I notice when I am charting after a call, there occasionally appears to be more time between interventions, diagnostics, and assessments than I remember. The tendency is to fill this space to avoid the chart reading as if you had long periods of time in which you sat twiddling your thumbs. 

The fascinanting part about retrospective reflection, is there may have never FELT like a time you were idle - but there was.

The time spent between "chartable" actions is by the far the most important and influential piece of your performance, but it can also be a weakness. I want to try and illustrate the parallels between real-time mental simulation and action.

"I make hundreds of mistakes on every call, except typically - they are all in my head." - George Blankenship (my paramedic instructor)

The Healthy Lag

The art of lagging interventions behind real-time mental simulation is a way of predicting errors or complications prior to encountering them. 


The Impulse Lag

Occasionally, our decision making precedes our mental projection. This is commonly seen in recognition-primed decision making. It is important in these circumstances to not hesitate in changing your mind and/or clinical course based off new information.


Influencing Factors

There are multiple factors that influence the speed at which my mental simulation parallels with my actions. This can be something as simple as working with a different partner or encountering an unfamiliar patient presentation. Aware of these influencers, I will intentionally delay my actions in an attempt to let my mental projection catch up.

The external manifestations of this process is increased time between actions. What I find most facinating is that occasionally our brain is playing a soundtrack that is whispering to us the next correct priority - but we do not listen until care is handed over.


Task saturation, communication, and operations of extrication and packaging will play a louder soundtrack as their needs are immediate. This is why you suddenly remember that you did not give TXA while you are making up the cot. 

My Solution

Obviously this is where someone would mention checklists. It's true, checklists are a fantastic way to assure you are not forgetting something due to the fact that your brain is subjectively prioritizing something else. With fixed tasks like starting an aircraft or performing an intubation, checklists work great. The solution however to organizing the space between interventions and diagnostics, is in the way we communicate.

The way we turn up the volume to an internal sound track is by literally saying it out loud. 

"I think we should get a 12 lead"

The next step is to have a physical reminder that you wanted to perform this task. This can be something as easy as placing the glucometer or 12 lead cables on the patients chest. You will not be able to look at the patient without remembering "oh crap we didn't do a 12 lead yet!"

The way I deal with congitive hiccups is by graphing out what I think happened. In reality there is probably very little we can do to manipulate our way around specific human factors. Sometimes just labeling the tendency is enough to bring it to the forefront. I hope this was as helpful for you as it was for me.