Emergency medicine in the UK is frequently cited by the British media as being like a warzone, and with that in mind I delved back into one my favourite books. It certainly isn’t a modern book and I very much doubt it was written with EM in mind, but there are lessons we can learn from it. As with any philosophical text, it is open to interpretation and whilst it was it was written around 2500 years ago, it is acknowledged throughout the miltary, political and sporting worlds of today. As the title of this post suggests, I am writing about The Art of War by Sun Tzu. I hope to share with you some of my interpretations; you may disagree, or you may agree, and that is absolutely fine. Emergency medicine is an amazing specialty but there is so much more to it than the clinical stuff we (awesomely) do.
Disclaimer: I wholeheartedly disagree with equating patients to enemies!!
Who is the ‘enemy’?!
In emergency medicine we have many ‘enemies’. I use this term as a metaphor, and I would invite you to see the term ‘enemy’ as a metaphor for a challenge rather than an arch nemesis. Our enemies/challenges are numerous; 4-hour targets; increasing age of the population; increasing demand on the NHS; bed-blocking; repeat attenders….the list seems endless. Please have an open mind and I would encourage you to think about these awesome snippets from the book could be applied to you and your ‘enemies’.
‘Know you’re the enemy, know yourself, and victory is never in doubt, not in a hundred battles. He who knows self but not the enemy will suffer one defeat for every victory. He who knows neither self nor enemy will fail in ever battle.’
This is so important on a personal and an organisational level. Reflect on what you do and don’t know. Strengthen the areas you are weak, you owe it to your patients. We can’t be experts in everything but we should be aware of the things we are not so strong on. Sun Tzu was around before we were aware of the stages of competency, but I believe he would have encouraged us to be aware of our conscious incompetencies.
Similarly, an organised department who knows the patients it sees, the strengths and weaknesses of the fellow specialities it works with, the strengths and weaknesses of each of its team-members has more chance of soaking up pressure and being able to cope with whatever walks through the door.
We can apply this to many of the ‘enemies’ that we face, and it seems obvious; if you fail to plan, plan to fail (Benjamin Franklin).
‘The skilful warrior does not rely on the enemy’s not coming, but on his own preparedness.’
There is no excuse to not prepare for something just because it may be unlikely to present to our department. The response to Ebola demonstrates that we can do this well. Most EDs will have a plan in place for viral haemorrhagic fever patient, despite the liklihood of it presenting. In this day and age, we have to anticipate that primary care patients will present to the ED. A hospital should anticipate this, otherwise it will never cope. In the ED, we should not berate these patients but educate them. We should strive to be the “skillful warrior” that Sun Tzu refers to.
‘The victorious army is victorius first and seeks battle later; the defeated army does battle first and seeks victory later.’
Have a think about a standby call. Think about two scenarios; in one you get 10 minutes warning; in the other you get no warning. How much more efficient is the intial care the patient gets if you have more warning? We can deal with a major trauma so much efficiently and effectively if we prepare as a team. Simulation training is so relevant and essential for this reason. If we can drill how we will deal with so many different events, no matter how likely they may be.
‘[The skilful warrior] He confronts chaos with discipline; he treats tumult with calm. This is mastery of the mind.’
Be steadfast, don’t succomb to the chaos of the ED. I personally love the chaos, but deal with it in a calm manner. Don’t meet chaos with chaos, or your life will be chaotic (obviously). Be disciplined in your approach, don’t cut corners with one patient just because there are ten others waiting.
‘Supreme military skill lies in deriving victory from the changing circumstances of the enemy’
We need to be reactive and flexible. We must have ability, both individually and organisationally, to be able to respond to meet the demands and circumstances of our patients.
The book is predominantly and very clearly a military strategy book, and there is a lot that I found difficult to apply to EM (especially the parts on attacking the enemy with fire). The organisational strategy is, however, fantastic. We are but a few on the shop floor, but we face hundreds of patients daily. The consultant in charge is very much a general, ordering their troops to where they can be most effective. I am in the miltary, as a reservist, and I see the benefit of that small amount of military training every day. It teaches you how to be a soldier, and how to follow orders as a part of a team, but it equally teaches you how to lead. It teaches discipline, and I can’t overstate how important this is in EM. We all wear the same uniform, and we should be proud to work with our colleagues as a team. We should have the discipline to turn up to work on time, maybe even early; and we should always have the discipline to treat every patient the same with the same respect and compassion.
Before you go please don’t forget to…