On the corner of Skyland Drive and 23 in a little town called Sylva in Western North Carolina, sit’s PJ’s gas station. One hot summer day back in 2005, I was filling up the tank in a convalescent transport van on my very first day as an EMT-Basic. That’s the most basic, entry-level certification of working as an Emergency Medical Technician or EMT.  My convalescent transport van had a wheelchair ramp and my role as an EMT-B was not to do 911 calls, but to drive this glorified shuttle bus. My role was to transport people to and from their doctor’s appointments. Maybe to help them get home after being discharged from the hospital. If you were too sick for a taxi but not quite sick enough for an ambulance, I was your guy.

The guy training me that day, a senior paramedic, was actually a good friend of mine and happened to also be my boss at a local outdoor education company. Everyone affectionally called him “the Padj,” a shortened third-person version of his last name, Padgett. The Padj ran Landmark Learning, which offers wilderness medicine educational courses for outdoor guides and enthusiasts and eventually became the Southeast training center for NOLS Wilderness Medicine. Pretty much everyone who taught for NOLS Wilderness Medicine had a part time gig working in EMS and so that became my path too and this was my first day on the job.

I felt supremely important because of two things: as part of my standard issue uniform, on my thick polyester blue shirt, I was wearing a chrome name badge that said “J. Lowrance, Since 2005” and I had a big, heavy, professional walkie talkie. We had no more checked out the van and driven a mile down the road from base to fill up with gas at PJs when the tones went off on the walkie talkie, indicating a serious 911 call had just been dispatched. As I was pumping gas and the Padj was relaxing in the passenger seat, the radio crackled with the call: there was an unresponsive patient about a half mile down the road from where we were. We looked at each other and shrugged, knowing that even though we were essentially in a shuttle bus with next to no medical supplies, we wanted to see if we could help. We hurriedly paid for the gas, jumped in the van and ended up beating the ambulance to the house where the 911 call came from.

We were met by a distraught woman in her 60’s who told us she couldn’t wake her husband up. We went in the house through the side door, immediately finding ourselves in her kitchen. The bedroom was just off the kitchen and walking in, I remember the time on the bedside clock – one of those little rectangular digital clocks with red numbers: the time was 10:10 in the morning.

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Photo credit: OpenAI (2025). ChatGPT 4o version. [Large language model]. https://chatgpt.com. 

The man was large, heavy and not moving. He looked like he was still asleep except he was a deep shade of purple… not quite blue yet, but definitely not alive-looking. 

The Padj called out to him and checked a pulse. Nothing. My heart, however, was racing. 

As my palms began to sweat, the Padj looked at me serious, which he never did, and said quietly out of respect for the man’s wife, standing in the doorway, “dead on arrival or do you wanna run the code?”

I could hear the sirens of the ambulance approaching the house.

“Let’s do it.” 

We heaved the man onto the floor… he was heavier than I thought he would be. It dawned on me that dead people don’t try to help you like our wilderness medicine students do when they’re trying to act like patients in simulated scenarios. This was not a scenario.

Padj said he’d get the O2 tank in the van and that I should start CPR.

I knelt down, looked left and right for our jump bag, which contained a bag-valve mask or BVM, which we used to breathe for patients in cardiac arrest. We left the jump bag in the kitchen. I was in rescue mode. No time to waste.

I looked at the man, zeroed in on those purple lips and scrubby, lifeless face, pinched his nose and leaned in to do mouth-to-mouth resuscitation. As time slowed down and I leaned in to my new career in EMS, a paramedic shouted from the front door, “STOP,” shaking his head. He had arrived just in time to yell at me and snarled, “JLo, we don’t do that! Somebody get him a BVM.” A bag-valve-mask was thrown at me from the kitchen. I quickly pumped two breaths with the bag into the man and started chest compressions.

We all worked together as hard as we could to save that man’s life but our efforts were in vain. Who knows when he had died before his wife found him that morning. We ran the code, started an IV, intubated him and did CPR the mile and half back up the road to the hospital, where the code was called. I walked out as his wife, crying, walked in to see him.

It was my first day on the job. It would be her first day without him.

Two things happened that day for me: 

I became hooked on resuscitation. 

And I realized that the people and teams doing this kind of work have their own special flare in the midst of the chaos. For the first time, I saw the human factor in emergencies.

Not just my ignorance and naiveté. But how more experienced providers find work arounds. How seasoned clinicians have unspoken rules that govern the work they do. A certain sort of knowing that only comes with experience. I’ll come back to that in a minute.

That first call on my first day in EMS in Western North Carolina seared into some deep squishy corner of my brain a true love of resuscitation. I was hooked. I thought this is definitely the kind of work I want to do, and I want to learn how to do it better and how teams can do this kind of thing better. That drive would become a central theme of my professional career moving forward and is why I’m writing this now.

The other thing it did was create a certain level of cognitive dissonance. It interjected the reality of human factors in resuscitation and emergencies in an incredibly powerful way. 

There was my ignorance coupled with an overwhelming desire to do the right thing. I’m going to breathe for this patient because that’s the right thing to do! And then there’s the disruption to that plan; the alternative approach; the wisdom of a senior clinician. Here I am about to follow the algorithm and get the job done despite my immediate resource limitation… adapt and overcome and all that and then there’s the senior paramedic saying, “What are you doing? We don’t do that!” I was like: but we’re supposed to save lives! In every TV drama I’ve ever seen – which I happen to be literally in the middle of right now on my first day on the job – EMS people are supposed to save lives; and now I’m an EMS people.  WE are supposed to SAVE LIVES!  Not wait for an AMBU bag because I left it in the kitchen. 

This disruption to my preconceived notion of how things were supposed to go was a poignant introduction to the idea that humans will often deviate from expected work patterns to best get the job done.  

What I learned was there is a way more senior people do things that the newbies don’t know about. They have that special kind of knowing that only comes with experience. 

Check this out: the Greeks have several different words for different kinds of knowing. There’s knowing about something, like scientific facts & figures, which is where most new anesthesia trainees are with their knowledge. This is gnosis (‘nō-sis), to know about something in a general way. Similar to this is epistēmē (ep-uh-steam), which is knowing more scientific, academic knowledge. Epistēmē is where we get epistemology (eh-puh-stuh-mo-lo-gy) from, which is the study of how we know things, what we know and the limits of that knowledge. 

There’s the work as imagined, which is informed by protocols and standards and expected norms of behavior or even expectations that society has on healthcare providers: we will save lives even if it means putting our own lives at risk.  And then there’s the work as done, which is often shaped and determined by this special kind of knowledge about how to do things.

What I’m talking about with experienced resuscitationists is ginōskō (gi-know-sko). Ginōskō is an experiential knowledge that only comes through deep experience or relationship with the subject, practice or person. You only get this kind of knowledge through experience.  If you know, you know, you know what I mean?

All right, so there’s your Greek lesson for the day and where my gnosis of the Greek language ends. 

So, what this very first resuscitation taught me is that providers who do this kind of work have a very deep, experiential knowledge that guides their decision-making. This goes beyond the algorithms. Gary Klein talked about this within his recognition-primed decision-making model (Klein, 2017). Daniel Kahneman (2011) spoke of System 1 and System 2, with System 1 being our intuitive decision-making and System II our more deliberate, concentrated thinking. 

These modalities of decision m