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Ruthless Preemption

In the past several years, I’ve traveled on area roads from several different perspectives. I’ve traveled as a motorist. I’ve also traveled in an ambulance as a first responder. And more recently, I have been on the roads as a cyclist. Many will nod their heads in agreement when I say that the way people many drive in this area is simply appalling.

In Fire/Rescue, our portable radios are equipped with an “emergency” button. This bright orange button allows us to depress it and to command the attention of dispatch and every other radio user on the air in the County. Obviously, it is intended to be depressed only in scenarios involving an immediate threat to life. Once depressed, if there is no response or a distressed response to the dispatcher, a massive police response ensues.

And once depressed, all other radio traffic on the air is inhibited until the “emergency” is cleared from the radio – a feature known as “ruthless preemption.” Depressing the “EB” button, as we call it, is a way of saying that what is happening to the user is so important, all other communication should stop until the dispatcher deems the situation is to be managed.

Many people (too many) in this area drive with ruthless preemption.

When I was in EMT training at the Academy, one of our instructors, a long-time paramedic in Montgomery County, was teaching a unit on responding to what we call “PICs,” (what the rest of the world calls “car crashes”). He set up a scenario for us – someone blows through a four-way stop, and T-bones another car on the driver side as it proceeds into the intersection. It is rush hour, and the driver of the T-boned vehicle is pinned and has serious injuries. The sky is clear and the wind is low, so you request a helicopter be dispatched to the scene. You begin clearing the intersection according to protocol for the incoming chopper.

“Then,” he paused, “because we need this to depict such a scene in Montgomery County,” he recruited several volunteers to act as the responders and he assumed the role of a bystander in his car on the scene. “EXCUSE ME!,” he shouted, “How long is this going to be?” He tapped his foot. “I am late for work and I am VERY important!” Everyone chuckled, and then, blushed: it is true, and it is pretty embarrassing if you live here. This is what first responders really think about us.

I learned the hard way that this is not hyperbole when I started running calls myself. One incident sticks out in my mind in particular — a night when it was pouring — the rain was coming down so hard you could barely see more than a few feet in front of you — we were called to the inevitable Beltway PIC. The engine blocked the scene properly to keep traffic away from where the involved vehicles were in the left lane, and the EMT who was our driver staged our ambulance properly. I looked out of the window of the cab for an opportunity to get out, and despite doing everything “right,” I was almost clipped by a driver who passed the engine and got into the third lane before passing the accident scene (this is a violation of traffic law, of course) and gunned it. I was passed whisper close by a vehicle doing about 45 mph in a torrential downpour, wearing a traffic vest and high visibility gear.

Who could suck all of the oxygen out of the air and engage in such ruthless preemption? I never saw that driver’s face, but I did see the face of a driver who cut off my husband and me while we were riding our bikes one day. We were taking the lane, riding abreast, and he passed too close and cut right in front of us. Neil decided to engage him, and he pulled up alongside him at the next traffic light. The driver rolled down his window and said, “There’s no bike lane here! Get off the road!” About 100 feet in front of us was one of the “share the road” signs that instructs drivers that cyclists are authorized, by law, to take the lane.

If you see people driving in an unsafe manner, whether around first responders, cyclists, pedestrians or other motorists, I encourage you to let them know – calmly. A few months ago a guy passed unsafely while I was riding my bike on Beach Drive. At first, I was enraged, and I chased him to the light. I made the “roll your window down” gesture, and he did. Fortunately, the rage left me and I said to him, quite calmly, “I see you have Virginia plates. In Maryland, the law is you are to pass cyclists at a distance of at least three feet. You passed me with two feet at most, and it was completely unsafe.” He blinked for a moment, and then apologized. “I had no idea I was that close to you. I’m really sorry.”

Maybe, just maybe, we can prevent someone else from engaging in ruthless preemption with deadly consequences.


Note:  This post might be difficult for nervous flyers to read.  Trust me though, it is actually reassuring if you stick with it. And keep in mind that although I edited this post over many months, I finished it while in the air. On a United flight, no less.

