Skill decay in EMS

A paramedic can insert an IV while asleep. Ask that same paramedic to place an IO on a child, something they’ve done twice in three years, and their confidence tells you nothing about whether they’ll get it right.

That’s not a guess. It’s what the data shows, again and again.

And here’s the uncomfortable part: the gap between “I’ve got this” and “I can actually still do this” isn’t the exception. For most people, it’s the default.

The experience curve

In 2012, a group of emergency medicine researchers finally put a name to something everyone in this field already knew, they just couldn’t prove it. They called it the Experience Curve. Training gets you climbing fast at first, then you level off.

But the moment you stop practising, a second curve kicks in, the forgetting curve, and it starts working against you straight away. Left alone, it just keeps dropping. The only thing that resets it is practice, and when you practise matters more than how hard you practise.

None of this is new, it’s just better documented now. Back in 1977, researchers tested 30 paramedics 6 to 30 months after they’d finished training. The result: the hardest, most technical skills fell apart fastest, and even the basics, despite being used constantly in the field, still slipped.

Nearly fifty years on, nothing’s changed.

What people feel confident about isn’t the same as what they’re actually good at

A 2026 study asked 41 ALS providers in South Africa a simple question: how often do you actually perform each of your 55 core skills? More than half came back “rarely.”

Here’s what the researchers found when they looked closer: how confident someone felt about a skill had almost nothing to do with how well they could still perform it. It was simply tracking how often they’d done it recently. One provider explained it well, IV access felt easy because it happened every shift, so of course it felt manageable. IO access, something they’d done far less often, still felt nerve-wracking no matter how many years of experience they had overall.

That’s the trap. Confidence isn’t measuring your skill. It’s measuring your recent practice. The two only line up if you’ve actually kept practising the thing you feel sure about.

Sometimes it’s not decay at all

Not every gap comes from time passing. One study on needle decompression found 79% of practitioners felt confident doing it alone, and 85% of those confident practitioners picked the wrong spot on the body.

That’s not a skill that faded. That’s a skill that was never solid to begin with. After a short, repeated training push, correct identification jumped from 16% to 53%, real progress, but still leaving almost half getting it wrong.

What actually works

The research doesn’t point to more classroom hours. It points to something smaller and less comfortable: doing the actual thing, on a schedule, before you forget how.

Short, spaced practice beats one long session a year. Training past “good enough” toward real fluency slows down how fast the skill fades afterward. And practising under real pressure, not a calm walkthrough, is what makes the skill hold up when things aren’t calm anymore.

Why realism matters more than repetition alone

Not all practice is equal, even when you’ve done it the same number of times.

There’s an old idea called “identical elements,” first written up in 1901, and it still holds up: skills transfer best when the practice looks and feels like the real thing. Not just the hand movements, the noise, the time pressure, the unfamiliar faces around you, all of it. A calm, unhurried walkthrough trains the motion. It doesn’t train the moment.

Stress is a part of this that’s easy to miss, and there’s genuine science behind it. A bit of stress while you’re learning actually helps things stick, that’s not new either, it goes back over a century to Yerkes and Dodson’s original work. Too little stress, and the practice doesn’t stick as well. Too much, and performance falls apart instead of improving. The sweet spot is narrower than most people think.

That’s the whole idea behind stress inoculation, deliberately adding pressure, time limits, noise, an audience, to practice, so the skill gets learned the way it’ll actually be used.

But here’s the catch: one dose isn’t enough. A study on emergency medicine residents found a single stress inoculation lecture made no measurable difference in how they handled a real simulated resuscitation. They said they valued the training, they just didn’t hold onto the benefit from one session.

Realism, like the skill it protects, isn’t something you add once. It’s a habit, and it works the same way the skill does, repeated, and spaced out over time.

Where this shows up in practice

Different skills fade for different reasons, and the training that actually helps looks different for each one.

Vascular access

IV and IO access is a textbook case of the confidence-tracks-frequency pattern above, the skill you use constantly feels easy, the one you barely touch stays nerve-wracking regardless of experience.

Repeated, low-stakes reps on dedicated trainers, an IV arm, a venous access trainer, or a catheterisation simulator, keep both the hand skill and the decision-making current without needing a real patient.

Medication administration

Dosage and the order of administration are cognitive skills, and cognitive skills fade faster than purely physical skills. Practising the full sequence, drawing up the correct volume, correctly reading the label on the bottle, administering under time pressure, is just as important as knowing the dosage in theory.

Simulated ampoules, vials, and IV fluid bags allow teams to repeatedly and safely practise the entire administration process, without using real medication or risking a real medication error during the learning process.

Airway management and ALS

Both named above as skills that fade quickly without upkeep, these share a requirement: the patient has to respond realistically, and the provider needs clear feedback on what actually happened during the scenario, not a self-assessment after the fact.

Atlas, the ALS simulator from 3B Scientific, is built to behave like a real patient during ALS scenarios, anatomically accurate airway, adjustable pulse and pupils, a CPR-capable chest that moves the way a real ribcage does.

Paired with REALITi 360, the system logs CPR quality, arrhythmia response, and time-to-intervention through the scenario, so the debrief afterward is grounded in what the crew actually did rather than what they remember doing.