloupe? Let’s drive on.
#1: What are perishable skills?
Perishable skills, most simply defined, are the ones we lose the ability to perform competently without regular practice. Some skills are highly perishable, some moderately so, some not at all. Riding a bicycle is the consummate example of a non-perishable skill. Once you’ve learned it, it’s difficult to forget it. Correctly performing a patient assessment is an example of a perishable skill. Unless you train on it regularly or are an EMT or paramedic, it was probably gone pretty quickly after your initial training. For the purposes of this article, we’ll be focusing specifically on lifesaving, practical psychomotor skills that are by necessity performed under stress. These are the most perishable skills of all. Let’s delve in to why that is.
#2: Why are some skills more perishable than others?
Not all skills are created equal. Why is it that some, once learned, pretty much stick with us for a lifetime, whereas some are gone very shortly after we stop practicing them?
There are several criteria that make some skills more perishable than others:
1. The higher the level of cognitive function required, the more perishable a skill is. To go back to the classic bicycle example, that’s primarily a motor skill. When you learn it, it becomes ingrained in your muscle memory (also called procedural memory), which is controlled by the cerebellum and basal ganglia of your brain – the lower brain. Once learned, it becomes as ingrained as any other activity which requires basic motor control, such as walking. Typing on a keyboard, and to an extent, driving, are also examples of skills retained through muscle memory. Higher-level cognitive skills, however, are much more difficult to ingrain. Hebb’s Rule states that “synaptic connectivity changes as a result of repetitive firing.” Meaning, the more you perform a given skill, the more connected the synapses are that control it, and the more effective those neural pathways become at transferring information. In the lower brain, this happens much more quickly and easily. However, higher-level cognitive skills take place in completely different parts of the brain: the cerebrum and the temporal lobe. Ingraining complex tasks in these areas of the brain takes a significant amount of time and effort, because it isn’t designed for it. Those areas of the brain prefer to work by retaining individual pieces of relevant information (“hitting the high points”) and piecing them together when recalled. Our own cognitive processes fill in the gaps. Linear processes that have to be performed in a specific order and cannot be deviated from (such as the patient assessment) go against how those areas of the brain work.
2. The more ways there are to perform a given skill, the more perishable it is. For example, if there are several ways that aren’t necessarily wrong, but only one “best” way, that skill can be difficult to retain. When you ride a bicycle, you’re pretty much going to do it correctly, or go over the handlebars. There’s not a lot of room for deviation. You either know it, or you don’t. When assessing a patient, there are plenty of things you can do that aren’t necessarily wrong. They won’t kill your patient or cause them further harm. But they’re not the best way. If you fail to follow the best way, you’re more likely to miss critical pieces of information, deliver care in certain areas in a timely manner, etc. As was mentioned above, if you don’t know the entire linear process by heart, your brain will try to pull the pieces you do know and “fill in the gaps” as best it can, sometimes incorrectly.
3. The more high-stress a skill is, meaning that the mission may fail if you don’t perform it correctly, the more perishable it is. There has been a tremendous amount of research devoted to the topic of skill deterioration under stress. And rightly so, because if you can’t perform a skill in the environment that necessitates it, what good is it? Remember the higher-level areas of the brain that dictate step-by-step linear cognitive processes? Well, those shut down under stress. Ironic, right? When we are faced with stressful situations, our brains are flooded with cortisol and adrenaline – the fight or flight hormones. Our heart rate, blood pressure, and respiratory rate all increase to prepare us for a physical confrontation. (Driskell & Johnson, 1998) This comes at the expense of blood flow to the brain, especially the ones not deemed unnecessary for survival: the cerebrum and the temporal lobe. During stressful situations, our brains also hyper-focus on what appears to be the biggest threat. Our vision focuses, we block out background noise and other distractions, and ignore our surroundings in order to devote our attention entirely to what’s in front of us. This goes by several names, including tunnel vision and target lock. Not only does this wreak havoc on your situational awareness, but your higher cognitive functions go out the window. (Honig and Lewinski, 2008) These two factors combine to severely decrease our memory recall and problem-solving abilities, leading us to either perform skills at an ineffective level, or “choke” entirely and freeze up, unable to take the next step. Any skill that inherently needs to be performed under stress is going to be more difficult to recall, and therefore, more perishable.
4. This one is fairly intuitive, but the more steps that are involved in performing a given skill successfully, the harder it is to retain. If you have to remember a two-step solution to a problem (do this, then do this), you’re likely to retain it without too much effort. If you have to remember a twenty-step process from beginning to end in the correct order, that’s a serious mental challenge.