I’m fascinated with those who keep their cool in extreme difficulty and manage to derive a good outcome in the face of major adversity. Hardly surprising, I guess, given that I am in EMS and as a friend said to me recently, “I have always thought of you as a grace under pressure.” I certainly aspire to that (although most don’t know how frequently I fall short of that). I like to admire those who have proven their mettle and think about ways that I can try to manage landmines in my own life.

There was a time in America, not too long, ago, when every aircraft had a single latch that would keep the cargo door on the underbelly of passenger aircraft shut.  In the rare instance that the crew failed to properly secure the door, or there was a mechanical or electrical problem, it could loosen in mid-flight. If it were to loosen enough, air would begin to leak around the seams of the door and if the airplane were at cruising altitude, the difference in pressure between the cabin and the thin air outside would cause what’s known as a “ring pull effect,” and cause the door to be sucked off the hinges. That’s exactly what happened on United Flight 811 in 1989. There was a warning light that came on in the cockpit, “DOOR FWD CGO,” that alerted the pilot of the problem. Unfortunately, in the case of Flight 811, it came on 1.5 seconds before the door blew off, taking a good chunk of the First Class cabin with it (killing 11 instantly), and almost sucking out a flight attendant, who was saved when a nearby passenger grabbed her ankle.

Once struck by the initial tragedy, the plane was in immediate jeopardy of losing control owing to the sudden depletion of oxygen in the air. And yes, the oxygen masks did deploy, but they did not work, because when the side of the fuselage was ripped off in mid-air, the lines carrying oxygen to the cabin were severed. The Captain and First Officer were able to remain conscious to get the plane safely landed in Honolulu by a stroke of luck. They made a rapid and controlled turn and descent back to the airport at Honolulu, landing without further injury or loss of life.

This incident created real change in the industry. First, airframe manufacturers began employing additional locks for the cargo door, so that if one failed, a pilot would at least have some time to try and make a controlled descent to equalize the pressure and prevent the door from being blown off the aircraft. Second, there is a a well-defined procedure in place now, through the use of a checklist, that specifies the precise steps the pilot and operating crew are to take in the event that the DOOR FWD CGO light comes on. There was one prior, but because there was no time to employ the measures it suggested before the door blew off, it was for all intents and purposes, a problem without a solution.

Atul Gawande extolls the virtue of checklists like these in just about every discipline in The Checklist Manifesto. His book is the result of a study on the efficacy of checklists in fields like aviation, with an argument that they would reduce mortality and complications in surgery (it was surprisingly rare to have checklists in surgery at the time he wrote the book in 2009). Gawande attributes the success of the landing with the remaining passengers and crew on board as the result of good hygiene by the pilot in employing emergency procedures. We use checklists (or “protocols,” as we like to call them) all the time in EMS. There’s a protocol for everything. Memorize the protocol, the theory goes, and you will be able to execute smoothly when you need it. Here’s an example for the protocol to follow when you have a pediatric patient with a heartbeat that is too slow: Ped Brad Algorhitim.

While protocols and checklists are, no doubt, helpful, there’s got to be more to it than that. Why is it people with the requisite knowledge and training can not execute even when they have the protocol at their fingertips? Why do they fail to follow it and make critical mistakes? Why can some people not even calm themselves enough to follow a protocol or checklist at all? I’ve spent some time trying to figure out what the formula for success in emergencies might look like. While I don’t think I could say I have identified and considered all the relevant factors, I think Gawande fails to account for the importance of two additional things other than good use of checklists: (1) the natural ability to focus; and (2) experience.

