The patient’s arms were splinted beautifully. No less than 10 paramedics and tech rescue personnel carried his litter to the incline where he was clipped in to the low-angle rig and slowly advanced up the slope. At the top of the hill, an ambulance idled waiting to rush the patient to a nearby landing zone so that he could be handed off to the helicopter that was still en route to the scene.
Everything went like clockwork. All of the team’s training and skills came together to make for a smooth transition from the bottom of the gulch, where the patient had fallen, to the trauma center several miles away.
You could have called the whole affair a raging success if it were not for a few minor details.
It would have been easier and safer to take the patient down the gulch than back up the hill. The trauma center was only 20 minutes away by ground. The patient’s injuries didn’t suggest a time-critical emergency. Worst of all, the helicopter only added time, cost and danger to an otherwise simple operation.
Evaluate the big picture
The lesson here is one that we see time and time again in our business. There is a difference between doing things right and doing the right things. Often we get so focused on doing things right that we don’t stop to ask ourselves if we are doing the right things in the first place.
Doing things right is important. I’m going to say that again because I suspect a few folks are going to miss that point. Doing things right is important. But doing the right things is far more critical and often overlooked.
In the fire service we separate these two distinctly different aspects of scene management with the terms strategy and tactics. Our strategy is our overall plan for the incident. It’s the big picture. It’s why we are choosing to do the things that we are doing. Essentially, strategy is picking the right things to do.
Tactics are the nuts-and-bolts ways to accomplish our strategy. In medicine, these are often the skills-based aspects of our job. Starting IV’s, performing a secondary assessment and listening to lung sounds are all tactics to accomplish the goal of forming a differential diagnosis … part of our strategy for treating the patient appropriately. Tactics are the things that we strive to do well.
Fire service and military organizations make a big deal about developing a viable strategy and then making sure that the tactics support the overall strategy. That’s not to say that we don’t sometimes rush forward into our tactics without giving enough time and thought to our overall strategy. Anyone who has watched a firefighter at a house fire jump out of the back seat of the apparatus and shoulder a pre-connect before the engineer can put the rig in park knows that we can all be guilty of neglecting our strategy from time to time.
We all make poor strategic decisions from time to time or fail to make them at all. And just as in fighting fires or fighting wars, perfectly executed tactics can’t overcome a bad strategy. It doesn’t matter if you do everything perfectly if you don’t do the right things in the first place. To this end I offer these four pieces of advice.
1. Take the time to evaluate and decide what to do before you start doing things
Frequently, a misguided strategy can be traced back to the first few moments on scene when the key decision maker rushed to begin performing tasks instead of thoroughly evaluating the situation. A hallmark of an experienced provider is their willingness to perform a thorough objective and subjective evaluation before committing to a detailed strategy.
If the situation warrants immediate medical interventions (i.e. choking, life threatening bleeding, cardiac arrest) take action immediately, but don’t forget to pause and ask yourself if you are doing the right things. What seemed obvious in the first few minutes of the call may be completely wrong.
2. When you are unsure about what to do, small tasks are comforting (and distracting)
Witness the EMT who climbs into a vehicle and begins holding c-spine while multiple patients remain unattended, triage is incomplete and additional resources have not yet been called. When chaos encircles us and the right thing to do is to fall back and develop an overall strategy for the scene, minor tasks that we are confident that we can perform well are like a warm, comforting blanket.
When we are unsure of the right thing to do, our instinct is to pick something that we know we can do well and begin doing it. Part of becoming an experienced provider is learning to fight that instinct and stay in the gray and murky waters of figuring out the right things to do. The more we force ourselves to manage the big questions, the more comfortable we will become at developing solid strategies and keeping people focused on the right things to do.
3. If you marry a problem, divorce it
I first received this advice from my training chief during an after-action review. Sometimes we commit to the wrong strategy and refuse to change it, even when we recognize that it is wrong. Reassess the direction of the scene from time to time and ask yourself, “Are we doing the right things?” If not, say something.
Sometimes it can be tough to admit that you have made the wrong decision or the team is moving in the wrong direction. Believe me, saying something like, “Hey guys, I think we should reevaluate our priorities,” or “This doesn’t seem to be working, let’s quickly talk about the plan,” is always better than riding a bad idea into the ground.
4. Evaluate yourself on the big picture as well as the little things
Too often we self-evaluate based on how well we performed our tasks without questioning if our overall priorities were appropriate. There’s nothing wrong with congratulating yourself on a difficult intubation or a great neurologic assessment, but don’t forget to consider if your scene time was appropriate for the situation:
- Was the destination facility chosen correctly?
- Was the differential diagnosis correct?
- Did any treatment options go unrecognized?
- How were communications?
- How was your patient rapport?
On every scene there can be errors. Sometimes, things get sloppy. Details get missed. In those moments, and doing the right things will always trump doing things right.
Read next: Never move faster than your ability to make good decisions
This article was originally posted Dec. 4, 2014. It has been updated.
