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
How often have you been dispatched to a call such as a "sick unknown," an "unknown nature" or a "sick person"? How often have you arrived on scene and found the nature of the call to be something completely different than what the dispatcher transmitted over the air? We might be sent to respond to a seizure and find out, hopefully before we get too close, that the patient was exposed to organophosphates in pesticide. Or we respond to a "bleeder" and arrive to find that the knife fight that started the bleeding is still going on. These are two real examples from my own career.
Let me be clear, this is not the dispatcher's fault. The fact that we arrive to find the person who called 9-1-1 has a problem different from what we expected based upon the dispatch is the nature of the business. People experiencing what they perceive to be an "emergency" are often not very clear on the phone with dispatchers and call takers. Sometimes people think they can get service faster if they exaggerate. Sometimes the person calling is simply freaking out and can't give coherent information. Whatever the case, don't blame the folks on the other end of the radio or the people sitting at a console in a basement somewhere.
Another dimension of uncertainty involves the medical conditions and injuries we see. The information patients, family members and bystanders provide to us is often incomplete, inaccurate or even contradictory. We don't always get good information. Have you ever completed your report to the nurse or physician at a receiving facility, then overheard the patient telling a completely different story than the one you were told?
When EMS practitioners arrive at work there is no way of knowing what the day (or night) will hold. We never know when the bells will ring, the pager will buzz or the tones will drop. We respond to simple calls for help, terrible traumatic events, mass casualty incidents, and sometimes to someone who is lonely or hungry or confused. We never know which sort of incident we will be called to handle. Uncertainty is just one aspect of the job we do, and we are exposed to uncertainty every day.
PREPARING TO RESPOND
Think about what you do. Now think about the most complex calls you have experienced. What made those calls "complex"? What was it that made each one difficult to sort out? Think of the times you were uncertain about what was happening, what the actual problem was and how to proceed. How can we prepare ourselves for the complexity and uncertainty we must deal with every day?
In order to react appropriately when faced with complex or uncertain situations, we must have a strong foundation of knowledge, skills, abilities and attitudes. We need a broad and deep understanding of the principles and concepts that underlie our practice. We need to be able to make good decisions under time pressure and stress. We need to be able to choose a course of action that will lead to a desired outcome. To do this we must be both competent and committed. We also need to be able to multitask. If you can't chew gum and walk at the same time, it is unlikely you will be successful in EMS.
How do we develop broad and deep knowledge? We study, review, attend continuing education programs and conferences, read articles and books, and discuss topics with our peers and with experts. Working toward a broad and deep understanding is a continuous process. We must constantly complete self assessments and self evaluations, reflect on our decisions and our actions. Self assessment and evaluation--thinking back on what we've done--helps us to identify weaknesses so we can work to improve and strengthen ourselves.
We can also practice our decision-making skills by asking others about their complex calls and the uncertainties they have experienced. Then discuss how they handled the case and how you might have acted in the same situation. This activity can be formal, as in peer review and morbidity and mortality sessions, or it can be informal, such as sitting around the table in the break room. Imagining what you would do in a particularly difficult situation helps to prepare for when you must actually respond to a similar situation.
Developing multitasking skill is based on reaching mastery in knowledge, skill and attitude. Once you learn how to ride a bicycle, you never have to think about how you ride ever again, unless, of course, you are going to do tricks, ride mountain trails or complete long distances on the road. You have to develop new skills, better endurance and confidence through practice, education and training. The same applies in EMS. You have to master the basics before you take on the really hard stuff. You have to practice, study and train.
We are often placed in complex and uncertain situations. It is part of EMS and always will be. In order to prepare ourselves we must constantly work hard to improve. This means honest self assessment and reflection. It means being open to criticism and willing to listen to others who want to help. It means being able to admit when we are wrong or make a mistake. Then we must choose to do the hard work to correct our weaknesses, and improve our skills, knowledge and attitudes. Finally it means becoming and continuing to be a lifelong learner. All of this is so we can behave as professionals and provide competent, compassionate and caring service to those who have asked for our help.
1. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612-616, June 2000.