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Performance Anxiety

Once in a while I do a little acting—I mean besides feigning exhaustion when it’s time to wash the dishes. I’m talking about short, educational skits in front of fellow EMS providers, where I play a paramedic working in nontraditional settings. I can always count on my Opryland connections for fresh material about show business medicine, and for a limitless supply of very talented cast members who, unlike me, can actually sing and dance.

While rehearsing our routines, I was struck by the similarities between EMS and entertainment.

Professionals in both disciplines appreciate the value of practice and the need to get it right before doing it for real. There’s respect for experience without discounting the possibility a newcomer might contribute something of value. When the unexpected occurs—an extra patient, for example, or a broken mic—partners/performers adapt promptly and wordlessly, usually without patients or audience members aware of improvisation.

Like singers who begin by studying breath control, EMS professionals learn the science of patient care before exploring the art. Supplementary business and communication classes make paramedics more marketable in much the same way voice and ballet lessons enhance actors’ versatility. Attributes of accomplished entertainers—timing, personality and self-control—match up well with desirable traits of caregivers.

That’s as far as the parallels go for me.

Acting is just for fun, without life-and-death consequences for missed cues. I’m comfortable on stage because I’m accustomed to working in front of people. As a real medic treating real patients, however, I’m uneasy about being watched.

I know my performances won’t be dissected to the same extent actors are reviewed by critics, but part of me realizes even subtle aspects of my behavior contribute to bystanders’ impressions of me and my profession. Even when I make good decisions, some of what I do in the field—temporarily ignoring traumatized extremities to treat critical conditions, for example—doesn’t necessarily look correct to untrained observers. Such misunderstandings can lead to second-guessing, sometimes extended by word of mouth to people who weren’t even on scene. Concern about such possibilities shouldn’t ever interfere with patient care, but having to manage perception-vs.-reality gaps is fatiguing and can certainly up our anxiety quotients.

I’m reminded of a cardiac arrest I treated while I was the sole EMS provider on duty at a concert a few years ago. The elderly male had been down less than a minute when bystanders summoned me to his side. He was in v-fib. I called for manpower, showed an onlooker how to do chest compressions, defibrillated and was inserting an OPA when the patient woke up in a sinus rhythm and wanted to know what happened.

Pretty much a best-case scenario, wouldn’t you say? Not according to a colleague, who passed along a rumor that the arrest hadn’t been managed properly. I can only guess someone in the crowd thought resuscitation doesn’t count unless compressions are accompanied by ventilations. Then there was the comment from Security that I hadn’t adequately communicated the urgency of the situation. I guess that explains why they didn’t show up.

Any branch of a prehospital decision tree might determine a call’s outcome. That’s a big enough burden for responders. When patient care becomes a spectacle, though, as it sometimes does when illness or injury strikes in a crowded venue, rescuers have to work even harder to optimize results. Developing “stage presence” can help.

To me, stage presence is a combination of attitude and aptitude. It tells your audience you’ve done this before, you enjoy it and you’re good at it. At its simplest level in EMS, stage presence is about managing a scene as effortlessly as possible. Making a big production of patient care gets noticed but is no more desirable than drowning out the lyrics of a gentle ballad with dance-club clatter.

What kinds of prehospital practices enhance stage presence?

• Maintaining eye contact with patients while assessing their mental status, circulation and respiratory effort.

• Allowing clarification—not interference—from significant others.

• Verbalizing treatment and transport recommendations calmly yet persuasively.

• Proceeding purposefully with time-sensitive therapeutics.

All contribute to a perception of proficient caregivers who are experienced, confident and in control. Crowds are less likely to become distractions, I think, when on-scene proceedings seem scripted to spectators. Like gifted entertainers, the best among us make it all look easy.

You’re on. As they say in show business (but not so much in EMS), break a leg!

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at

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