So what does this tell us? That linear, multi-step psychomotor skills that are by necessity performed under stress are the hardest ones of all to retain and repeat correctly. You may know them as tactical skills. Emergency medicine, combat shooting, and wilderness survival, among others. They involve all major parts of the brain (muscle memory as well as higher cognitive function), they are a step-by-step linear process in which all aspects have to be performed correctly, and they are highly vulnerable to the shutdown of the higher brain that happens under extreme stress.
#3: Which skills should I concentrate on?
We all have limited time and resources. There’s no debate about that. As cool as it would be to train all the time and be totally prepared for anything we might face, it’s simply not possible. For some people it’s more difficult than others, but even full-time first responders who literally live and die on their skill sets often find it hard to squeeze training in. So how do you know what to focus on, in order to maximize your limited time and resources for the greatest effect? There are two major categories of lifesaving skills to practice:
1. Those that are specific to your vocation, or pertain to specific activities that you commonly engage in.
2. Those that pertain to universal emergency situations that we could all potentially face.
The first one covers the specialized skills. For example, I’m a search & rescue technician. I have a set of skills that I have to keep sharp in order to continue doing what I do, because my fellow team members and the lost persons we serve depend on me to do so. Not everyone needs to know how to navigate with a map & compass, run a route search, and fill out an ICS 204 form, but if I don’t, I’m a liability. Hence, that’s what we train on.
Or say you’re an avid whitewater kayaker. Well, you’d better know how to perform self-rescue rolls and wet exits, throw a rope bag, and read a river to know which rapids are safe to run and which ones you need to portage around. If you don’t know the perishable skills that pertain to your vocation or your adventure hobby of choice, you can very quickly find yourself in a situation you can’t get out of without help. This makes you a liability at best, and at worst can get someone killed.
The second category are the perishable skills that EVERYONE should have, regardless of what you do for a living, where you volunteer, or how you spend your free time. CPR. First Aid. The Heimlich maneuver. How to shoot a gun. Better yet, how to shoot the one you carry every day while under stress. How to use a fire extinguisher. How to read an MSDS. (Sounds obscure, but it isn’t. We’re surrounded by toxic chemicals every day and most people have no idea what to do if they’re exposed to one of them.) How to effectively defend yourself with just your fists. Or a knife, a pen, your keys, or whatever else is handy. How to survive in the woods for at least 24 hours. How to swim, and within that, how to rescue someone who’s drowning – especially if that person is yourself. It’s difficult to be prepared for every situation. But these skills and a few others will cover most emergencies the average person will ever find themselves in. We’ve heard the refrain more times than we’d like to think about: “I just wish I had known what to do when ____ happened. Maybe if I’d had some training, I could have done something to help.” Don’t let that be you.
#4: How do I keep my skills fresh?
Training. Consistent, regular training. If you’ve ever read Malcom Gladwell’s excellent book Outliers, you’ve heard about the time principles of mastery. Gladwell states that it takes approximately 40 hours of training to gain competence in a given skill set. However, that competence is not retained if the training ceases. Other research backs this up. During a study done in the early days of CPR training, it was shown that one year after the initial training, only 20% of trainees could competently perform CPR. The initial signs of skill deterioration were seen only six weeks after training was complete. (Wynne, 1986) More recent studies by the Royal Canadian Mounted Police show the same trend. To quote:
“After two months, the ability to deliver the appropriate depth of chest compressions during CPR, as well as the ability to use the correct hand placement, had been seriously impaired. The impairment was so great that when trained participants were compared to untrained participants, there was no measurable difference in their performance ability.” (Einspruch, 2007)
That’s disheartening. So is it possible to break out of the endless cycle of training and forgetting? Yes, absolutely. It only takes 5,000 hours. According to Gladwell, to achieve true mastery of any given skill, it takes approximately 5,000 hours. (Gladwell, 2008) Remember when we talked about increasing synaptic connectivity to ingrain higher-level cognitive skills, and how it takes so much longer than ingraining something in your procedural memory? That’s how much longer it takes. Someone who has put in their 5,000 hours can conceivably walk away from a skill for as long as they like, and pick it right back up with a slight refresher. Those synaptic pathways are carved in neural stone.
For most of us, however, 5,000 hours is not possible. That works out to 125 40-hour work weeks. Unless it’s your actual vocation, or something you’re extremely passionate about, you’re not going to be able to put in the time. Even then, very few people are capable of truly mastering more than say, a half-dozen skills over their entire lives.
