Shooters refer to this phenomenon as a “training scar” when under stress your actions don’t match your intentions because of ingrained bad habits formed during training.
· Riding the safety instead of pressing the trigger.
· Short stroking the action of a semi-auto pistol because that’s all you’ve ever done on the range.
· Pumping a shotgun using a short-stroke because that’s all you’ve ever practiced.
· Sweeping the muzzle across your support hand because no one has ever corrected your bad habit.
Training scars are ingrained behaviors resulting from inadequate or improper training that was practiced to a level of instinctive response.
Medicine suffers from this problem too, and almost no one talks about it.
After teaching Wilderness Medicine courses for many years, I can tell you that the most dangerous student is almost never the one that doesn’t know anything. It’s the student that has had some sort of medical training before. CPR, Boy Scouts first aid, an EMT card that hasn’t been refreshed in a decade, a Combat Lifesaver card received during military service. They walk in with a sense of confidence that is based on ingrained behaviors that either were incorrect to begin with or have since been replaced with better care.
People under stress don’t rise to the occasion, they revert to ingrained behavior. If those ingrained behaviors are incorrect or out-dated that is what they revert to.
Medicine Changes. Your Training Might Not.
Here are a few examples.
Rib fractures
For years the standard of care for rib fractures has been to wrap the chest tightly to minimize chest wall motion and therefore pain. We now understand that this leads to splinting and shallow respirations and therefore an increased chance of pneumonia, especially in the older patient. Current wisdom is to actually encourage deep breathing
and only splint gently with one hand while moving. This would be especially important in an older patient who may be subject to a long evacuation process in the wilderness.
Control of hemorrhage
Have you ever been taught to control hemorrhage by applying pressure over an artery more proximal to the extremity than the wound? If so, you probably won’t be using that trick any more. Arterial pressure points have fallen out of favor as a hemorrhage control measure. The reasons are pretty clear cut, as it’s tough to do under stress, most people aren’t going to remember where those points are and in general it just doesn’t work as well as other options such as, well, direct pressure. If this is in your tool box, you’ve got a training scar.
How about using a tourniquet? Many of us were taught that a tourniquet is to be the last option for controlling extremity hemorrhage and should only be used if willing to sacrifice the limb. Casualty data from combat theaters has shown this just isn’t true. Tourniquets work, they are easily applied, and are unlikely to result in loss of the limb if used appropriately. Use early and often if you are dealing with life threatening extremity hemorrhage. If you’re still reaching for the tourniquet after elevation and pressure points have failed you may have just cost a life.
Control of anaphylaxis
Benadryl (diphenhydramine) is in nearly every first aid kit I’ve ever seen and most people know it as “the allergy medicine.” The problem is that an antihistamine doesn’t really help with the potentially life threatening manifestations of an anaphylactic reaction, thinking of airway swelling and closure, hypotension, etc. Benadryl should not be your first medication when treating anaphylaxis. Your first medication should be epinephrine. If you automatically reach for the pink pills before the auto-injector, you’ve got a training scar.
See a pattern? These are all pretty common concepts that likely have been passed on from medical provider to medical provider (and layman to layman) for the last 20 years with no one pausing to consider whether or not these practices are still valid. No one is going to send you an update, you need to seek out changes in medical management on your own.
The Sterile Room Scar
The second type of training scar comes not from technique, but from environment. I once taught a class that included a physician assistant and an anesthesiologist – more credentialed, medically speaking, than almost anyone else in the room. Both admitted to me that they would freeze outside of their normal work environments. They were
accustomed to sterile fields, brightly-lit exam rooms, monitors, imaging, climate control and so on, and without these things they froze.
How do you avoid developing scars like these? Practice your skills outside of your comfort zone. Get your hands cold and numb. Practice with bad or no lighting. Practice without your team. Practice with the wrong equipment. Practice in sideways rain. If the first time you practice abdominal palpation is in a nicely-lit, climate-controlled classroom, and the next time is at a dark, 40 degree F. trailhead, you’ll notice the difference.
Why the Scar Wins Under Stress
Autopilot is a double-edged sword. Deliberate practice is effective because of it, and that makes thoughtless practice incredibly dangerous. You will not perform actions you have never or infrequently performed correctly, no matter how well you understand them in theory.
Your improvised sling you made once in a classroom several years ago will not magically manifest itself in front of you when your hands are shaking and slick with sweat. The tourniquet you’ve only seen in a slideshow won’t suddenly become intuitive to use correctly at 0200 while your patient is screaming at you. Under real-world stress, with degraded fine motor skills, impaired cognition, tunnel vision, and flooding hormones/adrenaline you’re not going to be able to work a decision tree from first principles. You’re going to fall back on whatever is the most well-grooved. That’s why you have to practice until you can perform an assessment, apply a tourniquet, or manage an airway on autopilot. Your conscious mind will be occupied with trying to control the situation. It won’t be flipping through pages in its memory trying to remember what was on page 114.
The same goes for documentation. A lot of newer providers will avoid writing things like “signs consistent with heat exhaustion” or “possible fractured femur” because they feel like it amounts to making a diagnosis. This isn’t so much a product of old training as it is fear of being wrong. Unfortunately, fear of being wrong paralyzes people and makes them freeze up at exactly the times when clear-headedness and effective communication are required. Remember, a documentation is not a diagnosis, it’s simply documenting the best information you have so that the next provider can make better-informed decisions.
Burning It Out
Your training can help or hurt you. Ideally, your training will serve as an automatic set of instructions to help you respond appropriately in a crisis. However, sometimes, your training can hurt you, too. Those training scars are ingrained in you, and under stress, you will revert to them.
Here are a few tips to help make sure that, if and when your training takes over, it’s taking you in a helpful direction instead of a harmful one.
Audit your knowledge. Have you taken a refresher course in the last couple of years? Three? More? Medical knowledge and best practices change. Make sure you’re up to date.
Practice your skills with the actual equipment you carry, and under conditions that simulate a realistic stress response. Practice applying your tourniquet one-handeded, with limited light, after doing 30 push-ups, with your jacket on, etc. A CAT is not a SWAT-T. A blowout kit is only familiar if you’ve practiced with that exact blowout kit. Practice reveals how your skills hold up under pressure.
Find a good instructor. Ask prospective medical course instructors if their course has changed in the last five years to keep up with current evidence and best practices. A good instructor will be able to answer this question for you without hesitation. If not, be warned: you may be picking up some of their training scars
Read More
Don’t miss essential survival insights—sign up for Recoil Offgrid’s free newsletter today!
- Plug ‘Em Up: Puncture Wound First Aid
- Jase Case: Essential for Urban and Wilderness Medical Emergencies
- Book Review: “The Survival Medicine Handbook” by Joseph & Amy Alton
- A Basic Guide to First Aid Kits
Check out our other publications on the web: Recoil | Gun Digest | Blade | RecoilTV | RECOILtv (YouTube)
