Tools for the downward spiral

After reading responses to EMCrit’s tweet on BTSF (beat the stress, fool), I realised there’s little out there which helps paramedics and those practicing in the prehospital care environment actually manage when they’re out of their depth.

Generally we’ve come to accept that we’re going to get better by immersion and experience, but this doesn’t do any service to patients or peers. We know it’s collective critical incidents which build first responder stress, and resilience, when managed properly.

BTSF (breathe, talk (self), see (visualise), and focus is a tool for managing these instances, developed on research, but is likely only useful when you’ve practiced first. Its for all of us, from the first responders being talked through a chest decompression via Clinical Consult, or the ICP doing the only emergency cric of their career, to the thirty year vet who is now working on their grandfather. Critical stress training is a tool we can practice, to help us through stressful situations where we’re truly out of our depth.

Breathe- firstly gives a second to stop, and reassess if this is actually what you want to (or need to) be doing. A self assessment, and pre task immersion pause is proven to decrease human error. The increase in circulating oxygen makes you feel OK too…

Talk (self)– this has two steps: mantras and sayings to boost confidence in yourself and team. Beat the stress, fool, is one. Slow is smooth, smooth is fast is another, a personal favorite. Secondly, just thinking through the process aloud to ensure everyone is on the same page. This is particularly important in the RSI or multiple task extraction setting.

See– actually have an understanding of what you’re doing, from start to finish. Encourage others to do the same, and make sure your visualisations are similar. Foresee and pre-empt errors to pre-manage them, and only when you’ve got a fair picture in your head, do you proceed.

Focus– actually give your full attention to the task you need to be doing. Hand off scene command, give others tasks to manage, so you can perform your primary task. A lot of negative stigma is associated with task immersion, but if managed well it can achieve excellent outcomes.

Poor outcomes, in particular avoidable harm or mortality, are rarely the result of poor staff performance, but a reflection of poor or dated training failing hard working, well intentioned staff. US Army review of battlefield deaths suggested approx 25% of battlefield deaths are survivable, so why are they occurring? Human error and access to care. In no way can we be replacing definitive care, but for those who ARE definitive care, or are performing skills outside scope or active way about their pay grade, I hope the above guides you through your next sticky situation.

Performance through professionalism.

1) Britt, T., & Jex, S. (2015) Thriving Under Stress: Harnessing Demands in the Workplace. Oxford University Press: New York

The introduction chapter is worth a read.

2) Lauria, M., Gallo, I., Rush, S., Brooks, J., Spiegel, R., Weingart, S. (2017) Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Annals of Emergency Medicine

3) Cornthwaite, K., Edwards, S., Dimitrios, S. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology 27 (4): 571–581, doi:10.1016/j.bpobgyn.2013.04.004

4) Postma, J., Oldenholf, L., Putters, K. (2015) Organized professionalism in healthcare: articulation work by neighbourhood nurses. Journal of Professions and Organization 2 (1) DOI:

5) Kotwal, R., Montgomery, H., Kotwal, B et al., (2011) Eliminating Preventable Death on the Battlefield. Archives of Surgery 146(12): 1350-1358. doi:10.1001/archsurg.2011.213


5 Comments Add yours

  1. jugrum says:

    Nice one Andrew, I like how the negative ‘tunnel vision’ has been reworded as ‘task immersion’, in the right setting. Here are a couple of quotes from a SMACC dub conference that I think are quite apt:

    “Self discipline begins with the mastery of your thoughts. If you don’t control what you think, you can’t control what you do.”


    “Too much time is dedicated to the acquisition of technique, and too little to the preparation of the individual for participation.”

    Breathe in, breathe out : )


    1. Andrew O says:

      Can you provide a reference for breathe in, breathe out? Perhaps… biblical?

      I think the tunnel vision/ task immersion difference is quite important, as we’ve been drilled to say that we need to keep a more scene orientated approach. What we need to do is pay the appropriate attention to the tasks at hand, then step back and reevaluate. The second quote is very true, and there’s a (?Scott Weinghart) podcast that talks about task immersion in cric’ing: doesn’t matter how much you train in the cric procedure, the first time you do it you’ll remember you’re slitting a throat not that you’re cric’ing.

      Having sound knowledge and understanding in ones own capacity and limitations is proven to prepare for these times, so the fix is to keep training and educating to reach a point our thoughts exist on the same level as our actions


  2. Andrew O says:

    Where the younger ones pause because they think… oh, where’s someone who knows what they’re doing?


  3. Tatsu Kuwasaki says:

    Love it!
    This is when us older paramedics have slight advantage having natural ability to pause (delay) due to neural degeneration, lol.
    Thanks for another great post Andrew.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s