By Jim Mackensen
It鈥檚 another busy night for you and your crew. It鈥檚 0300 as you climb into the right seat of your paramedic engine for your 17th run of the shift 鈥� yet another medical aid for an unresponsive person, possible overdose. You recognize the address as one that you have been to many times before for the same chief complaint. How many times has it been? Ten? Twenty? All the calls are just a blur in your tired mind. You start to go into auto-pilot mode for what you are sure is yet another routine OD call. You update your crew and several 鈥渋nappropriate鈥� comments come over your headset.
You arrive at the house and, as always, there are several people milling about in the front yard. Most seem to be at least mildly intoxicated. The ambulance is pulling up behind you. You and the crew dismount, gather your equipment and make your way through the crowd that shows no interest in your presence. You notice that the ambulance has a crew of three this morning, which means one of them must be a paramedic intern.
As you make your way into the house, you notice that there are at least eight other people in the front room. They also seem to be intoxicated and are directing your attention to a young female on the floor. Your crew starts to evaluate your patient. A quick check shows her to be pulseless and apneic. The crew gets to work, starting CPR, hooking up the monitor, establishing an airway and getting an IV set up.
You do a quick scan of the scene and things look so familiar. The paramedic intern is standing back taking in the chaotic scene. She is looking around the room in wide-eye amazement. You get back to work trying to get a history from anyone, time-stamping when various tasks are completed, telling dispatch you have CPR in progress, and several other routine tasks. Suddenly the intern grabs your arm and says there is a gun on the chair. You glance at it and casually tell her not to worry; there are always weapons in this place. You go back to your tasks.
You yell out for everyone to please leave the room so you have room to work. All comply with your order and slowly shuffle outside except one who is just standing by the chair with the weapon on it. You yell at him to 鈥渕ove your ass and get out.鈥� He looks at you with a vacant look, reaches down and grabs the pistol. He immediately starts to fire indiscriminately around the room. In a matter of seconds, he has squeezed off six to eight shots, then puts the barrel in his mouth and fires off one last round.
Total chaos ensues. You quickly check yourself, the crew and anyone else in the room as you press the red button on your radio and call for help. Thankfully, no one else was hit. You and the crew quickly throw the first patient on the gurney and rapidly retreat out of the house. As you leave, you look down at the man with the gun and see that he is not going to be an additional patient. Law enforcement is arriving in masse, the scene is secured, and the OD patient is being transported to the ED.
Thoughts run through your mind: What the hell just happened? It was a routine call. I have been here so many times before. Everything seemed so typical for a call at this address. What went wrong?
Then you remember. The intern told you about the gun on the chair, and you dismissed it. She saw something and said something, but you did nothing. You have been trained to encourage your crew to tell you when they see something. You have trained your crew to say something. Why did it not work here? Why did you not listen?
Lowered standards = bad outcomes
There are many reasons why, when told something, we don鈥檛 do anything. You may be so engaged in your current tasks that you don鈥檛 recognize the significance. You may be that grizzled veteran who doesn鈥檛 listen to the new member or intern because 鈥測ou have seen it all.鈥� You may be in a situation you are not familiar with, and you simply don鈥檛 know what you don鈥檛 know. Maybe you simply did not hear it. Maybe you heard it but did not think it was important at the time. Maybe you felt pressure from your boss to continue down the current path action. Or maybe you just don鈥檛 like anyone questioning your perceptions and/or decisions.
Situations where someone said something but were ignored/overruled and a negative outcome resulted are far more common than most of us would like to believe. Sometimes it only results in making the situation more difficult. Sometimes the results can be catastrophic.
In the dynamic and chaotic environments in which we serve, it can be difficult for any one person to be able to gather all, or even most, of the information and data points that are needed to perfect our problem-solving. At best, we typically settle for a much lower standard.
For one, we make a lot of assumptions when we fall into the trap of identifying any incident 鈥渞outine.鈥� We, as leaders, must foster a work environment that encourages and even demands that everyone involved is using their situational awareness skills at every call. It also demands that if your SA tells you something is changing, it does not feel right, something unexpected is happening, you don鈥檛 like what is happening, or you don鈥檛 understand why something is happening, then you must speak up. You must be that change agent.
The Swiss Cheese Model
In accident investigation, when we identify and explain the events leading up to the accident, we often use the In simple terms, picture a block of Swiss Cheese that has been sliced up. Each slice represents a moment or situation that occurred during the incident. The holes in the cheese represent an action or inaction that contributed to a negative outcome. If you arrange all the slices so that there is a hole that runs completely through the block, a negative event results. If only one slice (situation) is moved, the hole (action) is blocked, and the negative event does not happen.
To move that slice, someone has to notice that the holes are getting lined up and a bad thing is about to happen. Because we know the outcome in a post-accident review, it can be easy to say, 鈥淚f they had done [this], then the accident would not have happened.鈥� However, operating in the moment and recognizing a potential outcome is much more difficult.
The fully understood and embraced practice of 鈥淚f you see something, say something鈥� will often result in that nugget of information you will need to prevent those holes from lining up. In the scenario above, how many slices (a moment or situation) can you identify? How many holes (action or inaction) can you identify? What slice would you have moved to prevent the hole from lining up with the others, thereby stopping the cascading series of events that resulted in the end result?
Speak up
Where you go from here is up to you 鈥� taking ownership of your own see something/say something mindset.
At the very minimum, company officers must foster this kind of environment with their crew. One advantage of forging this mindset together is better understanding your crew. You should know that when you get 鈥渢hat look鈥� from one of you people, they have something important to say. Use that inter-crew dynamic to your advantage.
What about firefighters 鈥� how do you get the new member of the crew to feel comfortable speaking up? It is one thing for recruit academy instructors to tell the students to speak up, but it is a totally different thing, as the new firefighter or paramedic, working with senior members, to take that step. You want desperately to be accepted into your new team. You don鈥檛 want to come off as the 鈥渂ooksmart probie鈥� with all the questions.
To breach that barrier, the leadership at all levels and all crew members at all levels must promote and grow a relationship that is both accepting of anyone鈥檚 input and ensuring that there are no repercussions, of any sort, when that input is given. And if the input given is indeed a non-issue, then use that as a training moment for everyone. The is a good format.
For leaders, consider whether you need to adjust the phrase to 鈥淚f you hear something, do something鈥� to better align with your more-frontline-removed position. Acknowledge and evaluate the information and then take action.
To be most effective, this mindset must be part of a department-wide culture. Everyone must be comfortable speaking up, no matter their rank or years on the job. Our members must be confident that their perception of a situation can be made better with additional information.
It will probably go a long way in keeping you, your crew and everyone else on the incident safer.
About the author
Jim Mackensen is a 50-year veteran of the fire service with 10 years as a volunteer and 35 years as a career firefighter, retiring as a captain. He has been part of federal and local Incident Management Teams for over 20 years and fills the role of a Division Supervisor, Incident Safety Officer, and Incident Public Information Officer.