Every organization needs individuals capable of making sound decisions. During low-frequency, high-acuity events, a responder's ability to make good decisions is more critical than ever. Therefore, knowledge and decision-making should be integral parts of any emergency training. The training you provide may fulfill basic requirements, but does it equip your team members to make effective decisions during an emergency? If not, you may not realize it until it's too late.

As a Battalion Chief and paramedic for Glynn County Fire Rescue, I have learned the importance of making good decisions during emergencies. It took me longer than I care to admit to master this skill. As a course coordinator for our EMT, Advanced EMT, and Paramedic programs, I am responsible for training my department’s responders. I am also a co-owner of Glynn Emergency Training, a company that specializes in customized emergency training for industrial organizations. Over the years, I have observed panic and the decision-making processes unfold in myself, my peers, and my students. I have also learned that what students successfully demonstrate in the classroom does not always reflect their performance in real emergencies unless their training is designed to bridge this gap.

The human brain and crisis

This discrepancy between classroom learning and actual emergency response is due to how the human brain handles crises. During a crisis, threat, or emergency, the brain is wired to make rapid decisions rather than well-thought-out ones. Think earlier in human history. When faced with a bear at the mouth of a cave, a person needed to escape quickly rather than analyze the type of bear, what it ate, or why it was there. Rapid decisions were more important than well-thought-out ones, as complex decision-making was not feasible under such immediate threat.

In modern emergencies, however, the situation often requires recalling detailed and/or complex information and using that information to make good decisions. Unlike our prehistoric ancestors, modern responders face lingering liabilities beyond the immediate emergency. This could be medical treatment, fire response, or hazardous material mitigation. Most organizations provide some level of training on these responses, but the challenge is creating a lesson plan that ensures the correct response becomes the default choice in the responder’s knowledge bank.

True teaching involves more than presenting information; it must be delivered in a way that integrates into the responder’s decision-making process. Humans have two decision-making models: naturalistic and classical. Our default setting is naturalistic.

Naturalistic decision-making relies on solutions that have worked in the past. In other words, it relies on experience with similar situations. I saw this in senior firefighters when I was new to the field. They always seemed to know exactly what to do and when to do it. Years of experience gave them a large playbook to pull from. But, this decision-making model fell apart when exposed to an incident they had no experience with.  The naturalistic model is quick and intuitive but relies on significant experience with similar emergencies. It may not work well when encountering a problem for the first time. In industrial settings, responders often lack the extensive experience with low-frequency, high-acuity events.

However, this model can still be incorporated into training. Realistic training scenarios are invaluable because they simulate actual experience. A simulation should be developed so realistically that the brain considers it experience. A common mistake when holding realistic scenario training is not in the delivery but in the after-action review.  During a critique of a realistic scenario, it is often assumed that discussing mistakes is sufficient in correcting the actions taken. Mistakes and shortcomings should be pointed out and addressed. However, In addition to pointing them out, the lessons learned in the after-action review still need to be verified by performance on the training ground. Scenarios should be repeated until the student's performance mirrors what is expected of them in the field. They demonstrate this in action, not discussion. During our drills, we run the scenario. Then we hold an after-action review. Asking each decision maker about issues they saw. The instructor also adds the shortcomings they recognized. Then the drill with the exact same scenario is run again. This is repeated until performance expectations are met. By working them through scenarios until a positive outcome is achieved, they develop their naturalistic decision-making playbook. 

Learning the ‘why’

Classical decision-making, similar to critical thinking, is slower but more thorough. It allows responders to navigate unique and low-frequency incidents more intelligently. This model relies on a strong understanding of the desired outcome and the factors surrounding the emergency. Effective training in classical decision-making involves detailed explanations and an understanding of the “whys” behind actions, not just “do this when that happens.”

