• Brian Behn (Guest Blog)

How To Avoid Being An Idiot : The Power Of Inversion

I’ve wasted most of my career trying to be a great paramedic.After fifteen years I’ve come to terms with the fact that I’m not a great paramedic and I don’t think I ever will be. Instead of trying to achieve greatness my time would have been better spent avoiding stupidity as much as possible. This is not to say that there aren’t truly great paramedics out there, there certainly could be – those that are truly gifted or are able to put in the thousands of hours to elevate their practice to true greatness, but they are a rare breed. There is no shortage however of paramedics that think of themselves as great.

Paraphrasing Charlie Munger of Berkshire- Hathaway “It’s great to have a paramedic with an IQ of 160 – unless he thinks it is 180.”

Trying to be a great paramedic is a difficult path and one that is full of risk; the few moments of brilliance in a career can easily be eclipsed by an equal (or greater) amount of stupid mistakes, careless errors and incredibly poor judgement made in the pursuit of greatness.

Most agencies tend to have the person who gets more “big” calls than the average provider. While this could be nothing more than the effects of random chance or bad luck (good luck?)and maybe they truly are just the proverbial black cloud, if they consistently, year in and year out, lead the agency in the number of skills performed like RSI, cricothyrotomy, synchronized cardioversion, and whatever other stuff is seen as cool at the moment, it kind of begs the question of why they are getting so many more of these kinds of things than the agency average. Are they “supersizing” their calls and being overly aggressive? Is it driven by ego or perhaps they are clinically superior to their peers and the average paramedic is too complacent?

There is often a spectrum of appropriate treatments for any given patient in any particular situation, but when these providers consistently end up on the maximally aggressive* end of the normal distribution curve it might be worth having a conversation with these providers…Or worse, engaging in some self-reflection. Cognitive dissonance can be a real bitch and reconciling how you are a great paramedic but also have made many, many mistakes is not a comfortable place to be. Then again little personal growth occurs when we are comfortable. The ego is a powerful force and exerts a strong influence on decision making. Very few people are thought of as great providers for not doing something, for not taking action and simply taking a wait and see approach even when it is the most appropriate decision. The do-something bias is endemic in healthcare and colors our perceptions in subtle but significant ways pushing us to take action even though it may be the wrong decision or the less-right decision. It is very hard to conceptualize that a series of choices where inaction, of consciously choosing to not doing something, is viewed as an attribute that makes someone a great provider. Doing nothing makes for a poor story around the table at shift change. What is the cure for this ego driven call to greatness for the majority of paramedics like myself that are not truly great? Using the power of inversion to guide the decision making process is an easy and effective way to start making better choices.

Carl Jacobi, a German mathematician, said, “Invert, always invert” referring to the practice of looking at an outcome that we wish to avoid and figuring out how to not end up there as opposed to only looking at the outcome we want. Dwight Schrute, the assistant to the regional manager on The Office said “Whenever I'm about to do something, I think, "Would an idiot do that?" And if they would, I do not do that thing.”

Rather than asking the question of “what should I do here?” which presents a myriad of options, asking what I really want to avoid often narrows down the options and brings much needed clarity to the situation.

Most decisions in healthcare are not black and white, when faced with a tough decision, asking “what would a great paramedic do here?” is a hard question to answer; countless possibilities fill the mind. It usually goes something like this for me (and this always occurs when there is no cell or radio reception to phone-a-friend): “Is starting a pressor on this frail, hypotensive, likely terminally ill patient what a great paramedic would do? Yes it is…Do it…Yes, definitely… Or, is too aggressive? I mean they are 86 years old with a DNR. Shit. Maybe I should do it, their MAP is 62mmhg but they seem stable….uh…Yes, remember you are a god-damn critical care paramedic-maximally aggressive care! Well, I mean, I guess it could also wait as there is only twenty more minutes in this transfer. Ah screw it – grow a set and start the levo! Save their kidneys! Hmmm, then again, they are 86 years old and probably going to be placed on comfort care when they get to the facility.Okay, maybe see what the next BP is in 10 minutes?”Analysis paralysis sets in and I am usually just end up making a decision on gut feeling or something even more random than that. Asking the reverse, “what would a bad paramedic do here?” quickly clarifies many things. Asking “what would I want to avoid here?” usually provides answers with little doubt.

