“There comes a precious moment in all of our lives when we are tapped on the shoulder and offered the opportunity to do something very special that is unique to us and our abilities, what a tragedy it would be if we are not ready or willing.”
― Winston S. Churchil
The Unforgiving Minute
The span of time between when you are confronted with a life and death crisis and when you seize the initiative to begin turning the odds of success in your favor. You have to rapidly synthesize so much input at once and then, just quickly, decide on a course of action. This is when fate taps you on the shoulder to do what you were put on the earth to do.
What a sad day indeed should you find yourself under prepared for that moment.
The reality is, it happens. It happens to everyone. Some people learn from it and take massive action to ensure that the next time they are caught off-guard that they will be able to respond. Others hope it never happens again… and we all know that hope is not a plan.
Unprepared vs. Under-prepared
There’s a difference between being unprepared for a no-notice critical event and being under prepared to deal with a no notice critical even. You see, we can’t control the variables that create the pressure of the situation.. But you can control how you respond to the pressure. You can prepare for it. In the moment you can control your response by influencing your physiology and using cognitive aids to expand your mental bandwidth. Practices like box breathing, meditation, and mindfulness can help you stay a little more collected in those high pressure situations. Having the checklist/reference cards readily accessible are key to their effectiveness.
In reality, you cannot change the variables that makes a situation a high stakes situation. You can’t change the stakes. You can’t make it less serious. You cannot make it easier. You can’t make it less critical, so what’s the difference? What allows somebody to be able to e unprepared yet successfully overcome he challenges of the situation versus the individual that’s under prepared and falls apart…
Being unprepared merely means that you’re merely surprised. You didn’t expect this event yet you’re still able to, after a short period of time (see: the unforgiving minute), get your wits together and execute to the level that the situation demands.
Being under-prepared speaks to the fact that not only is the individual surprised at the event, they are not prepared to deal with it in anyway, not mentally or physically. They are completely reactionary and at the mercy of the circumstances of the situation. No matter how much mindfulness or breathing exercises they do in the moment, they’re still not as effective as they would have been had they prepared.
Control the Predictable
You could be surprised that something happened and execute what is known as an IAD, or an immediate action drill. An IAD comes from the military and it is a drill or SOP that is executed during a certain event. Most commonly it is a type of ambush that you use an IAD for. Which is exactly what a no-notice critical event is.. An ambush. If an IAD has been developed and all of the tools are in their place, then you merely need a few seconds to know which drill/plan you want to execute and pull the trigger on it.
Check this out from EMCRIT where Dr. Lauria explains the applicability of IADs in the emergency medicine environment, which he refers to as Emergency Reflex Action Drills (ERADs): https://emcrit.org/emcrit/emergency-reflex-action-drills/
There’s a “but” here…
BUT, the ability to do that comes from work done in the weeks and months before that incident or ambush ever occurs. The folks that can do this successfully, well, they’ve trained; they’ve studied; they’ve practiced; and they’ve rehearsed. They’ve written their plan out and they know exactly what they want to do and how they’re going to execute it within the operational reality of the situation. This is what is known as “controlling the predictable.” I first heard about this some time ago at a conference talk by Stephen Hearns. We control what equipment shows up on scene. We control the mindsets we bring to the scene. We control the PERSON that shows up on scene. All of these things we can predict will be there, and we can dictate in what condition they show up. We merely need to take the time and set it all up the way we need it.
To get deeper on Dr. Hearns’ work, check this book out: https://a.co/d/6JjHt0H
If you have not done the work on the front end, a response will not materialize in a moment of crisis. You will not even know where to start. That is the power of the pressure of that unforgiving minute. It is unbearable if you are not ready.
Close Out
You can’t predict when something catastrophic is going to happen, but you can prepare for the eventuality that it will. That way, when it does, you can function and operate. It will allow you to positively influence the outcome the situation. Failing to do so is to be a risk to your community and your patients. You, by virtue of your job and position, cannot be link in the chain that fails.
The patient may not have time for you to “figure it out” or take your time deciding what you want to do. It is dangerous to spend too much time thinking and not enough time doing. Eventually what happens is you lose the initiative. The initiative is the window of time that you have to execute on something and still influence the outcome. If you lose the initiative, you are at the mercy of the circumstances and you’re completely reactionary.
You cannot create readiness after the incident.
References
Mike Lauria. The Necessity of Emergency Reflex Action Drills. EMCrit Blog. Published on April 24, 2018. Available at [https://emcrit.org/emcrit/emergency-reflex-action-drills/ ].
Scott Weingart, MD FCCM. EMCrit 350 — Mind of the Resuscitationist — Emergency Teams with Dan Dworkis. EMCrit Blog. Published on June 1, 2023.. Available at [https://emcrit.org/emcrit/emergency-teams-dan-dworkis/ ].
Dan Dworkis, MD. Emergency Mind Podcast 86 — Scott Weingart on Maxmially Aggressive Care. Emergency Mind Podcast. Published June 2023. Available at https://open.spotify.com/episode/39CmfEwpQ0EyqAMTbhnVWF?si=a64bfe83482845fa