When asked how he made it through the event, and landed Flight 811 safely, the pilot, David Cronin, told a surviving passenger who was writing a book about the experience that, “I just prayed and got on with it.” Similarly, the “Miracle on the Hudson” pilot Sully Sullenberger said, “I had to focus on the task at hand, despite the stress,” he explained. “I only did the highest priority items and I had to do them well. This required the discipline to ignore everything else.”* What these two men have in common is that they were able to give a razor-sharp focus to the task at hand and to ignore everything else that was around them. Athletes often refer to this as “going into the zone.” There is little doubt that these two people were “in the zone” at the time they executed their respective emergency landings. I’ve wrestled with the question whether this is an innate attribute or whether it can be learned. There’s little literature on this topic, but I believe you have an inherent ability to do this or you do not. And the professions that value it (EMS, Airline Pilot, SWAT Team Member, Soldier, and many others) tend to be self-selecting. Someone who has anxiety every time the door closes is not likely to say “I think I will become an airline pilot.” If, by some aberration, you wind up in one of these fields despite lacking this attribute (which I will call “inherent focus”), you will likely be selected out in training.

What else must there be besides a coherent set of guidelines and inherent focus? The third attribute that seems to be important in clutch performance is experience. Sullenberger had thirty years experience and was less than a year from retirement when he landed on the Hudson. Cronin was on his second-to-last flight and was just weeks before retirement when he piloted Flight 811. This suggests to me that there is something beyond the checklist and inherent focus at work. In fact, Sullenberger did not have a checklist for a double engine geese strike — he had to devise a solution in under three minutes. The years of experience gave these individuals the ability to remain calm, focus, and to solve a novel problem. (This also makes me wonder whether we should be imposing mandatory retirement on pilots who are at the peak of their careers.)

As a society, we undervalue maturity and wisdom. Gawande’s theories certainly have merit and providing guidelines to follow reduces the risk of error when encountering common problems, but there is no substitute for the inherent focus and the experience that guides people toward better outcomes. This is our best hope to respond better to emergency situations.


Hidden Compartments

There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. – Hamlet

Friday afternoon was the first true Spring day. It was sunny, with a warm breeze and I wished I could goof off and enjoy it when I got into my car around noon. But more serious business awaited – I had a meeting at my son’s school to talk about educational evaluations, so I tried to enjoy it by rolling down the windows and turning on the radio on the drive over.

The meeting was like many others. A lot of subtext and undercurrent, various agendas moving this way and that. One of the administrators present told us she was concerned that Ryan was falling behind his peers, specifically in Social Studies and Science. She wondered (aloud) if that was because of a “cognitive problem,” (read: incapable of being taught) and if, therefore, he belonged in a program with fewer demands (read: the most expensive baby-sitting the state can buy). Hence, the tests. I droned on about the lack of credence that can be placed in these things. At least one person on the team agreed with me. To be fair, I think there was some basis for the concerns, but our son is complex. Those who know him well know that he is secretive, with hidden currents that flow under the surface. There is much that he knows but ordinarily leaves unspoken.

When I was studying for my EMT license, one of the things the instructors drilled into us was the importance of evaluating whether trauma patients had palpable pulses, normal sensation and normal motor responses in their limbs (particularly in an injured limb). On every flow sheet there was a reminder: “Did you check pulse/motor/sensory?” I was terrible at finding one of the pulses in the feet – the posterior tibial pulse – I fretted and worried that I would fail my trauma exam, so I practiced on everyone in my family and in class, hunting around for that mysterious pulse that is nestled behind the ankle bone.

Our EMS textbook admonished us to heed the warning of a person with recent trauma and diminished pulses in the affected limbs. Such a disappearance, our textbook warned us, was a sign of Compartment Syndrome, “which is a medical emergency requiring an immediate upgrade to Priority 1 status for all patients.” What was this mysterious syndrome? Our instructor talked about it briefly, but did not dwell on it. There was a limited space between the muscle and the fascia layer, he told us, and if swelling or bleeding exceeded the capacity of that space, bad things started to happen. He also told us it was rare and we would probably never see it.

Until Saturday, that was the sum and substance of my knowledge of Compartment Syndrome. That is, of course, until an out of breath resident came running up the stairs from where my son was in the OR, having his broken tibia set, and informed us that there was a problem….pressure in the compartment…..fasciotomy…..incision….closing difficult with swelling….keep him in a medically-induced coma until we can achieve closure…..

