• Tyler Christifulli

The Goldfish Paradox


I sat in my office, opened up a spread sheet, and started to develop the different education tracks for the Wisconsin Emergency Medical Service’s Association's (WEMSA)  annual conference. Typically you would have a basic life support (BLS), advance life support (ALS), critical care, and operations track. Even though ALS & BLS providers respond to the same emergencies, we create an educational delineation to allow appropriate transfer of knowledge in relation to baseline education. This prevents a cross contamination of either bored or confused clinicians. This probably also explains the reason children are sometimes taken into a different room or class while their parents attend church.

I created a graphic explaining this. I call it the "Degree of Separation Theory." 

Often we see teachers or preceptors discuss topics that they feel very confident with. The further they stray from the students confidence, the harder it is for information to transfer. I think of it like trying to "AirDrop" a large file on my iPhone to someone. The further they are from me, the harder it is to transfer that information or data.

While this concept appears to be valid at face value, it has an interesting effect on the figurative glass ceiling of growth within a BLS provider. I remember at a very young age being told that a goldfish would only get as large as the tank it is kept in. I thought it was cruel for me to prevent the fish's growth by keeping it contained in a small bowl for viewing pleasure only. The potential for growth was there, but the limitations were tangible. In some ways I feel that we are building a figurative glass bowl around the BLS providers growth by having them attend sessions that are strictly limited to stuff they already know. 

If you know everything that is being discussed, you are not learning. - David Nielsen

This evening during our crew brief my pilot was telling me that in aviation, you do not put a cap on your knowledge. Just because you are not certified in instrument flight rules (IFR), doesn't mean you shouldn't know how to fly by instruments in the event the weather goes down and you go into intermittent meteorological conditions (IMC). 

As a BLS provider you are expected to know the basic physiology of common emergencies, how to perform a thorough assessment, and the scope of skills to provide necessary interventions. However what we tend to occasionally see happen in combination license systems, is a degradation of skill level at the basic life support level. They naturally will rely on an advanced life support level provider for the heavy-lifting. Phrases such as "this is above my pay grade" echo from a self encapsulating chamber. 

In the list above, number four states "temptation to continue to utilize VFR flying techniques," Obviously this can quickly lead to disastrous consequences and disorientation. However, we often see providers get into an unfamiliar or uncomfortable situation and keep repeating the same thing over & over again looking for a different response. The glass ceiling of your "pay grade" can quickly become fogged by lack of preparation in response to cognitive limitation. 

I can remember one time asking my partner  "what would be the scariest page for you to get right now?" He looked up with a  smile while eating left-over Taco Bell and said: "I really don't have anything that scares me because you are the paramedic, and if anything goes wrong its on you." He said it while laughing, and I knew his sense of humor enough to get the joke-but I did have to consider the amount of truth that could be hidden in that statement.

ACLS For BLS

To prevent BLS providers from being put in an educational cycle of splints, aspirin, and trauma assessments- I developed a session at Lifestar called "ACLS for BLS." I would take a group of BLS providers and actually teach a two day ACLS course. They would take the test, get cards, and have to recert amongst the rest of the ALS providers. They were obviously not allowed to practice at that level, but they expanded their knowledge and felt proud. The feedback I received was astonishing. Not only were they proud to understand what their partners were talking about on a new level, but their partners loved having a BLS colleague that took the initiative to further their own education. 

Every time we respond to a page or put on a uniform we are expected to be knowledgable and proficient at our trade. We work as a team, die as a team, and in my humble opinion - should train as a team. Is it time we stop treating our fellow BLS clinicians like goldfish?