For example, in CPR training, most students and instructors might say chest compressions are done to circulate blood. While not inaccurate, this explanation lacks depth. A more detailed explanation involves cardiac perfusion pressure and how chest compressions impact the aorta's pressure. The aorta is a large flexible pipe that supplies the heart muscle with blood. The blood is pushed into the heart by the pressure created by the shrinking of this pipe. Similar to the pressure behind a steam of water coming from a water balloon. Every chest compression makes the aorta get bigger in increases pressure. Every break in compressions gives the aorta time to shrink and lose pressure. 

This understanding helps students make better decisions in real-life scenarios. Let's imagine that this responder determines the need to relocate a cardiac arrest patient. They identify two different methods in which to move the patient. The first option will only take 4 minutes, but compressions will need to be suspended. The second option may take seven minutes, but will allow for continuous compressions during patient movement. Without the “why” the quicker option seems like the best. Given the “why” behind compressions, the correct and second option is seen as the best option. This scenario was very unique in the fact the patient required movement before EMS crews arrived. Given they “whys” affords the responder the ability to make good decisions in unique scenarios.  It is unrealistic to train for every single scenario, so we do the next best thing, we provide the responder with the tools to make good decisions.

Keep new information long term

The final teaching strategy we will discuss is anchoring. Storing information long-term is biologically expensive for the brain, which is why we have developed a short-term memory. To convert information into long-term memory, it must be either frequently revisited or be an imprinting experience. Annual or biannual training alone may not be sufficient to develop long-term memories, so anchoring becomes crucial. 

Anchoring is attaching new information to existing knowledge. This could be a physical object the student is already familiar with or an imprinting past experience. This is why training scenarios should not be conducted in remote locations. They should be conducted in the environment in which they work. Going back to our CPR class example. While the classroom portion of the course is often appropriately held in the classroom, where is the hands-on portion conducted? While commonly held in the classroom, it should be held in their work environment. The student's brain is more likely to remember the information when it is somehow associated with something they already know. 

Imprinted past experiences are also a great way to benefit from the anchoring strategy. Whenever we teach anything ranging from fire response to first aid, we break the ice and use the anchoring strategy. For example, when teaching a first aid class, we ask for any medical emergencies they have responded to in the past. Asking follow-up questions and pulling out the details of this experience is valuable to them, their fellow students, and the climate of the class as a whole. Imagine teaching proper hemorrhage control to a student who has just recalled a past experience of trying to stop a major bleed on a patient a few years ago. Discussing this experience with the students is more impactful than just showing them the different kinds of bandages while adding relevance to the course for all the students. As the hemorrhage control lesson is taught, the students, particularly the students who shared their experiences, will be adhering to the new information you are sharing to already existing information that resides in the long-term memory. 

Sorting through knowledge

Emergency response training is like health insurance. For most of us, it is often unused. But it would be unwise to neglect your health insurance premium. This is not because of the frequency of use. It is because of the consequences of not having insurance if and when we do need it. Poor emergency response training goes unnoticed until it causes major problems. These problems in the industrial setting can pose threats to life and increase liability for the organization. Responders need to make good decisions that limit loss of life and liability. 

Decisions are at the most fundamental level, sorting through your knowledge and determining what, if any, action to take. Was the knowledge needed to make good decisions created during their training, or were they just exposed to information? If the responders can't recall the information during an emergency, the training is only as valuable as the paper the certificate was printed on. Panic and bad decisions start where knowledge ends. Sitting in a classroom and hearing how to react to an emergency a year from now does not instill true knowledge. It is simply checking the box. If responders are expected to make good decisions in the field, they deserve to receive information they can retain and turn into knowledge. 

References

Brown, P. C., Roediger III, H. L., & McDaniel, M. A. (2014). Make It Stick: The Science of Successful Learning. Harvard University Press.

Duhigg, C. (2013). The Power of Habit: Why We Do What We Do, and How to Change. Random House.

Klein, G. A. (1998). Sources of power : how people make decisions. MIT Press.