Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Skills Monkey or Skilled Medic?

What is a skills monkey?

A skills monkey is someone who has been trained to perform skills well enough to pass a simple choreographed test of that skill.

Medical skills monkeys are not limited to paramedics or EMT basics. Doctors, nurses, PAs (Physician Assistants), NPs (Nurse Practitioners), et cetera can all be skills monkeys.

What is most important in the use of medical skills is not the ability to do what we practiced on a mannequin, but the understanding to know when to treat the patient with that skill and when not to treat the patient.

Because it is the Standard Of Care! is not a competent reason to harm a patient with a skill. Every skill can harm patients.

Why are we using a particular treatment?

What are the possible benefits?

What are the possible adverse effects?

If we do not know of many more possible adverse effects of a treatment (than possible benefits), we probably do not know enough about the treatment to use the treatment safely.

How will we possibly know what to expect?

How will we know what to watch out for?

How will we know when to stop, when to increase, when to repeat, or when we have good evidence that what we were treating the patient for is not what is making the patient sick?

A skills monkey does not understand anything more than –

Α. Select a protocol.

Ω. Follow the protocol to the letter.

Skills monkeys tend to be literalists. Literalists generally cannot comprehend abstract thought and should probably not be allowed to make decisions. Skills monkeys tend to be only aping what they have seen others do. Their reasoning is – That’s what the protocol says to do.

Here are some examples from the skills monkey playbook –

Crackles = Lasix, even if the crackles are from pneumonia.

Fall = backboard, collar, and straps, even if the patient has contraindications to this treatment.

Pain management = transport to the hospital so that someone who has a clue can take care of this scary treatment.

It is better to do nothing than to do something that might be wrong.

If that is what we believe, we should not be making any decisions that affect patients. We can teach that kind of thinking in grade school.

You were expecting a monkey? This kind of thinking does not require the higher thinking skills of a primate.

Everything has the possibility of causing harm.

If we cannot handle that, we should not be permitted to hide behind protocols, or medical command permission requirements, or Standards Of Care.



  1. Well put together. Perhaps the best summation of what is, in my opinion, one of our biggest problems.

  2. That’s how many EMS people are taught and managed. If no one ever got in trouble for putting a NRB on someone, people just put them on everyone. That is why I like Canada’s education system – two years of assessment to start, then a year of the invasive skills after. It’s the oposite of us.

  3. Amen…Church is dismissed for the day…

    It is just as bad when we have Medical Directors that force us into this. A great example of that is a clinical experience I had during school. I was given an order by a physician to give 2mg of Dilaudid to a patient. Afterwards I ask the physician, who is now our Medical Director, why we are limited to 1mg a dose with a 2mg max without permission when it was clear that this patient needed a higher dose. The answer….

    Wait fot it…

    We do not trust Paramedics to think…

    God forbid if you embrace the fact that as a Paramedic you are a clinician and it should be expected of you to think and treat a patient. There has never been and never will be a protocol or standing order written that will cover every patient every time.