Stagecraft in EMS: Maintaining the illusion of control

EMS is a lot like improvisational acting

There is a single cardinal rule of improvisational acting. Never deny or contradict your partner’s premises. As the actors in an improvisational team spontaneously create their roles and tell the story, they need to be willing to go with the flow and support the direction of the scene.
Comedy actress Tina Fey explains the rule in this way:

"When you’re improvising, this means you are required to agree with whatever your partner has created. So if we're improvising and I say, ‘Freeze, I have a gun,' and you say, 'That’s not a gun. It’s your finger. You're pointing your finger at me,' our improvised scene has ground to a halt.

"But if I say, 'Freeze, I have a gun!’ and you say, 'The gun I gave you for Christmas! You bastard!' then we have started a scene because we have AGREED that my finger is in fact a Christmas gun."

EMS is a lot like improvisational acting. On the scene we understand our role and the general direction that things are supposed to go, but we don’t have all of the details. We don’t know who all the actors are yet and we aren’t sure how the story will evolve.

In this environment, things don’t always go according to plan. Little mistakes happen on every scene.The medical kit gets dropped down the stairs. Someone forgets to attach the oxygen tubing to the tank. IV bags get dropped on injured limbs.

In the unpredictable environment of medical emergencies, what can happen will happen. And it will often happen at the worst possible time.

Mistakes aren’t a symptom of dysfunctional teams or incompetent caregivers. Errors and glitches have been present in the performance of every EMS team that I have ever worked with. Good teams aren’t good because of their error-free performances.

Good teams are good because they manage to overcome the little errors and missteps while still moving the scene forward.

Great teams have an uncanny ability to recognize and overcome mistakes seamlessly. In fact, if you don't have immediate and detailed knowledge of how an emergency response team is supposed to operate, you probably won’t know when a good team makes a mistake. They don't make it obvious.

Actors call that stagecraft. When all of the uncontrolled elements are silently and seamlessly accounted for and overcome, the scene moves forward and the audience takes no notice of the gaff. This is where the first rule of improvisation comes in handy.

When we recognize that the oxygen tubing isn't hooked to the oxygen bottle we can fret about it, or we can fix it. When the medical kit tumbles down the stairs we can have a tantrum or we can calmly say, "John can you bring me up the blood pressure cuff, I think it's on the third floor landing. And Mary might need some help putting our stuff back in the medical bag."

When the IV bag falls on the patient's injured limb we can lay blame, become angry and vigorously apologize to the patient, or we can say, "Mr. Smith, I apologize for dropping that on your injured leg. What can I do to make you more comfortable?"

The moment you become visibly perturbed or angry over a minor mistake, you let everyone else in the audience know that this wasn't part of the plan. It's akin to saying, "That’s not a gun. It's your finger."

Our ego wants us to be the person who points out the error and makes it public. (If we recognized it, it couldn’t possibly be our fault, right?) But once you go down that road, you violate the cardinal rule. You lift the curtain on your own stagecraft.

We are never completely in control, but if we're good at staying calm, taking things in stride and improvising we can almost always maintain the illusion of control. The gap between what we control and what we don't is where we can choose to employ our own personal stagecraft.

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