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Without a Plan

Posted by Daved van Stralen on Sunday June 19th, 2016

In times of confusion we may find comfort in a good strong plan or reliable leader. How easily we disregard George Orwell’s observation, “A story always sounds clear enough at a distance, but the nearer you get to the scene of events the vaguer it becomes” (Shooting an Elephant). It is this way with plans, which seem well worked out before the event, and distant authority, who seem in control from a distance. This sense that “somebody must know what to do” impedes engagement when the unexpected occurs. We do quite well with the overt, decompensated state where we obviously have a problem but we do not do well with the covert, compensated state, which we are unlikely to recognize (covert) and more likely disregard (compensated). In fact, we could likely do better at teaching how to identify the early stages of an event before it comes to a common final pathway of cascading failure. We must do better to engage when we don’t have a plan.

For this to happen we must characterize early heralds of failure and make salient these signals in a way that, rather than being a weak signal, they become strong signals- prominent and conspicuous to the, now trained, eye. We must also discuss how to approach this uncertainty and ambiguity to create a plan while we act. Every unexpected event is a process with a beginning, which is hidden only to the uneducated eye. These processes will first come to our attention from a discrepancy in a response to what we do or something being out of place. Every process emerges from interactions we cannot see, and these interactions create novel properties. To have a plan for every contingency, creating a plethora of plans, is to have no plan

To identify a discrepancy we must teach what normal patterns are in normal responses. Further, we must teach what something looks like between the structured and normal and the unstructured and unexpected. This is the early herald and our goal is to make salient these signals.

To accept a discrepancy we must move from reliance on the normal distribution, comprised of random, independent events, and move towards the power distribution, often called the Pareto distribution. If in outlying event occurs it can occur again, if it occurs again it can be worse. This is also referred to as the 80-20 rule.

To move from discrepancy to engagement we must take the arousal from this salient, discrepant feature and turn it into a challenge. The all-too-normal response to arousal is observation, disregard, wishful thinking it will go away, or a fear response. The fear response will generate situational cognitive distortions of anger and frustration (fight- adrenaline mediated), avoidance or evacuation (flight, adrenaline mediated), or confusion and freeze (freeze- cortisol mediated). Engagement, directed towards problem-solving (dopamine mediated), becomes self-sustaining.

This is both an education and a conditioning approach. We can make discrepancy expected because we teach to search for it as the early herald of failure in the covert, compensated state rather than the overt, decompensated state; this is cognitive. Discrepancy can be unexpected from the overt, decompensated state; this is conditioned. I call it a conditioned response because it is associated with the fear response manifested as situational cognitive distortions; it sets one up to be overwhelmed. Through conditioning the individual comes to engage the unexpected.

To engage without a plan we must identify something we know within the event. This will be different depending on one's experience, position in the organization, and authority. Belief in Black Swan Events allows us to justify failure to respond properly because nobody has seen this before. Within each Black Swan Event are elements that we have seen before; those become our attachment points.

Rather than a singular problem to solve, engage in without a plan involves parallel problems with some interacting with each other. Problem solving, however, implies a solution, which brings into the discussion “Was a solution correct?” It may be better to see this as resolution of the situation, directing resolution towards the best results possible.

Engagement without a plan is to interact in real time, constantly assessing and managing risk, observing closely for response to actions, and continued observation for discrepancies.

 

 

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Daved van Stralen, MD, FAAP, is Medical Director for the Riverside County EMS Agency and an Assistant Professor of Pediatrics, pediatric critical care, on staff at Loma Linda University Children’s Hospital and Children’s Subacute Center at Community Hospital of San Bernardino (California). He is also Adjunct Professor of Emergency Medical Service at Crafton Hills College, Yucaipa, California. He currently works with the San Bernardino City Unified School District to bring High Reliability methods to K-12 education. He developed and runs the International HRO Conferences and the HRO website www.High-Reliability.Org. He has previously served as medical director for American Medical Response, San Bernardino County and for San Bernardino County Fire Department.

Daved van Stralen worked as an ambulance person and fire department rescue ambulance driver for the Los Angeles City Fire Department in the 1970s with over 7,000 ambulance responses, mostly in South Los Angeles. He has a BA in Social Ecology and a BS in Biological Science from the University of California, Irvine; an MD degree from UC Irvine California College of Medicine where he completed his Pediatric Residency. By one review, he is the first career fire department paramedic to attend medical school. He completed a Pediatric Critical Care Fellowship at Children’s Medical Center and Parkland Memorial Hospital, Dallas, Texas.

At Loma Linda University he helped develop the Pediatric Intensive Care Unit, the pediatric critical care transport service, and the Emergency Medical Care bachelor’s degree, the first clinical academic degree in the US for paramedics. Using a fire service/EMS model with critical care principles he developed a subacute care model for profoundly handicapped children that allows them to play and develop despite dependency on mechanical ventilation for life.

Daved van Stralen collaborates with safety, risk, and reliability experts from wildland firefighting, business, and healthcare in the US and Europe to identify common approaches the individual uses to ensure safety and reliability. He connected the US Forest Service with the Bouches du Rhone Fire Service (France) for the joint US-France Wildland Firefighting project. He developed a website to share individual experiences in this field www.High-Reliability.Org and directs a series of international high reliability organizing conferences. He has traveled twice around the world.

 

 

 

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