What does that mean for the rest of us, then? We train. We train often, we train well, and we train consistently. Although it’s no substitute for true mastery, regular training will keep perishable skills constantly refreshed and keep the neural pathways open. Especially on those skills that will be tested under stress. Stress reactions to an environment, the ones that cause target lock and shut down your higher brain, are lessened when you’re less surprised by what you face. Prior knowledge, that is, identifying what life-threatening situations you might face and training accordingly, “allows people to form accurate expectations”, “decrease distraction”, and “identify and avoid performance errors.” (Driskell & Johnston, 1998) Over-practice, meaning continuing to practice a skill after it has already been learned, also significantly improves the retention of skills under stress. (Jones, 1989) Training regularly also keeps you from experiencing the unpleasant surprise of having forgotten something you used to be very well-versed in.
This happens to us all the time at SARCRAFT. We’re used to hearing a lot of guys say “I don’t need survival training. I _____.” (was in Scouts, the military, hunted a lot back in the day, spent a lot of time in the woods as a kid, etc.) Then they actually come to a class (usually because they brought their wife/girlfriend/kids to learn), and are shocked by how much they’ve forgotten. It’s not uncommon to see guys with serious woods experience in the past struggle just as much as their wife, who’s never started a fire before in her life. Woods skills, especially those related to survival, are highly perishable.
So if there’s a skill you’re short on, go out and practice it, preferably with a buddy who’s practicing with you. Iron sharpens iron. Start with an hour a week. Anyone can manage that. More practice is better (Cherokee Fire says 12 hours a month minimum for its volunteers), but if you get that hour a week in, you’re still ahead of everyone else who’s not training at all. We encourage all of the students who come through our classes to practice on their own time, and even give out “prescriptions” of what to train on when they get home, and for how many hours.
A few weeks after my embarrassing patient assessment incident, there was another patient. This one was real. It was the night before our EMR practical exam, and one of my fellow SAR members and I had agreed to meet at a local fire station to practice one last time. As we arrived, a man pulled up in a minivan and got out, clearly agitated. He approached us and said he was trying to drive himself to the ER, but couldn’t make it. He said he was going to pass out, and asked if we could help him. We said absolutely, follow us. My friend went into the station’s living quarters to get the paramedics on duty, and I took the patient into the bay and sat him down in a rocking chair by one of the engines. I went through the medical patient assessment step-by-step, getting his name, age, and other basic information, followed by his baseline vitals. I ensured a clear airway and checked his respiration rate, rhythm, and quality, just like in training. I was about halfway through my SAMPLE history when the paramedics took over. I was able to give a verbal handoff report detailing all the care I’d given up to that point. The medics treated him, hooking up an IV, attaching the heart monitor electrodes to him, and all the other cool stuff that’s way out of my scope of practice. I have a lot of respect for those guys and what they do. True professionals. If you wanna talk about perishable skills… paramedic level emergency med training is some of the most complex out there. Those guys have to know stuff from memory that even doctors don’t. After a squad arrived, they loaded him up and took him to the ER. It was over. Although it was a relatively minor incident, it was a big confidence-booster. Being trained felt good. I did my job. I stayed calm, didn’t choke, I treated my patient as best I could, and turned him over to a higher level of care. Everything was completely by the book, and putting in the hours training made all the difference in the world. My friend and I shook hands with the medics on duty and went back to our skills practice… because after all, you don’t rise to the occasion, you fall back on your training.
We passed the practical exam, by the way.
State of California, Commission on Peace Officer Standards and Training (2017). Perishable Skills Program.
Driskell, J.E., & Johnston, J.H. (1998). Stress exposure training. In J.A. Cannon-Bowers & E. Salas, Making decisions under stress: Implications for individual and team training (pp. 191-217). Washington, DC: American Psychological Association.
Honig, A., & Lewinski, W. (2008). A survey of the research on human factors related to lethal force encounters: Implications for law enforcement training, tactics, and testimony. Law Enforcement Executive Forum, 8(4), 129-151
Gladwell, Malcom. (2008). Outliers: The Story of Success. Little, Brown & Co., Boston, Mass.
Einspruch, E.L., Lynch, B., Aufderheide, T.P., Nichol, G., & Becker, L. (2007). Retention of CPR skills learned in traditional AHA heartsaver course versus 30-min video self-training: A controlled randomized study. Resuscitation, 74, 476-486.
Royal Canadian Mounted Police (RCMP) (2010). RCMP Skill Retention and Perishability Literature Review. Retrieved from: http://cord.acadiau.ca/tl_files/sites/cord/resources/Documents/RCMP%20Skill%20Retention%20and%20Perishability%20Literature%20Review.pdf
Wynne, G. (1986). ABCs of resuscitation: Training and retention of skills. British Medical Journal, 293, 30-32.