You are dispatched to a reported "unresponsive patient." You arrive on location and a man greets you at the door. He is agitated and appears to be very upset. He says he called 9-1-1 because his mother doesn't seem to be breathing. He tells you she is upstairs in the front bedroom. You go upstairs and the son follows you. He is very close to you and you feel uncomfortable.
The first thing you see from the hall as you approach the bedroom is that it is literally full of stuff. You see boxes, medical equipment, several televisions on piles of unidentifiable material and dozens of full trash bags in places piled at least four feet high.
As you move into the doorway you can't see any furniture, nor can you see any part of the floor. Then you see an elderly woman lying in a hospital bed. The bed is surrounded by piles of clothes, and more boxes and trash bags. Even though there appears to be a path from the door to the bed, it is going to be really difficult to get to the woman. The son, who is more upset than he was before says, "I'm sorry about the room, I'm really sorry. I'm from out of town. I came to visit and check up on her and I found her like this." He starts to cry and says, "She's not breathing, is she? Is she dead? I hope she's not dead. Oh, please don't let her be dead." He starts to scream and shout, "Please do something! DO SOMETHING, PLEASE!" He is becoming hysterical.
Have you ever been in a situation like this? It is really complicated. You need to figure out how to get to the patient and do an assessment. You need to deal with the patient's son, who may become a second patient. You will also have to determine how to treat the patient, whom you can see is not breathing, how to get her out of the bedroom, and address all sorts of other problems that can, and likely will, arise during this incident.
According to Dr. Herbert Swick, one of the behaviors that make up medical professionalism is dealing "with high levels of complexity and uncertainty."1 EMS practitioners deal with high levels of complexity and uncertainty on a regular basis. Swick goes on to say more about physicians dealing with complexity and uncertainty. If we change "physicians" in his statement to "EMS practitioners," we have the following: EMS practitioners must be able to make appropriate decisions in the face of complex, often unstable conditions, and usually with incomplete information.
How would you define complexity? According to the Free Online Dictionary it means "the state or quality of being intricate or complex."2 To really understand complexity, we need to know the definition of "complex." The same source says complex means "consisting of interconnected or interwoven parts; composite" and "involved or intricate, as in structure; complicated."3
If you have been working or volunteering in EMS for even a short length of time, you have probably experienced at least one very complex case, a difficult extrication or an unusual medical situation. If you've been doing EMS for a while, you've handled many. We all have. The complexities we face are not all related to the calls we handle. Sometimes we must address complex issues related to our partner, the people we work with, the place where we work or the culture of EMS. What are some other sources of complexity in our lives and work? The sources are numerous.
HANDLING THE UNKNOWN
We are also regularly forced to deal with uncertainty. The term uncertainty seems pretty simple: not certain, not sure, not known. To take a composite of the Free Online Dictionary's several definitions, uncertainty means all of the following: not known or established; questionable; not determined; undecided; not having sure knowledge, not able to be accurately known or predicted, not precisely determined, established, or decided, not to be depended upon; unreliable and liable to variation; changeable.4