Ryan’s compartments in his leg had swollen with blood from the fracture. Shards of bone had lodged into his muscle and tissue and he had slowly been bleeding into the space, so by the time they got him in the OR to reduce and set the fracture, his leg was pale and pulseless, just as my flow sheet warned. It is important to understand that this was an inevitable consequence of the fracture he sustained. What was not inevitable was how long it went undetected, which is, unfortunately, an indeterminate length of time. We need to wake Ryan up to know for sure what he feels and can do with this leg, and that might not be evident for some time. Before he went to the OR, our ordinarily secretive and uncommunicative boy was almost poetic in his expression.

“Mom, when the swing broke, I was flying through the air for a minute, like a pilot. But I was a pilot without an airplane, so I crashed.”

“That’s an interesting way to look at it, honey. Next time make sure you bring your plane with you, please.”

Our boy, who some believe has fallen far behind even his developmentally disabled peers, has some hidden compartments, and they are not in his leg.  In the ambulance, he asked me, “am I going to die?”

“Of course not honey,” I soothed, not realizing the events of the next 36 hours might bring us slightly closer to that prospect than I ever could have imagined. “Why would you think that?”

“Because I saw this man on the news, and he fell jumping into the pool. He hit the edge of the pool and he broke his backbone. He almost died. He’s in a wheelchair now.”

And I thought he watched the news every morning for the weather report. Of course, he hasn’t — he’s been absorbing it all, the stories he has seen, secreting it away inside. I wonder what the school administrator would think, if she could see him as he truly is, if she could see what I see.

I can’t wait to see him again.


When I was doing my EMS training, one of the career EMT/Firefighters talked to me about a call we had just run one night. It was an older woman with abdominal pain. We get those kind of calls all the time. He asked me “so, what did you think of that call?” I told him that she seemed kind of routine to me and there could have been a variety of different causes for her abdominal pain. “Right,” he replied, “and quickly, you will develop a sense for when those seemingly routine calls are not routine by just looking at the patient and seeing that something just doesn’t look right.”

That kind of judgment that comes with experience obviously can’t be taught, but perhaps the “nose for trouble” that comes with practice alone is not enough to be good at what you do. Atul Gawande, in his book Better, A Surgeon’s Notes on Performance , talks about the importance of vigilance, borne out of a desire for betterment. In the introduction of his book, he tells a story about an old woman who “didn’t feel good,” much like the EMS patient I had. He recounts that this woman came into the ER at the hospital when he was in his residency, and he thought she was probably fighting an infection, and that’s about all the thought he gave to her. The senior resident, however, was not so sanguine. He thought she “didn’t look right,” and so he went back to check on her twice between rounds. As a result, he caught the fact that she did, in fact, have pneumonia and the infection had progressed to sepsis (an infection in the bloodstream), which can rapidly be fatal. As a direct result of his diligence, he spotted her sepsis fast enough to avoid having to put her on a ventilator and she was released in a few days.

Gawande attributes the senior resident’s instincts and more importantly, his vigilance, as critical in changing this woman’s outcome. “What does it take to be good at something in which failure is so easy, so effortless,” he wonders. He concludes that one of the essential ingredients to be good is diligence — that this makes a doctor better. Competence is not enough.

His lessons are equally applicable to almost any discipline. The legal profession would be well-served by this sort of self-reflection. One place where I think it matters greatly is in parenting. And no where is the necessary diligence as challenging than in parenting the child who can not tell you what is wrong or what is bothering him or her. Parents of infants and those special children with whom the world can never communicate must read subtle signs and be ever vigilant.

So, on this Mother’s Day, my hats off to those of you who pursue whatever it is you do with a sense of diligence, whether it is being a great teacher, mother, caregiver to an ill family member, a nurse, a doctor, or EMT. You truly are better for it.