FIGHT FIRE WITH FIRE – 10 RESUS ORDERS

firefighter icon 2We all know that there’s so much to learn from other professions whom, although working outside of healthcare, function in comparably unpredictable high risk, high pressure environments. This mutual cross-pollination enriches the way we think about and look at our own practice and gives us new perspectives on what it means to perform under pressure. And this time it’s got nothing to do with aviation.

10 standard fire orders
In 1957 a 16 year old boy in Inaja near San Diego threw a match into some dry grass “to see if it would burn”. The resulting bushfire claimed 11 lives and changed firefighting forever.

The 10 Standard Fire Orders: USDA Forestry Service 1957

1. Keep informed on fire weather conditions and forecasts.
2. Know what your fire is doing at all times.
3. Base all actions on current and expected behavior of the fire.
4. Identify escape routes and safety zones and make them known.
5. Post lookouts when there is possible danger.
6. Be alert. Keep calm. Think clearly. Act decisively.
7. Maintain prompt communications with your forces, your supervisor, and adjoining forces.
8. Give clear instructions and ensure they are understood.
9. Maintain control of your forces at all times.
10. Fight fire aggressively, having provided for safety first.

The 10 standard fire orders were devised in 1957 by the USDA forestry sevice in reponse to the Inaja bushfire and 15 other tragedies in fire fighting over the preceding years. They were designed as a core principles rule book for safety in firefighting and were themselves inspired by a similar document used by US military sentries. They have been used by thousands of firefighters over a period spanning over forty years and have become a sort of sacred text.

When I stumbled across them for the first time, I was awestruck with just how relevant they are to resuscitation. With just a few minor word changes this could just as easily be…

10 standard resuscutation orders

The point of the orders is of course that they can be applied by the individual to any situaiton. Below are only my interpretations. You may have your own interpretations which are more valid in your own particular situation.

1. Keep informed on current conditions and forecasts

Keep yourself informed. Keep up to date. For pre-hospital, this is clear, but also in-hospital: Know your resus bay and environment. And know your stuff. If you don’t know your stuff, what the latest research is, and what the future of your speciality is – how can you expect to keep up and give your patient safe care?

2. Know what your patient is doing at all times.

How will you know what’s going on if you’re not looking. Monitor up, use ultrasound, look, listen, feel. You can only get so far from a computer, from the other end of a phone call or from what the situation was 5 minutes ago. Get hands on and pay attention, really pay attention.

3. Base all actions on current and expected behavior of the patient.

Dont assume you know what’s going on or what’s going to happen. Base your actions on what’s actually happening with the patient. If something deviates from your mental picture of the situation, look to explain it, not to explain it away. And based on what’s really happening now, project what’s likely to happen next.

4. Identify escape routes and safety zones and make them known.

This is a great one. Make your escape routes known to the whole team. “If I dont get this tube in after 2 attempts we’re calling x and doing y”. “If this patient becomes unstable in CT we’re going straight to theatre and not to the ICU.”

5. Post lookouts when there is possible danger.

Delegate tasks when you know you wont be able to give certain things your full attention. “While I’m intubating I want you too look at the sats and blood pressure and tell me every 20 seconds”. “Can you take over actively leading the team while I’m putting in this line”.

6. Be alert. Keep calm. Think clearly. Act decisively.

No explanation necessary. This simple but brilliant mantra would almost be number one on my list.

7. Maintain prompt communications with your forces, your supervisor, and adjoining forces.

About logistics, about your reasoning, about your uncertainties. There’s no place for secrets or unnecessary surprises in resuscitation. Keep in touch with necessary specialties, and communicate with CT, OR and the ICU as needed.

8. Give clear instructions and ensure they are understood.

Yep, understood.

9. Maintain control of your forces at all times.

Importantly, I believe control here refers to cohesion and order, not to ruling with an iron fist. A resuscitation team without control will disintegrate. Know what they are doing, and let them know what you are doing.

10. Fight critical illness aggressively, having provided for safety first.

We should always resuscitate aggressively. But safety of both the patient and the team is paramount. There’s no place for starting slow and overly cautiously. That’s a sure fire way of getting burned.

Fired up resus
The simplicity of these orders is their magic. They are clear, uncomplicated, unambiguous, easily accessible by all and easily applicable in any situation. I know nothing about fighting fires, but these orders speak to me in a language I can understand.

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