Preparation vs. Improvisation

Everything in its place

I have a new partner who called me obsessive once.

“Eh?” I asked.

“Everything has to be just so. When you come in you make sure the collars are organized and facing the same direction, you fold over the ends of the tape and stack it in a certain order, you make sure the handles on the bags are easy to grab…”

“I’m not obsessive… have you seen my car?”

“Well, you are here.”

And it’s true. When I show up in the morning, I do my damnedest to ensure that all of our equipment is as stocked, ready, and prepared as possible. I’m the guy who checks the integrity of the air-filled gaskets on the BVM masks, and considers two spare O2 tanks one and one none. If my blood pressure cuffs aren’t labeled, I label them, and I ensure my map book is turned to the correct page.

And all of that may sound funny, because everybody knows that one of the hallmarks of EMS is improvisation, the ability to adapt to unusual situations and “make do.” If you’re juking around at a chaotic scene and discover that you haven’t got any splints, or your stretcher strap is broken, or your patient is dangling over the side of a balcony and needs to be boarded, you see what you have and use your noodle and make it work. Not long ago I saw somebody apply pressure to a laceration on top of a patient’s head by tying a bandage to both stretcher rails and rubber-banding it over their skull like a bow-and-arrow. Why not?

We find a way. So why am I so anal about being prepared while we’re still standing on solid ground?

The fact is, in this job, things are going to go wrong. They just are. And you’re going to handle them the best you can. But if too many things go wrong, the situation may reach a breaking point — your capacity to “adapt and overcome” is not infinite.

Have you ever read a book or watched a show about a major disaster? Plane crashes, reactor meltdowns, bridge collapses. What they have in common is that numerous intelligent people usually foresaw the possibility of such an event, and so they designed systems and safeguards to prevent it from happening. When disaster happens nonetheless, it isn’t because one thing went wrong. It’s because five, six, twelve things went wrong. The backups to the backups to the backups failed. More problems occurred simultaneously than anybody expected..

In this job, too, the only time when feces hit fans is when problems accumulate. It’s not that the patient was sicker than you expected. Or that the stairs were rickety and covered in snow. Those are a nuisance. It goes from whoopsie to trainwreck when you didn’t bring your stairchair and your suction. Then when you go back, the chair falls open while you’re walking, and as you try to fold it you trip over your untied laces, and when you finally get inside you realize the suction canister is missing a cap and won’t hold pressure. And then once you get the patient extricated they’re already unconscious, but you can’t find any Yankauer tips in the truck, and by the time you do they’ve stopped breathing…

See? With this job, even at the best of times, the line between well-in-hand and circling-the-drain can be pretty slim, and once you’re on that slope it’s hard to recover. The only way to stay safely in control is to create a buffer, and that means doing everything you can to prepare yourself when you have the chance, because you won’t always have a chance. If you don’t bother dotting your I’s and crossing your T’s before you enter the mix, then when things inevitably go wrong, the sum of those unhingings may be too much to handle.

Consider your emergency responses. It’s a safe bet that you’re going to drive past the address, or turn the wrong way, or get caught behind the world’s slowest schoolbus. Something is going to cause problems, whether it’s your dyslexic partner who confuses Gable Street with Bagel Street, or you forgetting the apartment number three times in a row. But that’s just a small delay. It won’t be a real problem unless you also stopped to pee before leaving the base, or forgot where your boots were, or had to spend five minutes backing out of where you parked. In that case, you already burned through your margin for error, and now when the unexpected (but inevitable) comes along, you’ve got no slack left.

In short, you can be the best in the world at rolling with the punches, and in this job, you ought to be. But that doesn’t mean you shouldn’t also try to be prepared to the point of obsessiveness. One lays a foundation for the other, and when you habitually have both to work with, you can handle whatever comes your way; if you’ve only got one, you’ll be lucky to get through your shift.


  1. This pretty sums up my entire mindset at work: I don’t ever want to ever be surprised.

    Most days I’m in a big building that says EMERGENCY on the side or I’m in a big truck that says EMERGENCY on the side. Either way I hate it when people are shocked that an actual emergency sometimes presents without warning. It’s kinda the whole reason our jobs exist…

    Improvisation is fun, but mentally it’s very resource-intensive I’d much rather focus my entire attention on the patient and just know that I’m going to have the right tool for the job when I need it and where I want it. I like to think that a resus runs smoother in my truck or room than anywhere else, even if I’m just standing back and observing others utilizing my setup.

    Like you, my first task at the beginning of the shift is always to set up my rig how I always have it or make sure all five of my rooms have the same stocks and supplies in all the same locations, right down to organizing the BP cuffs by size. In addition to finding useless items and recognizing a lot of missing ones, I like to think my routine also helps mentally prepare me for whatever might come through the door as I briefly visualize how and when each item might be used.

    Like Weingart says in his logistics podcast, it’s one thing to rattle off the steps of ACLS, but it’s another thing to really consider how each individual step is actually going to be performed. “The mind of a resuscitationist…”

    • I try not to get stuck in the same way of doing things — you don’t want to be paralyzed when your little flawless feng shui is disturbed — but if you control your environment, you can introduce variety in a managed way. For instance, occasionally practicing blood pressures on unusual sites or on the opposite arm to make sure you remember how — but doing it on a routine transfer so you’re okay if you fumble. If you’re using a child cuff on a forearm, it shouldn’t be because it’s the only cuff you could find…

  2. I agree 100% and wish more people thought this way.

    I also work in outdoor education in addition to EMS, and we have a saying that you could be the best person ever at improvising and doing things by the seat of your pants, but you”d still do even better by planning ahead and being prepared.

    I think it’s even more essential to be ready and organized in EMS. I view a significant portion of our job as bringing order and calm to a chaotic situation; it’s essentially impossible to do this if you’re fumbling and improvising everything.

    Maybe it’s just being prudent, maybe it’s OCD, or maybe it’s a holdover from my days in the Boy Scouts, but I try to apply this concept of “Be Prepared” to everything we do in EMS. Whether it’s checking the truck, practicing infrequently used skills during downtime, reviewing on my own, running through scenarios either with a partner or in my head, or thinking back to previous calls and seeking feedback on them, I probably end up spending more time on making sure I’m ready for anything than I do actually running calls.

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