What do I want to avoid? I do not want to end up in court and I certainly don’t want to end up in court looking like an asshole and losing. I do not want to harm a patient. I don’t want to make a patient worse by giving them an optional treatment (one that could be deferred until we have labs to confirm a diagnosis, etc.) that ends up causing iatrogenic harm. I don’t want to look like a dickhead in front of my coworkers because I made a medication error, and many other things that I have in fact done in my career in the name of greatness.

How this works for me in real life:

At 3am when I am tempted to clear a scene as no aid needed instead of taking the time to document a refusal I remind myself of the outcomes I do not want such as ending up in court on a refusal that went south and I have no documentation.

When I am tired and I have a patient that is very low risk but still they probably should have a 12 lead ecg performed. I do not want to be the provider who missed the atypical STEMI in a female diabetic because I was tired or lazy. While the odds are low, the effects of missing it could be very bad.

A 12 lead should be done but I know is going to be a pain in the ass - huge breasts, clothing that is going to make it an ordeal, a homeless person wearing a full wetsuit under their clothes, a short transport where I could get away with saying I would have done a 12 lead but I ran out of time. Again, I do not ever want to be the provider who missed an MI because I didn’t performed a 12 lead.

With a patient who previously declined pain meds but now, when we are two minutes away from the hospital, the patient decides they do want some pain medications. I could easily defer the meds until they arrive at the ED with some bullshit about how by the time I get the meds out we will be there; but I know the truth - that it will take some time to get them registered and to be seen and it is going to be about twenty minutes until they get some drugs. Because I am lazy I have to ask myself what I want to avoid. Being a bad paramedic or an asshole are pretty high on my list of things to avoid and I know that both an asshole and a bad paramedic could employ the two-minute excuse so I draw up the fentanyl and treat their pain even if we are parked in the ED ambulance bay. I’m fine with being lazy as long as I am the only one who suffers any ill effects from it, if it causes other to suffer then I need to not be lazy.

Mornings are just the worst for me. I am the opposite of a morning person – those cheery, doe-eyed people who insist on talking to me loudly and asking me questions when the lights hurt my eyes and I am only capable of communicating in grunts and moans. Unfortunately my shifts start early in the morning and one of the first tasks of the day is completing an ambulance check-off. It is so very tempting to trust the off-going crew when they tell me that the crew before them said the ambulance was fully stocked and it is good to go. But somehow, through the fog of morning I remember to invert: I do not want to be the paramedic that shows up at a cardiac arrest with a monitor with dead batteries in it. That seems like one of those situations where my service will be writing a big fat check to someone and I will be left unemployed and feeling like and asshole – all things I wish to avoid. So I slam one or two or three energy drinks and do the daily check off.

The last thing you want to introduce to a patient with a head injury is hypoxia or hypotension. When faced with a patient with a head injury and a GCS that is in the low single-digits it isn’t wrong to RSI them (whether it is the “most right” decision is a different discussion) but sometimes I believe that the notion of “can” overrides “should” in this scenario although that might be a different article for a different day. Maybe it is the do-something bias, maybe it has been a while since I last intubated someone and I get a bit excited about it and want to dive right in and get that tube, but I pause, and ask myself what I might want to avoid here with this patient. I want to avoid making the patient worse – I think someone said this in Latin at one point a few years ago - and doing an RSI without pre-oxygenating, optimal positioning, having a plan B and C in place and without being ready to treat/prevent hypotension will do just that.

Charlie Munger, who introduced me to the ideas contained in this piece, sums it up better than I ever could, “It is remarkable how much long-term advantage people like us have gotten by trying to be consistently not stupid, instead of trying to be very intelligent. Invert, always invert: Turn a situation or problem upside down. Look at it backward. What happens if all our plans go wrong? Where don’t we want to go, and how do you get there? Instead of looking for success, make a list of how to fail instead. Tell me where I’m going to die so I don’t go there.”

Losing the ego is never easy; it is a constant battle and one must remain vigilant as it readily sneaks back in. Giving up the notion of greatness is a tough pill to swallow, but in the end settling for simply not being stupid might be the better course of action, at least for me. Your mileage may vary. ________________________________________________________________________________ Brian Behn works for a rural EMS agency in the mountains of Colorado, where he spends most of his free time trying to be less lazy and searching for comfortable shoes.

*There is nothing wrong with being maximally aggressive when it is the right time. Knowing when that time is, is the hard part of the equation.