3 steps to improve EMS situational awareness, spot danger

The more complex the skill, the more attention it requires; so how do we get work done and still maintain awareness of the whole scene?


I was involved in a film project recreating a firefighter close call event that occurred during a basement fire. While interviewing the firefighters who were on the hose line in the basement, I recognized an interesting dynamic.

The firefighter who was on the nozzle heard the least amount of radio traffic and recalled the least about the changing conditions in the basement.

As my interviews progressed through the firefighters farther back on the hose line, the descriptions of the radio traffic and interior conditions became more detailed. Ultimately, the firefighter who was the first to recognize that the fire had moved behind the crew and was threatening their exit was the firefighter farthest back on the hose line.

The differences in these firefighter’s stories and observations are a classic example of the difference between task orientation and situational orientation. Each moment that we are on scene, we are choosing to devote our attention toward specific tasks and skills, or the details around us.

Every task and skill that we devote attention toward robs us of a little bit of our situational orientation, or our awareness of the environment around us.

Task orientation

When we are primarily involved in skill orientation, most of our attention is dedicated to the task being performed. In these moments, the details of the task or skill tend to consume us.

Where is the best site to establish an IV? Am I getting a good seal on the BVM mask? Which blade should I select for this intubation attempt and where is it located?

The more complex the skill being performed, the more of our attention it will require. Securing a patient to a spine board may require only a small percentage of our awareness, while an oral intubation attempt may draw upon all of our focus and attention.

Situational orientation

When we are not engaged in tasks or skills, our attention naturally turns to the details of our environment. We notice the color of the curtains, the ash tray filled with cigarette butts and the closed bedroom door at the end of the hallway. This orientation is more commonly referred to as situational awareness.

This broader awareness allows us to see the big picture. Only when we are unburdened by complex skills and uninvolved in tasks can we truly devote our mental focus to situational awareness.

In our scene safety lectures, we often pay a lot of lip-service to situational awareness, but we don’t always mention how to achieve it.

Tasks need to be accomplished. Someone needs to do the work of assessing and treating the patient. So how do we get the work done and still maintain our awareness of the whole scene?

Here are three ways to improve situational awareness.

1. Practice your front-door survey

Inexperienced providers often charge forward into the scene and become involved in tasks. We do this for several reasons.

First, we are often insecure that any hesitation will be interpreted as uncertainty. When we are new EMS providers, we struggle to appear confident and in charge, so we begin patient care without hesitation.

Scene management can also be far more difficult than basic assessment and care for one patient. The larger and more complex a scene, the more enticing and comforting task orientation becomes. Practicing a front-door survey, or scene survey, is one way to overcome this challenge.

Remember the scene survey? It’s not just for the national registry skills test.

Try to actually stop for a moment as you enter a scene and let your senses take in the whole picture. Before you rush to the patient’s side, spend a few seconds and take in the sights, sounds, smells, mood and emotional tempo of the scene. Ask yourself if everything fits. Consider what resources you are likely to need.

2. Reorient yourself after a task

Sometimes, you will be the person doing the bulk of the task work. That doesn’t mean that you need to completely disregard your surroundings.

After each task that you complete, look around. Take in everything for just a few seconds before you begin your next task. Reconsider if the scene is being managed around you appropriately, or if a change in tactics is necessary.

You can also use the natural pauses in the flow or progression of the scene to shift back into scene survey mode. While strapping down the patient on the pram or waiting for someone to hand you a blood pressure cuff, shift your mental focus back to the environment and prepare for your next task.

3. If you’re in charge, act like it

Scene presence, leadership and delegation can be some of the toughest skills to learn, especially when we are personally good at the tasks and skills that need to be completed. Doing things yourself is comfortable; leading others on the scene is not. This is why we so often see those who are supposed to be in charge carrying backboards and holding c-spine.

A huge part of scene leadership is maintaining situational awareness and looking out for the folks on scene who are involved in tasks. Their task orientation leaves them in a high-risk mode where they could easily miss an important big-picture detail.

Is the person holding the end of the backboard too close to the passing cars? Should you find out if anyone is in that back bedroom? Is the patient’s drunk husband becoming agitated?

In training, it’s OK to talk about scene safety being everyone’s job. It is.

But mostly, it’s your job. Someone needs to stand back and maintain situational awareness. If you are the leader, that is your primary job. Put down the blood pressure cuff and lead. 

About the author

Steve Whitehead, NREMT-P, is a firefighter/paramedic with the South Metro Fire Rescue Authority in Colo. and the creator of blog The EMT Spot. He is a primary instructor for South Metro's EMT program and a lifelong student of emergency medicine. Reach him through his blog at steve@theemtspot.com or at Steve.Whitehead@EMS1.com.

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