How to prepare EMS students to succeed in high-stress environments

Educators must use these four steps when planning to add stress to a drill for EMT and paramedic students

By Gustavo E. Flores

Emergency responders — EMS, police, and fire — are tasked with performing critical assessments and interventions under extreme stress. Yet, these assessments and interventions are oftentimes drilled under controlled circumstances. Still, the expectation is that all responders will be able to perform under stress just as they were taught to perform in the classroom.

The objective of any formal training program should be to ensure that providers are confident in their ability to perform core skills under realistic circumstances. Under pressure you don’t rise to the occasion, you sink to the level of your training.

Introduce stress and fear with yelling, smoke bombs, moulage and loud noises with a sequenced approach to foster a positive learning environment.
Introduce stress and fear with yelling, smoke bombs, moulage and loud noises with a sequenced approach to foster a positive learning environment. (Greg Friese)

Stress from a different kind of pressure
Training for SCUBA, a different type of pressure, needs to prepare students for the real conditions they will experience. A known effect of deep dives is nitrogen narcosis, which causes divers to feel euphoric and to lose fine motor skills.

Because of this, advanced open-water diver programs require participants to do a deep dive. They do so under recreational diving parameters so that participants get to experience narcosis under the close supervision of a diving instructor.

Fortunately, nitrogen narcosis is quickly fixed by ascending a few feet. As a diver becomes more used to deep diving, narcosis occurs less often.

In my days as a PADI Instructor, I would discuss nitrogen narcosis with students and have them do a simple drill of rubbing their abdomen with one hand while tapping their head with the other hand. Also, I would have them do a simple math calculation.

Underwater, to the student’s surprise, they were oftentimes unable to carry out these drills despite the fact that they felt OK and completely in control. It clearly showed them that a small and manageable degree of narcosis had set in.

Participants learned what nitrogen narcosis is, experienced it under controlled circumstances, expanded their comfort zone under my close supervision and then are sent out on their own to dive after certification.

Stress inoculation in EMS
Just as deep divers must learn the effects of nitrogen narcosis, EMS students must learn what stress is and how it affects them. All EMS educators should apply this important teaching methodology lesson from the diving industry.

Introducing stress and fear — with yelling, smoke bombs and loud noises — in students without a sequenced approach is not an effective educational strategy. On the contrary, current best practices consist of fostering a positive learning environment, but that may leave students unprepared for the real world.

It is better for the student to be exposed to stress in a controlled environment rather than out in the streets when lack of skills may result in psychological and/or physical injury or even death.

But educators must have a clearly outlined plan on how to properly do this in order to achieve the best possible outcomes. Here are four steps an educator must do when planning to add stress to a drill.

1. Understanding fight-or-flight
Explain to students what happens when the body is under stress. Under stress, the human body activates the fight-or-flight response. Adrenaline rushes through the body, preparing it for immediate action.

The beta-adrenergic effects of epinephrine are easily predictable: tachycardia, tachypnea, peripheral vasoconstriction, increased blood flow to large muscles (to allow for quick bursts of physical activity such as running or fighting), loss of hearing, tunnel vision, tremors and pupil dilation. These fight-or-flight responses have served humankind very well, whether it is to fight a lion inside a cave or running towards safety when there is an active shooter.

But these responses have profound implications on our ability to perform fine motor and cognitive skills. Students should know that they will be subjected to stressors during their final drills. If they understand the normal human response, knowing that they will be subject to a stressful simulation will lead to a better understanding of the drill’s objectives, a better performance, fulfilment of intended learning outcomes and a non-traumatic experience.

2. Non-stressful instruction
All the content must be first presented in a standard, non-stressful way. Most educators agree on the importance of a stress-free and threat-free environment. Before any kind of stress is added to a training scenario, students must have ample time to demonstrate competence with the elements of the skill or assessment.

Break complex scenarios into individual skills to make teaching and learning more manageable. For instance, laryngoscopy and tube placement is only one component of a complex rapid sequence induction scenario.

Also, it is critically important that the students learn how to cope with stress. Equipment preparation, mental visualization, controlled breathing and meaningful communication amongst team members can help to minimize stress.

3. Walk through
More often than not, complex scenarios are distilled into single tasks, but never later combined back into a full scenario simulation. This may give the false sense of competence. Before any stress inoculation session, students should have the opportunity to do a full scenario of combined tasks under a simulated environment. 

A walk through allows students to perform initially under close guidance and eventually completely independent. This may take some time, depending on the scenarios and the students. In fact, the walk through will be initially stressful by itself.

With skillful structured debriefing, students should be able to successfully perform the walk through. Students should never progress to a stressful drill without first mastering a dry run.

4. Manageable and doable training
Depending on the student’s comfort level, many circumstances can cause stress. For example, background noise, alarms, family members, equipment failures and scene safety issues can spike the stress levels.

More experienced students or participants may benefit from other types of simulated special effects such as deliberately poor communication amongst team members. In the 2015 AHA CPR Guidelines, team-based skills are differentiated from clinical-care skills, therefore teamwork practice and leadership training can improve resuscitation team performance.

In any case, the training must depend on the context under which the skills are expected to be applied. Try to keep it real. Distractors must be manageable and the drill must be doable. If not, there is no point in drilling students unless the intended learning outcome was to bail out due to provider safety concerns.

We don’t train heroes. We train our EMS students to be competent in the core assessment and treatment skills. We give them the knowledge and tools to do so effectively, so they can go out into the real world and do heroic work. Don’t let your training fail your students.

About the author
Dr. Gustavo Flores is a physician and paramedic from San Juan, Puerto Rico. He has been involved in EMS for more than 15 years as a provider and educator. Gustavo is very active in EMS education. He is the director for his consulting firm Emergency & Critical Care Trainings LLC. He is a BLS, ACLS, ACLS-EP and PALS instructor as well as training center faculty and regional faculty for the American Heart Association. He also sits on the AHA’s Emergency Cardiovascular Care Committee’s Educational Science and Programs Subcommittee at the national level. He is also a PHTLS, TCCC, EPC and AMLS Instructor for the National Association of Emergency Medical Technicians (NAEMT). As part of NAEMT, he is an advocacy coordinator and member of the Advocacy Committee. On the clinical side, Gustavo is an air medical crew member of a fixed-wing, air medical transport company.


  1. EMCrit Podcast. Mental Toughness and Resilience 
  2. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 14: Education.

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