In a training scenario, a lose-lose situation may make a lasting impression on students, but does little to improve the decision-making skills of the responders. Regularly faced with making life-or-death decisions, emergency responders should receive training that includes no-win as well as winnable alternatives, thus reflecting real-life scenarios while not deflating student confidence.
“Imperative! This is the Kobayashi Maru, … nineteen periods out of Altair Six. We have struck a gravitic mine and have lost all power.… Our hull is penetrated and we have sustained many casualties.… Life support systems failing. Can you assist?” –“Star Trek II: The Wrath of Khan,” Jack B. Sowards
This message, which crackled across the radio, marked the start of the Starship Enterprise’s training mission to Gamma Hydra. The scenario posed a choice: (a) save about 80 crew members of a disabled freighter and violate a treaty with a hostile neighboring government; or (b) let the freighter drift to a certain doom, honoring the treaty but violating the commitment to save those in distress. As a plot device, such scenarios define aspects of main characters in a motion picture and set the stage for later conflict, but they also could serve as a valid training tool for first responders.
Choices Leading to Unwinnable Places Emergency medical technicians and paramedics often face life-or-death decisions, with cardiac arrest being the most severe condition a patient can be in and still receive care from these emergency medical services (EMS). According to 2013 statistics from the American Heart Association, only 9.5 percent of people who experienced out-of-hospital cardiac arrests survived long enough to be discharged from the hospital. EMS programs often teach and test treatment skills for various patient scenarios using simulations, where the simulated patient experiences many conditions, including cardiac arrest.
In order to create an unwinnable scenario, the rules must be stacked against the student, often in an artificial manner. One such scenario is called the “two doors,” which may be used to simulate the EMS response to an active shooter situation. The two-student team would be dispatched to a shooting, and enter a scenario room with an instructor playing the role of a police officer. The sounds of gunfire come from outside, and students have the choice between two doors at either end of the room. Unbeknownst to them, an instructor/shooter with a balaclava – that is, a ski mask that covers portions of the face – awaits behind each door. Since EMS personnel have no effective response to an active-shooter situation, they rely on the police officer for safety and control of the scene. If they call for EMS resources, they simply put more EMS staff in harm’s way without improving the situation. Inherent in this scenario’s design is that the only way to win is to not play.
Instructors may support such scenarios as a way to impress upon students that there are such scenarios that they may encounter in real life. However, what all no-win scenarios need is a winnable path. After the student arrives at the unwinnable corner, the instructor explains what the student could have done to succeed. In other words, there actually should not be any no-win scenarios, just scenarios that branch off and could lead to unwinnable places. In an EMS scenario, student teams should have the opportunity to spot the threat during scene size-up and to pull back before they become trapped in the room, or alternatively to remove the patient quickly enough that the shooter’s return does not trap them in a room with only two doors, both with dangerous consequences.
Balancing Success & Failure These decision-making skills should continuously build on previous training and experience. Applying the training received, students should be able to succeed in the scenario, even if each team does not. Observing the success of other teams also can be valuable learning experiences. The stakes are high in EMS and the training should be difficult enough to make students think about what they are doing and understand that there are branches on the decision tree, in most encounters, that may lead to negative consequences.
Training should offer students the tools to make good decisions and understand the necessary procedures intended to keep them safe and make them successful. A no-win branch should only be included in a scenario when three criteria are met: (a) the branch is realistic to conditions in the field; (b) the stakes in a similar real-life scenario are high; and (c) the students’ training would lead them to another path, but they just did not take it. Care must be taken not to paint an outlook that is too positive, but not so negative as to crush the confidence of the students.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.
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