Senior Nurse Mentor

Managing a Crisis

About lunchtime, I was driving across what some say is the world’s longest floating bridge, one running across Lake Washington between suburban Bellevue and Seattle. About halfway across, I noticed a large pillar of black smoke to my northwest. Since the fire creating that smoke had to be over five miles away, I knew it must be huge.

Exiting the bridge near the University of Washington, I headed north for home. It was then that I began to worry. The smoke seemed to be coming from where I lived. Could that be on fire? When I got home, all was fine, but I could see the smoke rising high into the sky to the north and within walking distance. It proved to be a fire in a block-long row of small retail businesses. The area around was filled with fire vehicles, firefighters, and hoses. 

Have you ever wondered how fire departments manage these large fires? Later, when I worked as a volunteer for an emergency response team based at Seattle’s hospitals, I discovered the answer. It’s called the Incident Command System (ICS).

Think of a major fire. First to arrive is a fire truck with husky guys from the nearest fire station. Seeing the situation is bad, they call for assistance and concentrate on making sure everyone gets out of the burning building. As other vehicles and firefighters arrive, the situation grows complicated. In minutes, a fire scene with six firefighters can grow into one with hundreds. How do fire departments prevent the situation from descending into chaos? 

That’s where Incident Command comes into play. When someone’s workload becomes unmanageable, a division of labor takes place. Responsibilities are formally divided, with each party knowing what their new role is. Because everyone has been trained in the same system, fire fighters from other cities can join. At that large fire I saw fire trucks from Bellevue. 

In short, under ICS, everyone has assigned responsibilities, no one has too many responsibilities, and no necessary responsibility gets neglected. The goal is to prevent a situation that was joked about when I studied engineering: “When you’re up to your neck in alligators, it’s hard to remember that your original goal was to drain the swamp.” Incident Command would assign someone to alligator control, so the others could focus on draining. 

Incident Command grew out of necessity and experience. While I was involved in an emergency drill involving the area’s hospitals, I talked with a physician who’d come from Japan to study how we respond to disasters such as earthquakes. In Japan, he told me, they usually react by forming a group and discussing the situation until a consensus was reached. Unfortunately, he said, that takes too long. For an emergency, there must be one person responsible for specific decisions. A good decision made quickly can be better than a perfect decision made too late.

For instance, if fire fighters are running out of filled air tanks for their respirators, there must be someone responsible for that. He could say, “I have a truck with tanks and air compressors coming. It’s ten minutes out and will park at the south end of this street.” That’s Incident Command. Every task has a taskmaster.

Today, hospitals, particularly their emergency rooms, often study Incident Command to prepare for major disasters. Many have brightly colored vests designating who does what, and there are call lists to bring in additional staff when required. That’s good.

But hospitals can fail to see a crisis that develops slowly. The result can be like the tale from India about several blind men examining an elephant and coming away with radically different descriptions. One sees one aspect and acts on that. A second person sees another aspect, and acts differently. A third sees nothing and does nothing. No one sees and understands the whole. 

That’s exactly what was happening with air embolisms. We’ll look at the parties involved, what each saw, and how each responded.

First were our nurses, who were in the front lines of this new technology. Our central lines were so new, most nurses were passing in a few months from having no experience with them to having handled several with no specific training. They were muddling along as best they could. Because those lines worked like peripheral IVs, many thought that was all they were. Typically, they only realized the seriousness of  an air embolism when one struck them. That was true in all four of the cases where I was involved. Nurses often learned but too late. Experience can be a poor teacher.